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WESSQL300.MEPSSpring2024
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This is the cover page. Additional contents currently project specific.
RF - Page 1 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Rout
Full Detail Spec
BOX_00
Route Details:
(RF1000)
Item Type: Route
Type Class: If Then
01 Box = BOX_00, BOX_10, BOX_20, BOX_30, BOX_40, BOX_70, BOX_80, BOX_
90, BOX_100, BOX_110, BOX_120, BOX_130, BOX_140
02 Loop = Loop 10, Loop 20, Loop 30
03 End Loop = END_LP10, END_LP20, END_LP30
04 Single Select = RF60, RF100, RF105_01, RF105_02, RF105_04, RF105_05, RF150_
01, RF150_05
13 Address – Preloaded = RF70_01, RF70_02, RF70_03, RF70_04, RF70_05, RF70_06,
RF70_07
14 Regular Date Entry = RF90_01, RF90_02, RF90_03, RF150_04
20 OS Text Field = RF105_06, RF150_02, RF150_06
23 Text Field = RF150_03
24 Information Screen = RFIntro, RF20, RF30, RF115, RF125, RF135, RF140_01, RF160
26 Regular Date Entry – Preloaded = RF80_01, RF80_02, RF80_03 Roster 2 = RF105_03
RF - Page 2 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Rout
Full Detail Spec
BOX_10
Item Type: Route
(RF1005)
Route Details:
Type Class: If Then
Placeholder for Context header display instructions:
Note: Fall 2020 CAPI administration requires additional AF colors to support the extension
of P23R6 and ongoing.
RFIntro
Item Type:
Type Class:
Answer Type:
Help Available (
Panel
MPC
P24
Green
Gray
P26
Blue
Pink
P27
Goldenrod
Ivory
P28
White
Orchid
(RF1006)
Question
Enumerated
TContinue
)
Pharmacy
BLAISE NAME: RFIntro
Field kind: Datafield
ArrayMin:
Min value:
Field Size:
Answers allowed: 1
ArrayMax:
Max value:
Show Card (
)
Look Up File (
Question Text:
CAPI WILL NOW DETERMINE WHICH, IF ANY, AUTHORIZATION FORMS ARE REQUIRED FOR THIS HOUSEHOLD.
THIS PROCESS MAY TAKE A FEW MOMENTS.
ANY EVENTS ADDED AFTER THIS POINT WILL NOT GENERATE NEW AUTHORIZATION FORMS UNTIL THE NEXT
ROUND.
PRESS 1 AND ENTER TO CONTINUE.
Responses:
CONTINUE
1
RF - Page 3 of 77
BOX_20
(RF1010)
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
After ‘1’ is entered, CAPI will use the AF Rules to populate the AF array.
The rules for creating records that meet the authorization form (AF) definition are included
here:
(https://mepspm.westat.com/FinalDesignDocsbyGroup/Respondent%
20Form%20(RF)%20Section%20Supporting%20Documents/AF%
20Rules_rev.xlsx)
The specifications for the AF array are included here:
(https://mepspm.westat.com/FinalDesignDocsbyGroup/Respondent%
20Form%20(RF)%20Section%20Supporting%20Documents/AF%
20Array_rev.xlsx)
Note: OF events added at any point in the RF section will not generate new AFs until the
next round.
Display
Instructions:
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)YYYY.RF_Main
Variable stored at MEPS(Fall/Spring)YYYY_PersSect.RF_Main
RF - Page 4 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Rout
Full Detail Spec
BOX_20
Route Details:
(RF1010)
Item Type: Route
Type Class: If Then
If:
Round 1 and at least one person-provider-pair eligible for MPC authorization form
collection for the current round [at least one record where (AF.AFType=MPC) and
(AF.RequestRd1=Yes)]
OR
Not Round 1 (RndType<>First) and at least one person-provider-pair eligible for MPC or
Pharmacy authorization form collection for the current round [at least one record where
(AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]
OR
Not Round 1 (RndType<>First) and at least one person that is part of this RU
(MostRecentRU=RUUnit) rejoined the community this round from previously being
institutionalized in a health care setting [at least one record where (AF.AFType=MPCHCI (original)) and (AF.AFInstStatus=1 or 2)]
Continue with BOX_30.
Otherwise, go to BOX_140.
BOX_30
Route Details:
(RF1020)
Item Type: Route
Type Class: If Then
If not Round 1 (RndType<>First) and at least one person that is part of this RU
(MostRecentRU=RUUnit) rejoined the community this round from previously being
institutionalized in a health care setting [at least one record where (AF.AFType=MPC-HCI
(original)) and (AF.AFInstStatus=1 or 2)], continue with RF20.
Otherwise, go to RF30.
RF - Page 5 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Instr
Full Detail Spec
RF20
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1025)
Instruction
Enumerated
BLAISE NAME: AFSumm2
TContinue
Answers allowed: 1
Field kind: Datafield
)
Show Card (
)
Look Up File (
Question Text:
FORM COLLECTION SUMMARY, CONTINUED.
{PERSON 1}, {PERSON 2}, {PERSON 3}, {PERSON 4}, {PERSON N} {HAVE/HAS} {REJOINED THE HOUSEHOLD} {OR}
{DIED} AFTER BEING IN A HEALTH CARE FACILITY.
CAPI WILL ALSO PROMPT YOU TO COMPLETE AUTHORIZATION FORMS FOR INSTITUTIONAL STAYS THAT
OCCURRED DURING THE TIME {HE/SHE/THEY} {WERE/WAS} AWAY AT A HEALTH CARE FACILITY.
PRESS 1 AND ENTER TO CONTINUE.
Responses:
CONTINUE
1
RF - Page 6 of 77
RF30
(RF1035)
)
MEPSSpring2024
Respondent Forms (RF) Section
(Instr
Full Detail Spec
Programmer
Instructions:
Display
Instructions:
Roster 1- Report
Roster definition:
This item uses the authorization form array to display RU-members. (AF.FName, AF.MName,
AF.LName)
Roster filter:
Display only those RU members who have returned from being institutionalized in a
previous round [persons where (AF.AFType=MPC-HCI (original)) and (AF.AFInstStatus=1 or
2)].
Display RU members’ first, middle, and last names (AF.FName, AF.MName, AF.LName) in
question text. If exactly two names displayed, separate names with the word “and” and no
comma. If more than two names listed, separate names using commas, except for between
the last two names displayed. Between the last two names displayed, separate names using
the word “and”.
Display “HAVE” and “WERE” if more than one name displayed. Otherwise, display “HAS” and
“WAS”.
Display “REJOINED THE HOUSEHOLD” if there is at least one RU member listed who is living
with the family after leaving the institution (AF.AFInstStatus=2). Otherwise, use a null
display.
Display “DIED” if there is at least one RU member listed who died after leaving the
institution (AF.AFInstStatus=1). Otherwise, use a null display.
Display “OR” if there is at least one RU member listed who is living with household and at
least one RU member who is listed died after leaving institution. Otherwise, use a null
display.
Display “HE” if only one RU member meets the roster filter conditions and that RU member
is male. Display “SHE” if only one RU member meets the roster filter conditions and that RU
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)YYYY.RF_Main
Variable stored at MEPS(Fall/Spring)YYYY_PersSect.RF_Main
RF - Page 7 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Instr
Full Detail Spec
RF30
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1035)
Instruction
Enumerated
TContinue
)
BLAISE NAME: AFRequest
Field kind: Datafield
Answers allowed: 1
Show Card (
)
Look Up File (
)
Question Text:
{[As I mentioned during the last interview], we/We} request authorization to contact {medical providers} {and} {pharmacies}
to obtain complete and accurate information about health care use and expenditures.
{I would like to get authorization from {MPC_PERSON 1, MPC_PERSON 2, MPC_PERSON 3, MPC_PERSON 4,
MPC_PERSON N….} to contact medical providers for more information about the services they provide.}
{I would {also} like to get authorization from {PHAR_PERSON 1, PHAR_PERSON 2, PHAR_PERSON 3,
PHAR_PERSON 4, PHAR_PERSON N….} to contact pharmacies to obtain a printed summary.}
{{In addition, we/We} would still like to get authorization to contact {medical providers} {and} {pharmacies} for
{AF_PERSON 1, AF_PERSON 2, AF_PERSON 3, AF_PERSON 4,
AF_PERSON N….} [although they have since passed away].}
[HAND RESPONDENT THE AUTHORIZATION FORM BOOKLET.]
[These materials explain more about why we contact {medical providers} {and} {pharmacies} and answer questions people
sometimes ask about this part of the study. Please take a minute to review this information.]
PRESS 1 AND ENTER TO CONTINUE.
Responses:
CONTINUE
1
RF - Page 8 of 77
BOX_40
(RF1037)
MEPSSpring2024
Full Detail Spec
Display
Instructions:
Respondent Forms (RF) Section
(Instr
DISPLAY “[As I mentioned during the last interview], we” if not round 1. Otherwise, display “We”.
Display “medical providers” if at least one person in the RU has at least one active MPC AF in the
current round [at least one record where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1
=Yes)]] or [at least one record where [not Round 1 (RndType<>First) and (AF.AFType=MPC) and
(AF.AFSuperceded=Empty)]]. Otherwise, use a null display.
Display “and” if there is at least at least one active MPC and one active Pharmacy AF in the current
round. Otherwise, use a null display.
Display “pharmacies” if at least one person in the RU has at least one active Pharmacy AF in the current
round [at least one record where (RndType<>First) and (AF.AFType=Pharmacy) and
(AF.AFSuperceded=Empty)]. Otherwise, use a null display.
Display “I would like to get authorization from {MPC_PERSON 1, MPC_PERSON 2, MPC_PERSON
3, MPC_PERSON 4, MPC_PERSON N….} to contact medical providers for more information about
the services they provide.” if at least one person in the RU has at least one active MPC AF in the
current round. Otherwise, use a null display.
For the second paragraph “{MPC_PERSON 1, MPC_PERSON 2, MPC_PERSON 3, MPC_PERSON
4, MPC_PERSON N….},” display the first names (AF.FName) of all RU members whose
AF.AFPersonStatus=1, 2, 4, 6 and where that person has at least one active MPC AF in the current
round. Substitute “you” for the person’s first name if the respondent is included in this list. If exactly
two names displayed, separate names with the word “and” and no comma. If more than two names
listed, separate names using commas, except for between the last two names displayed. Between the last
two names displayed, separate names using the word “and”.
Display “I would {also} like to get authorization from {PHAR_PERSON 1, PHAR_PERSON 2,
PHAR_PERSON 3, PHAR_PERSON 4, PHAR_PERSON N….} to contact pharmacies to obtain a
printed summary.” if at least one person in the RU has at least one active Pharmacy AF in the current
round [(RndType<>First) and (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)]. Otherwise,
use a null display.
Display “also” if there is at least at least one active MPC and one active Pharmacy AF in the current
round. Otherwise, use a null display.
For “{PHAR_PERSON 1, PHAR_PERSON 2, PHAR_PERSON 3, PHAR_PERSON 4,
PHAR_PERSON N….},” display the first names (AF.FName) of all RU members who have an
AF.AFPersonStatus=1, 2, 4, 6 and where that person has at least one active Pharmacy AF in the current
round [(RndType<>First) and (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)]. Substitute
“you” for the person’s first name if the respondent is included in this list. If exactly two names
displayed, separate names with the word “and” and no comma. If more than two names listed, separate
names using commas, except for between the last two names displayed. Between the last two names
displayed, separate names using the word “and”.
Display entire paragraph starting with “{In addition, we/We would} still like to get authorization...” if
at least one person in the RU has an AF.AFPersonStatus=3 or 5.
Display “In addition, we” if at least one person with an AF.AFPersonStatus=1 ,2, 4, or 6 has at least one
active MPC or one active pharmacy AF and at least one person with an AF.AFPersonStatus=3 or 5 and
has at least one eligible MPC or one Pharmacy AF”.
Otherwise, display "We".
Display “medical providers” if at least one person in the RU has an AF.AFPersonStatus= 3 or 5 and has
at least one active MPC AF in the current round [at least one record where [(Round 1) and
(AF.AFType=MPC) and (AF.RequestRd1=Yes)]] or [at least one record where [not Round 1
(RndType<>First) and (AF.AFType=MPC) and (AF.AFSuperceded=Empty)]]. Otherwise, use a null
display.
RF - Page 9 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Instr
Full Detail Spec
Display “and” if at least one person in the RU has an AF.AFPersonStatus= 3 or 5 and there is at least at
least one active MPC and one active Pharmacy AF in the current round. Otherwise, use a null display.
Display “pharmacies” if at least one person in the RU at least one person in the RU has an
AF.AFPersonStatus= 3 or 5 and has at least one active Pharmacy AF in the current round [at least one
record where (RndType<>First) and (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)].
Otherwise, use a null display.
For this paragraph, “{AF_PERSON 1, AF_PERSON 2, AF_PERSON 3, AF_PERSON 4,
AF_PERSON _N}”, display the first names (AF.FName) of all RU members who have an
AF.AFPersonStatus= 3 or 5 and that person has at least one active MPC or Pharmacy AF in the current
round. If exactly two names displayed, separate names with the word “and” and no comma. If more than
two names listed, separate names using commas, except for between the last two names displayed.
Between the last two names displayed, separate names using the word “and”.
Testing/Editing
Notes:
BOX_40
Route Details:
Variable collected at MEPS(Fall/Spring)YYYY.RF_Main
Variable stored at MEPS(Fall/Spring)YYYY_PersSect.RF_Main
(RF1037)
Item Type: Route
Type Class: If Then
If not Round 1 (RndType<>First) and at least one person that is part of this RU
(MostRecentRU=RUUnit) rejoined the community this round from previously being
institutionalized in a health care setting [person has record where (AF.AFType=MPC- HCI
(original)) and (AF.AFInstStatus=1 or 2)], continue with LOOP_10.
Otherwise, go to RF105_01.
RF - Page 10 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Rout
Full Detail Spec
LOOP_10
Route Details:
(RF1040)
Item Type: Route
Type Class: Begin Loop
For each element in the RU-Members-Roster, ask LOOP_20 - END_LP10.
Loop Definition: LOOP_10 cycles on RU members who have returned from institution.
This includes RU members that meet the following conditions:
⦁ Not Round 1 (RndType<>First) and
⦁ person is part of this RU (MostRecentRU=RUUnit) and
⦁ person rejoined the community this round from previously being institutionalized in a
health care setting [person has record where (AF.AFType=MPC-HCI (original)) and
(AF.AFInstStatus=1 or 2)].
LOOP_20
Route Details:
(RF1090)
Item Type: Route
Type Class: Begin Loop
For each of the following:
Institution 1
Institution 2
Institution 3
Institution 4
Institution 5
Ask BOX_70-END_LP20.
Loop definition: LOOP_20 collects/verifies the name, address, admit and discharge dates
of every health care institution a person who has rejoined the community resided in
during the time they were not part of the MEPS interview. The response to RF100
determines if the loop cycles again. If RF100 is coded ‘1’ (YES), the loop cycles to collect
the next health care institution. If RF100 is coded ‘2’ (NO), ‘RF’ (REFUSED), or ‘DK’ (DON’T
KNOW), the loop ends. However, there can only be a maximum of 5 health care
institutions, so RF100 will not be asked once there are 5 institutions.
BOX_70
Route Details:
(RF1095)
Item Type: Route
Type Class: If Then
If first cycle of LOOP_20, continue with RF60.
Otherwise, go to RF70_01.
RF - Page 11 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF60
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1100)
Question
Enumerated
TYESNO
)
BLAISE NAME: HCIConf
Field kind: Datafield
ArrayMin:
Min value:
Field Size:
Answers allowed: 1
ArrayMax:
Max value:
Show Card (
)
Look Up File (
Question Text:
I have recorded that {you/{PERSON}} {rejoined the household/passed away} after being in a health care facility.
I would like to collect the name, address, and telephone number for each nursing home or other long-term care
institution that provided 24 hour skilled nursing care where {you/{PERSON}} resided between {DATE ORIG
INSTITUTIONALIZED} and {DATE REJOINED COMMUNITY}.
In an earlier interview, I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME}. Is that correct?
Responses:
YES
NO
REFUSED
DON'T KNOW
1
2
RF
DK
RF - Page 12 of 77
RF70_01
RF70_01
RF70_01
RF70_01
(RF1105)
(RF1105)
(RF1105)
(RF1105)
)
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Programmer
Instructions:
Display
Instructions:
For “{PERSON}” display the full name of the person being looped on (Person.FullName).
Display “rejoined the household” if person has returned to live in this RU [(AF.AFInstStatus=
2) for the record where AF.AFType=MPC-HCI (original)]. Display “passed away” if person
died after leaving the institution [(AF.AFInstStatus=1) for the record where AF.AFType=MPCHCI (original)].
For “{DATE ORIG INSTITUTIONALIZED}”, display the date the person was first
institutionalized [(AF.OrigInstMM, DD, YYYY) for the record where AF.AFType=MPC-HCI
(original)]. Display as full month, xx, YYYY - e.g., "January 1, 2016". Display “DK” or “RF” for
missing values.
For “{DATE REJOINED COMMUNITY}”, display the date the person left the health care facility
[(AF.DtRejoinedMM, DD, YYYY) for the record where AF.AFType=MPC-HCI (original)]. (This is
the date collected at RE200/RE220/RE240). Display as full month, xx, YYYY - e.g., "January 1,
2016". Display “DK” or “RF” for missing values.
For “{ORIG INSTITUTION NAME}”, display the name of the health care facility the person
reported when he/she was first institutionalized [Use AF.ProvName for the AF record where
AF.AFType=MPC-HCI (orginal)].
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 13 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF70_01
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1105)
Question
String
BLAISE NAME: HCIName
Field kind: Datafield
Field Size: 40
{Continuous Answer.} Answers allowed: 1
)
Show Card (
ArrayMin:
Min value:
ArrayMax:
Max value:
)
Look Up File (
Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}
{Is the name:/What is the name?}
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}
Responses:
1
RF - Page 14 of 77
RF70_02
(RF1110)
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
Refused and Don’t Know disallowed.
General programming instructions for RF70_01 to RF70_06: If first cycle through LOOP_20
and RF60 is coded ‘1’ (YES), prefill each available address field in the response pane entry
fields with health care institution information from the round the person was first
institutionalized (RE450_01-RE450_06). Use AF.ProvName, AF.StrtAddr1, AF.StrtAddr2,
AF.City, AF.State, and AF.Zip for the AF record where AF.AFType=MPC-HCI (orginal).
General programming instructions for RF70_01 to RF70_06: If first cycle through LOOP_20
and RF60 is coded ‘2’ (YES), ‘RF’ (REFUSED) or ‘DK’ (DON’T KNOW) or if not first cycle
through LOOP_20, leave the response pane entry fields empty for completion. As name,
address, and phone are collected, these values must be added to both the provider fields in
the AF array as well as the provider array so that a ProvID can be created.
General programming instructions for RF70_07: Leave the response pane entry field empty
for completion for all cycles of LOOP_20.
Set Provider.ProvID and AF.ProvID to MaxProvID +1. Set Provider.MPTP to 1 (Facility). Set
Provider.CreateQ to RF70. Set Provider.OrigRnd to current round. Set Provider.OrigRU to
current RU. Set Provider.MPLName and AF.ProvName = RF70_01.
Display
Instructions:
Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” and “Is the name:” if first cycle through LOOP_20
and RF60 is coded ‘1’ (YES). Otherwise, display “Please give me the name, address and
telephone number of the nursing home or long term care institution (that provided 24 hour
skilled nursing care) where {you were/{PERSON} was} living.” and “What is the name?”
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {INSTITUTION NAME} in the info pane in bold, black, but all other address display
fields in lighter “grayed-out” text.
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 15 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF70_02
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1110)
Question
String
BLAISE NAME: HCIStrt
Field kind: Datafield
Field Size: 40
{Continuous Answer.} Answers allowed: 1
)
Show Card (
ArrayMin:
Min value:
ArrayMax:
Max value:
)
Look Up File (
Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}
{Is the street address:/What is the street address?}
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}
Responses:
REFUSED
DON'T KNOW
1
RF70_03
(RF1115)
RF
DK
RF70_03
RF70_03
(RF1115)
(RF1115)
RF - Page 16 of 77
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
See general programming instructions at RF70_01.
Set Provider.MPStrt and AF.StrtAddr1 = RF70_02.
Display
Instructions:
Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” and “Is the street address:” if first cycle through
LOOP_20 and RF60 is coded ‘1’ (YES). Otherwise, display “Please give me the name, address
and telephone number of the nursing home or long term care institution (that provided 24
hour skilled nursing care) where {you were/{PERSON} was} living.” and “What is the street
address?”
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display “VERIFY THE NAME…” or “Please give me…” in brackets and lighter “grayed-out” text
when on RF70_02 through RF70_07.
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {STREET ADDRESS1} in the info pane in bold, black, but all other address display
fields in lighter “grayed-out” text.
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 17 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF70_03
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1115)
Question
String
BLAISE NAME: HCIStrt2
Field kind: Datafield
Field Size: 40
{Continuous Answer.} Answers allowed: 1
)
Show Card (
ArrayMin:
Min value:
ArrayMax:
Max value:
)
Look Up File (
Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}
{VERIFY/ENTER} BUILDING OR ADDITIONAL ADDRESS INFORMATION, AS NECESSARY. IF NONE, PRESS ENTER TO
CONTINUE.
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}
Responses:
EMPTY
REFUSED
DON'T KNOW
1
RF70_04
(RF1120)
Empty
RF
DK
RF70_04
RF70_04
RF70_04
(RF1120)
(RF1120)
(RF1120)
RF - Page 18 of 77
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
See general programming instructions at RF70_01.
Set AF.StrtAddr2 = RF70_03.
(There is no street address 2 in the provider array.)
Display
Instructions:
Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” and “VERIFY:” if first cycle through LOOP_20 and
RF60 is coded ‘1’ (YES). Otherwise, display “Please give me the name, address and
telephone number of the nursing home or long term care institution (that provided 24 hour
skilled nursing care) where {you were/{PERSON} was} living.” and “ENTER”.
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display “VERIFY THE NAME…” or “Please give me…” in brackets and lighter “grayed-out” text
when on RF70_02 through RF70_07.
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {STREET ADDRESS2} in the info pane in bold, black, but all other address display
fields in lighter “grayed-out” text.
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 19 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF70_04
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1120)
Question
String
BLAISE NAME: HCICity
Field kind: Datafield
Field Size: 35
{Continuous Answer.} Answers allowed: 1
)
Show Card (
ArrayMin:
Min value:
ArrayMax:
Max value:
)
Look Up File (
Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}
{Is the city:/What is the city?}
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}
Responses:
REFUSED
DON'T KNOW
1
RF70_05
(RF1125)
RF
DK
RF70_05
RF70_05
(RF1125)
(RF1125)
RF - Page 20 of 77
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
See general programming instructions at RF70_01.
Set Provider. ProvCity and AF.City = RF70_04.
Display
Instructions:
Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” and “Is the city:” if first cycle through LOOP_20
and RF60 is coded ‘1’ (YES). Otherwise, display “Please give me the name, address and
telephone number of the nursing home or long term care institution (that provided 24 hour
skilled nursing care) where {you were/{PERSON} was} living.” and “What is the city?”
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display “VERIFY THE NAME…” or “Please give me…” in brackets and lighter “grayed-out” text
when on RF70_02 through RF70_07.
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {CITY} in the info pane in bold, black, but all other address display fields in lighter
“grayed-out” text.
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 21 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF70_05
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1125)
Question
String
BLAISE NAME: HCIState
Field kind: Datafield
Field Size: 2
{Continuous Answer.} Answers allowed: 1
)
Show Card (
ArrayMin:
Min value:
ArrayMax:
Max value:
)
Look Up File (
Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}}
{Is the state:/What is the state?}
TYPE THE FIRST LETTER OF THE STATE, THEN USE ARROW KEYS IF NEEDED TO LOCATE STATE, AND PRESS ENTER
TO SELECT.
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}
Responses:
REFUSED
DON'T KNOW
1
RF70_06
(RF1130)
RF
DK
RF70_06
RF70_06
(RF1130)
(RF1130)
RF - Page 22 of 77
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
See general programming instructions at RF70_01.
Use the state lookup file.
Set Provider.MPST and AF.State = RF70_05.
Note: The entry Foreign country (FC) is allowed.
Display
Instructions:
Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” and “Is the state:” if first cycle through LOOP_20
and RF60 is coded ‘1’ (YES). Otherwise, display “Please give me the name, address and
telephone number of the nursing home or long term care institution (that provided 24 hour
skilled nursing care) where {you were/{PERSON} was} living.” and “What is the state?”
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display “VERIFY THE NAME…” or “Please give me…” in brackets and lighter “grayed-out” text
when on RF70_02 through RF70_07.
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {STATE} in the info pane in bold, black, but all other address display fields in lighter
“grayed-out” text.
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 23 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF70_06
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1130)
Question
String
BLAISE NAME: HCIZip
Field kind: Datafield
Field Size: 5
{Continuous Answer.} Answers allowed: 1
)
Show Card (
ArrayMin:
Min value:
ArrayMax:
Max value:
)
Look Up File (
Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}
{Is the zip code:/What is the zip code?}
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}
Responses:
REFUSED
DON'T KNOW
1
RF70_07
(RF1135)
RF
DK
RF70_07
RF70_07
(RF1135)
(RF1135)
RF - Page 24 of 77
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
See general programming instructions at RF70_01.
Hard check: Exactly 5 digit numeric entry required. If less than 5 numeric digits entered or
any characters entered that are not numeric, display the following message: "ZIP CODE
ENTRY REQUIRES EXACTLY 5 NUMBERS. PROBE AND RE-ENTER OR ENTER F5 (DON'T KNOW)
IF FULL ZIP CODE IS NOT KNOWN."
Set Provider.ProvZip and AF.Zip = RF70_06.
Display
Instructions:
Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” and “Is the zip code:” if first cycle through LOOP_
20 and RF60 is coded ‘1’ (YES). Otherwise, display “Please give me the name, address and
telephone number of the nursing home or long term care institution (that provided 24 hour
skilled nursing care) where {you were/{PERSON} was} living.” and “What is the zip code?”
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display “VERIFY THE NAME…” or “Please give me…” in brackets and lighter “grayed-out” text
when on RF70_02 through RF70_07.
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {ZIP CODE} in the info pane in bold, black, but all other address display fields in
lighter “grayed-out” text.
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 25 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF70_07
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1135)
Question
String
BLAISE NAME: HCIPhone
Field kind: Datafield
Field Size: 10
{Continuous Answer.} Answers allowed: 1
)
Show Card (
ArrayMin:
Min value:
ArrayMax:
Max value:
)
Look Up File (
Question Text:
{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON}
WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care
institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}
What is the telephone number?
IF NO TELEPHONE, ENTER DON’T KNOW.
{INSTITUTION NAME}
{STREET ADDRESS1}
{STREET ADDRESS2}
{CITY}, {STATE} {ZIP CODE}
{TELEPHONE NUMBER}
Responses:
REFUSED
DON'T KNOW
1
RF80_01
(RF1140)
RF
DK
RF80_01
RF80_01
(RF1140)
(RF1140)
RF - Page 26 of 77
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
See general programming instructions at RF70_01.
10-digit entry required; use number input mask (xxx-xxx-xxxx) in response field.
Hard check: Exactly 10 digit numeric entry required. If less than 10 numeric digits entered
or any characters entered that are not numeric, display the following message: "PHONE
ENTRY REQUIRES EXACTLY 10 NUMBERS. PROBE AND RE-ENTER OR ENTER F5 (DON'T
KNOW) IF FULL PHONE NUMBER IS NOT KNOWN."
Set Provider.ProvPhone and AF.Phone = RF70_07.
Display
Instructions:
Display RF70_01 through RF70_07 vertically on the same form pane.
Display “VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE
FACILITY WHERE {PERSON} WAS LIVING.” if first cycle through LOOP_20 and RF60 is coded
‘1’ (YES). Otherwise, display “Please give me the name, address and telephone number of
the nursing home or long term care institution (that provided 24 hour skilled nursing care)
where {you were/{PERSON} was} living.”
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
Display “VERIFY THE NAME…” or “Please give me…” in brackets and lighter “grayed-out” text
when on RF70_02 through RF70_07.
Display address fields in the info pane with most recent health care institution address
information. Use a null display if response entry fields are empty. As entries are updated in
the current round, the display in the info pane should also be updated.
Display {TELEPHONE NUMBER} in the info pane in bold, black, but all other address display
fields in lighter “grayed-out” text.
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 27 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF80_01
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1140)
Question
Integer
BLAISE NAME: HCIAdmitMM
Field kind: Datafield
Field Size: 2
{Continuous Answer.} Answers allowed: 1
)
Show Card (
ArrayMin:
Min value: 1
ArrayMax:
Max value: 12
)
Look Up File (
Question Text:
{I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME} on {DATE ORIG INSTITUTIONALIZED}. Is
that correct?/What date {were you/was {PERSON}} admitted to {INSTITUTION NAME}?}
{VERIFY/ENTER} MONTH.
Responses:
1
RF - Page 28 of 77
RF80_02
(RF1145)
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
DK AND RF disallowed for month.
If first cycle through LOOP_20 and RF60 is coded ‘1’ (YES), prefill RF80_01 with
AF.OrigInstMM.
Display
Instructions:
Display “I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME} on {DATE ORIG
INSTITUTIONALIZED}. Is that correct?” and “VERIFY” if first cycle through LOOP_20 and RF60
is coded ‘1’ (YES). Otherwise, display “What date {were you/was {PERSON}} admitted to
{INSTITUTION NAME}?” and “ENTER”.
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
For “{DATE ORIG INSTITUTIONALIZED}”, display the date the person was first
institutionalized [(AF.OrigInstMM, DD, YYYY) for the record where AF.AFType=MPC-HCI
(original)]. Display as full month, xx, YYYY - e.g., "January 1, 2016". Display “DK” or “RF” for
missing values.
For “{ORIG INSTITUTION NAME}”, display the name of the health care facility the person
reported when he/she was first institutionalized [Use AF.ProvName for the AF record where
AF.AFType=MPC-HCI (orginal)].
For “{INSTITUTION NAME}”, display the name of the institution verified/entered at RF70_01
during this loop (also AF.ProvName for this record).
Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 29 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF80_02
Item Type:
Type Class:
Answer Type:
(RF1145)
Question
Integer
BLAISE NAME: HCIAdmitDD
Field kind: Datafield
Field Size: 2
{Continuous Answer.} Answers allowed: 1
Help Available (
)
Show Card (
ArrayMin:
Min value: 1
ArrayMax:
Max value: 31
)
Look Up File (
Question Text:
{I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME} on {DATE ORIG INSTITUTIONALIZED}. Is
that correct?/What date {were you/was {PERSON}} admitted to {INSTITUTION NAME}?}
{VERIFY/ENTER} DAY.
Responses:
REFUSED
DON'T KNOW
Programmer
Instructions:
Display
Instructions:
1
RF80_03
(RF1150)
RF
DK
RF80_03
RF80_03
(RF1150)
(RF1150)
If first cycle through LOOP_20 and RF60 is coded ‘1’ (YES), prefill RF80_02 with
AF.OrigInstDD.
See display instructions at RF80_01.
Display the first paragraph in grayed-out text.
Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 30 of 77
)
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF80_03
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1150)
Question
Integer
BLAISE NAME: HCIAdmitYYYY
Field kind: Datafield
Field Size: 4
{Continuous Answer.} Answers allowed: 1
)
Show Card (
ArrayMin:
Min value: 1900
ArrayMax:
Max value: 2100
)
Look Up File (
Question Text:
{I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME} on {DATE ORIG INSTITUTIONALIZED}. Is
that correct?/What date {were you/was {PERSON}} admitted to {INSTITUTION NAME}?}
{VERIFY/ENTER} 4-DIGIT YEAR.
Responses:
1
RF - Page 31 of 77
RF90_01
(RF1155)
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
DK and RF disallowed for year.
If first cycle through LOOP_20 and RF60 is coded ‘1’ (YES), prefill RF80_03 with
AF.OrigInstYYYY.
Hard check: For first cycle through LOOP_20 (cycling to admit date and institution name
entered in prior interview), Month and Year entered at RF80_01 and RF80_03 must be on or
before month and year rejoined community (AF.DtRejoinedMM, YYYY). For second and
subsequent cycles through LOOP_20, Month and Year entered at RF80_01 and RF80_03
must be on or after month and year originally institutionalized (AF.OrigInstMM, YYYY) and
on or before month and year rejoined community (AF.DtRejoinedMM, YYYY). If the month
and year entered fall outside of this range, display the following message: “DATE ADMITTED
TO HEALTH CARE FACILITY MUST BE BETWEEN THE DATE FIRST INSTITUTIONALIZED
({AF.OrigInstMM, DD, YYYY}) AND DATE {REJOINED COMMUNITY/DIED} ({AF.DtRejoinedMM,
DD, YYYY}). VERIFY AND RE-ENTER DATE.” Note: If any part of the dates for the month and
year originally institutionalized (AF.OrigInstMM, YYYY) or the date rejoined community
(AF.DtRejoinedMM, YYYY) are DK, RF, or empty, do not invoke the hard check. Only use
month and year since those fields are required at these three items, whereas day is not.
Display
Instructions:
See display instructions at RF80_01.
Display the first paragraph in grayed-out text.
Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.
In the hard check message, display “REJOINED COMMUNITY” IF [(AF.AFInstStatus=2) for the
record where AF.AFType=MPC-HCI (original)]. Display “DIED” if person died after leaving the
institution [(AF.AFInstStatus=1) for the record where AF.AFType=MPC-HCI (original)].
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 32 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF90_01
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1155)
Question
Integer
BLAISE NAME: HCIDischMM
Field kind: Datafield
Field Size: 2
{Continuous Answer.} Answers allowed: 1
)
Show Card (
ArrayMin:
Min value: 1
ArrayMax:
Max value: 12
)
Look Up File (
)
Question Text:
What date {were you/was {PERSON}} discharged from {INSTITUTION NAME}?
ENTER MONTH.
Responses:
Programmer
Instructions:
Display
Instructions:
1
RF90_02
(RF1160)
DK AND RF disallowed for month.
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
For “{INSTITUTION NAME}”, display the name of the institution verified/entered at RF70_01
during this loop (also AF.ProvName for this record).
Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 33 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF90_02
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1160)
Question
Integer
BLAISE NAME: HCIDischDD
Field kind: Datafield
Field Size: 2
{Continuous Answer.} Answers allowed: 1
)
Show Card (
ArrayMin:
Min value: 1
ArrayMax:
Max value: 31
)
Look Up File (
Question Text:
What date {were you/was {PERSON}} discharged from {INSTITUTION NAME}?
ENTER DAY.
Responses:
1
RF
DK
REFUSED
DON'T KNOW
Display
Instructions:
RF90_03
RF90_03
RF90_03
(RF1165)
(RF1165)
(RF1165)
See display instructions at RF90_01.
Display the first paragraph in grayed-out text.
Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 34 of 77
)
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF90_03
Item Type:
Type Class:
Answer Type:
(RF1165)
Question
Integer
BLAISE NAME: HCIDischYYYY
Field kind: Datafield
Field Size: 4
{Continuous Answer.} Answers allowed: 1
Help Available (
)
Show Card (
ArrayMin:
Min value: 1900
ArrayMax:
Max value: 2100
)
Look Up File (
Question Text:
What date {were you/was {PERSON}} discharged from {INSTITUTION NAME}?
ENTER 4-DIGIT YEAR.
Responses:
1
RF - Page 35 of 77
BOX_80
(RF1170)
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
DK AND RF disallowed for year.
Hard check: Month and Year entered at RF90_01 and RF90_03 must be on or after month
and year originally institutionalized (AF.OrigInstMM, YYYY) and on or before month and
year rejoined community (AF.DtRejoinedMM, YYYY). If the month and year entered fall
outside of this range, display the following message: “DATE DISCHARGED FROM
HEALTH CARE FACILITY MUST BE BETWEEN THE DATE FIRST
INSTITUTIONALIZED ({AF.OrigInstMM, DD, YYYY}) AND DATE {REJOINED
COMMUNITY/DIED} ({AF.DtRejoinedMM, DD, YYYY}). VERIFY AND RE-ENTER
DATE.” Note: If any part of the dates are DK, RF, or empty, do not invoke the hard check.
Only using month and year since those fields are required at these three items, whereas day is
not.
Hard check: Month and Year entered at RF90_01 and RF90_03 must be on or after month
and year admitted (HCIAdmitMM, HCIAdmitYYYY). If the month and year entered fall
outside of this range, display the following message: “DATE DISCHARGED FROM
HEALTH CARE FACILITY MUST BE ON OR AFTER ADMIT DATE (HCIAdmitMM,
DD and YYYY). VERIFY AND RE-ENTER DATE.” Note: If any part of the dates are DK,
RF, or empty, do not invoke the hard check. Only using month and year since those fields are
required at these three items, whereas day is not.
Display
Instructions:
See display instructions at RF90_01.
Display the first paragraph in grayed-out text.
Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.
In the hard check message, display “REJOINED COMMUNITY” IF [(AF.AFInstStatus=2) for the
record where AF.AFType=MPC-HCI (original)]. Display “DIED” if person died after leaving the
institution [(AF.AFInstStatus=1) for the record where AF.AFType=MPC-HCI (original)].
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
RF - Page 36 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Rout
Full Detail Spec
BOX_80
(RF1170)
Route Details:
Item Type: Route
Type Class: If Then
If [(first cycle of LOOP_20) and (RF60 is coded ‘1’ (YES)) and (month and year at RF90_01
and RF90_03=AF.DtRejoinedMM, YYYY)], go to END_LP20 (Loop 20 will cycle only once).
Else, continue with RF100 if there are less than 5 health care institutions already recorded.
Otherwise, go to END_LP20.
RF100
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1175)
Question
Enumerated
TYESNO
)
BLAISE NAME: HCIOth
Field kind: Datafield
ArrayMin:
Min value:
Field Size:
Answers allowed: 1
ArrayMax:
Max value:
Show Card (
)
Look Up File (
Question Text:
Between {DATE ORIG INSTITUTIONALIZED} and {DATE REJOINED COMMUNITY}, did {you/{PERSON}} stay in
another nursing home or other long-term care institution that provided 24 hour skilled nursing care [other than
{INSTITUTION NAME}]?
Responses:
YES
NO
REFUSED
DON'T KNOW
1
2
RF
DK
RF - Page 37 of 77
END_LP20
END_LP20
END_LP20
END_LP20
(RF1180)
(RF1180)
(RF1180)
(RF1180)
)
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Programmer
Instructions:
If coded ‘1’ (YES), create a new record where: AF.AFType=MPC-HCI (additional). Set
AF.OrigRnd and AF.AFYearRev. Set AF.ReqSignDt to RU reference period end date. From the
MPC-HCI (original) record, copy over all the “info about person” variables to the new record.
The next cycle of LOOP_20 will cycle to set the info about provider information for this
newly created record.
Display
Instructions:
For “{DATE ORIG INSTITUTIONALIZED}”, display the date the person was first
institutionalized [(AF.OrigInstMM, DD, YYYY) for the record where AF.AFType=MPC-HCI
(original)]. Display as full month, xx, YYYY - e.g., "January 1, 2016". Display “DK” or “RF” for
missing values.
For “{DATE REJOINED COMMUNITY}”, display the date the person left the health care facility
[(AF.DtRejoinedMM, DD, YYYY) for the record where AF.AFType=MPC-HCI (original)]. (This is
the date collected at RE200/RE220/RE240). Display as full month, xx, YYYY - e.g., "January 1,
2016". Display “DK” or “RF” for missing values.
For “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName,
AF.LName).
For “{INSTITUTION NAME}”, display the name of the institution at RF70_01 verified/entered
during this cycle of LOOP_20 (also AF.ProvName for this record).
Testing/Editing
Notes:
END_LP20
Route Details:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF_LOOP20Block.RF_Loop20[1..100]
(RF1180)
Item Type: Route
Type Class: End Loop
If RF100 is coded ‘1’ (YES), cycle to collect next institution if there are less than 5 health
care institutions already recorded.
Otherwise, end LOOP_20 and continue with END_LP10.
RF - Page 38 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Rout
Full Detail Spec
END_LP10
Route Details:
(RF1182)
Item Type: Route
Type Class: End Loop
Cycle on the next person that meets the condition stated in the loop definition.
If no other person meets the stated condition, end LOOP_10 and continue with RF105_01.
RF - Page 39 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF105_01
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1183)
Question
Enumerated
TAFWHOSIGN
)
BLAISE NAME: AFWhoSign
Field kind: Datafield
ArrayMin:
Min value:
Field Size:
Answers allowed: 1
ArrayMax:
Max value:
Show Card (
)
Look Up File (
)
Question Text:
[I need to confirm some information that will go on the authorization forms. Please let me know if any information needs to be
updated.]
{I am recording that {you/{PERSON}} can provide {your/his/her} own authorization to contact {medical providers} {and}
{pharmacies}.}
{I am recording that {PERSON} needs a proxy signer to provide authorization to contact {medical providers} {and}
{pharmacies}.}
{Because {PERSON} is between the ages of 14 and 17, I am recording that a {parent/guardian} as well as {PERSON} needs
to provide authorization to contact {medical providers} {and} {pharmacies}.}
{Because {PERSON} is under the age of 14, I am recording that a {parent/guardian} needs to provide authorization to contact
{medical providers} {and} {pharmacies}.}
{Authorization forms for children between the ages of 14 and 17 require both the child and a parent or guardian signature.
Should I record that {you/{PERSON}} {are/is} over 18 and can sign for {yourself/himself/herself}, or that {you/he/she}
{need/needs} to sign along with a parent or guardian?}
{Authorization forms for children under the age of 14 require only a parent or guardian signature, while forms for children
between the ages of 14 and 17 require both the child and a parent or guardian signature. Should I record that {PERSON}
needs only a parent or guardian signature, or should they sign along with a parent or guardian?}
{ADULT RU MEMBERS SHOULD BE THE SIGNER (SELF) UNLESS A PROXY IS NEEDED.}
{RU MEMBERS BETWEEN THE AGES OF 14 AND 17, REQUIRE BOTH RU MEMBER AND A PARENT OR
GUARDIAN AS SIGNERS.}
{RU MEMBERS 13 YEARS OR YOUNGER REQUIRE A PARENT OR GUARDIAN AS THE SIGNER.}
{RU MEMBERS 13 YEARS OR YOUNGER REQUIRE A PARENT OR GUARDIAN AS THE SIGNER. RU MEMBERS
RF - Page 40 of 77
MEPSSpring2024
Full Detail Spec
Respondent Forms (RF) Section
(Ques
BETWEEN THE AGES OF 14 AND 17 REQUIRE BOTH TEEN AND A PARENT OR GUARDIAN AS SIGNERS.}
{{PERSON} IS DECEASED. DECEASED RU MEMBERS REQUIRE A PROXY SIGNATURE.}
{IF INCORRECT, MAKE NECESSARY CORRECTIONS. IF CORRECT, PRESS ENTER TO CONTINUE./RECORD
REQUIRED SIGNATURES.}
NAVIGATION: Complete the grid in order of respondent’s answer.
Responses:
SELF
PARENT
GUARDIAN
TEEN AND PARENT
TEEN AND GUARDIAN
PROXY
WITNESS
1
2
3
4
5
6
7
RF - Page 41 of 77
RF105_04
RF105_03
RF105_03
RF105_03
RF105_03
RF105_02
(RF1187)
(RF1185)
(RF1185)
(RF1185)
(RF1185)
(RF1184)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
Preloaded Grid Type 2 including questions : RF105_01, RF105_02, RF105_03, RF105_04,
RF105_05, RF105_06.
RF/DK not allowed for RF105_01, RF105_02, RF105_03, RF105_04, RF105_06.
If RF_Person.eSigAppDone=Yes for an RU member upon backing up to the RF105 grid, that
RU member’s cells for
columns RF105_01, RF105_02, RF105_03, RF105_04 should become protected; no changes
are allowed.
If RU Member’s age is 18 years old or older or in age categories 5-9, and they are not
deceased; prefill RF105_01 answer field with ‘1’ (SELF).
If RU Member is deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a
prior round (RF_Person.AFPersonStatus=5); prefill RF105_01 answer field with ‘6’
(PROXY).
If RU Member’s age is 14-17 inclusive, and they are not deceased in the current round
(Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5), and
they have a parent, step parent, or foster parent in the RU (RE900= 1, 2, 15, 16, 34, or 35);
prefill RF105_01 answer field with ‘4’ (TEEN AND PARENT). Otherwise, if RU Member’s
age is 14-17 inclusive and are not deceased, prefill with ‘5’ (TEEN AND GUARDIAN).
If RU Member’s age is 13 or younger or in age categories 1-2, and they are not deceased in
the current round (Person.CtrlTrackSumm=1) or deceased in a prior round
(RF_Person.AFPersonStatus=5), and they have a parent, step parent, or foster parent in the
RU (RE900= 1, 2, 15, 16, 34, or 35) in the RU; prefill RF105_ 01 answer field with ‘2’
(PARENT). Otherwise, if RU Member’s age is 13 or younger or in age categories 1-2 and are
not deceased, prefill with ‘3’ (GUARDIAN).
If RU Member is in age category 3 or 4, and they are not deceased in the current round
(Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5), do
not prefill RF105_01 answer field.
If coded ‘1’ (SELF), set AFReqSign as ‘1’ (Patient Only).
If coded ‘2’ (PARENT), ‘3’ (GUARDIAN), or ‘6’ (PROXY) set AFReqSign as ‘2’
RF - Page 42 of 77
MEPSSpring2024
Full Detail Spec
Respondent Forms (RF) Section
(Ques
(Proxy/Parent Only).
If coded ‘4’ (TEEN AND PARENT) or ‘5’ (TEEN AND GUARDIAN), set AFReqSign as
‘3’ (Both).
If coded ‘2’ (PARENT) or ‘3’ (GUARDIAN), set AFRsnSecSign as ‘1’ (Patient 13 or
Younger).
If coded ‘4’ (TEEN AND PARENT) or ‘5’ (TEEN AND GUARDIAN), set AFRsnSecSign as
‘2’ (Patient 14-17).
Soft check: If RU Member’s age is 18 years old or older or in age categories 5-9, and they are
not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round
(RF_Person.AFPersonStatus=5), and response is coded ‘2’ (PARENT), ‘3’ (GUARDIAN),
‘4’ (TEEN AND PARENT) or ‘5’ (TEEN AND GUARDIAN) display the error message “If
RU Member is 18 years of age or older, they must sign their own AF unless a proxy is
needed.”
Soft check: If RU Member’s age is between 14 and 17 (inclusive), and they are not deceased
in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round
(RF_Person.AFPersonStatus=5), and response is coded ‘1’ (SELF), ‘2’ (PARENT), ‘3’
(GUARDIAN) or ‘6’ (PROXY) display the error message “ If RU Member is between 14 and
17 years of age, both the patient and a parent or guardian are required to sign.”
Soft check: If RU Member’s age is 13 or younger or in age categories 1-2, and they are not
deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round
(RF_Person.AFPersonStatus=5), and response is coded ‘1’ (SELF), ‘4’ (TEEN AND
PARENT), ‘5’ (TEEN AND GUARDIAN) or ‘6’ (PROXY) display the error message “If RU
Member is 13 years of age or younger, a parent or guardian must sign.”
Soft check: If RU Member is in age category 3, and they are not deceased in the current round
(Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5), and
response is coded ‘1’ (SELF) or ‘6’ (PROXY) display the error message “If RU Member is
13 years of age or younger, a parent or guardian is required to sign. If RU Member is between
14 and 15 years of age, both the patient and a parent or guardian are required to sign.”
Soft check: If RU Member is in age category 4, and they are not deceased in the current round
(Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5), and
response is coded ‘2’ (PARENT) or ‘3’ (GUARDIAN) display the error message “If RU
Member is between 16 and 17 years of age, both the patient and a parent or guardian are
required to sign. If RU Member is 18 years of age or older, they must sign their own AF
RF - Page 43 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
unless a proxy is needed.”
Soft check: If response is coded ‘7’ (WITNESS), display the error message “Please verify
response. Witness signatures are rare and allowed only for adults. Paper authorization forms
will be requested in this situation.”
If coded ‘7’ (WITNESS) continue to next RU member on grid. At grid completion, continue
with BOX_90. NOTE: AFMode and AFMode_AtBox_100 will be set to paper at Box_100.
Note: Age categories are based on values for RF.Person.AgeRng (which is a combination of
Person.AgeRng and Person.AgeGuess). See RE Wall specs for further details.
Display
Instructions:
Roster 1- Report
Roster 1- Report Roster Definition:
This item uses the RF array to display RU-members. (RF_Person.FullName)
Roster Filter
Display only RU members who meet one of the following conditions:
Round 1 and person eligible for MPC authorization form collection for the current round [person has at
least one record where (AF.AFType=MPC) and (AF.RequestRd1=Yes)] OR
Not Round 1 (RndType<>First) and person eligible for MPC or Pharmacy authorization form collection
for the current round [person has at least one record where (AF.AFType=MPC or Pharmacy) and
(AF.AFSuperceded=Empty)]
OR
Not Round 1 (RndType<>First) and person that is part of this RU (MostRecentRU=RUUnit) rejoined
the community this round from previously being institutionalized in a health care setting [person has
record where (AF.AFType=MPC-HCI (original) or HCI(additional)) and (AF.AFInstStatus=1 or 2)]
Display the following columns formatted in the response pane:
Col #1 Header: Who Signs
Instructions: Item RF105_01.
Col #2 Header: Proxy Reason
Instructions: Item RF105_02. Display as an active cell if RF105_01 is coded ‘6’ (PROXY).
RF - Page 44 of 77
MEPSSpring2024
Full Detail Spec
Respondent Forms (RF) Section
(Ques
Col #3 Header: Select Signer
Instructions: Item RF105_03. Display as an active cell if RF105_01 is not coded ‘1’ (SELF) or ‘7’
(WITNESS).
Col #4 Header: Signer Status
Instructions: Item RF105_04. Display as an active cell if RF105_01 is not coded ‘7’ (WITNESS) or
RF105_03 is not coded ‘98’ (SIGNER OUTSIDE THE RU).
Col #5 Header: Other Name
Instructions: Item RF105_05. Display as an active cell if RF105_01 is not coded ‘7’ (WITNESS), or
RF105_04 is not coded ‘3’ (IF VOLUNTEERED: {AT LEAST ONE} SIGNER UNWILLING), OR
RF105_03 is not coded ‘98’ (SIGNER OUTSIDE THE RU).
Col #6 Header: Specify Name
Instructions: Item RF105_06. Display as an active cell if RF105_05 is coded ‘1’ (YES).
Display “I need to confirm some information that will go on the authorization forms. Please let me
know if any information needs to be updated.” in bold black text if it’s the first person in the grid.
Otherwise, always display in brackets and “grayed-out” text.
Display “I am recording that {you/{PERSON} can provide {your/his/her} own authorization to contact
{medical providers} {and} {pharmacies}.” if RU Member’s age is 18 years old or older or in age
categories 5-9, and they are not deceased (in the current round (Person.CtrlTrackSumm=1 or prior
round (RF_Person.AFPersonStatus=5)). Otherwise, use a null display.
Display “I am recording that {PERSON} needs a proxy signer to provide authorization to contact
{medical providers} {and} {pharmacies}.” if RU Member is deceased in the current round
(Person.CtrlTrackSumm=1) or prior round (RF_Person.AFPersonStatus=5). Otherwise, use a null
display.
Display “{Because {PERSON} is between the ages of 14 and 17, I am recording that a
{parent/guardian} as well as {PERSON} needs to provide authorization to contact {medical providers}
{and} {pharmacies}.” if RU Member’s age is 14-17 years old inclusive, and they are not deceased in
the current round (Person.CtrlTrackSumm=1) or deceased in a prior round
(RF_Person.AFPersonStatus=5). Otherwise, use a null display. Display “parent” if they have a parent,
step parent, or foster parent in the RU (RE900= 1, 2, 15, 16, 34, or 35). Otherwise, display “guardian”.
Display “{Because {PERSON} is under the age of 14, I am recording that a {parent/guardian} needs to
provide authorization to contact {medical providers} {and} {pharmacies}.” If RU Member’s age is 13
years old or younger or in age categories 1-2, and they are not deceased in the current round
(Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5). Otherwise,
RF - Page 45 of 77
MEPSSpring2024
Full Detail Spec
Respondent Forms (RF) Section
(Ques
use a null display. Display “parent” if they have a parent, step parent, or foster parent in the RU (RE900
= 1, 2, 15, 16, 34, or 35). Otherwise, display “guardian”.
Display “Authorization forms for children between the ages of 14 and 17 require both the child and a
parent or guardian signature. Should I record that {you/{PERSON}} {are/is} over 18 and can sign for
{yourself/himself/herself} or that {you/he/she} {need/needs} to sign along with a parent or guardian?”
if RU Member is in age category 4, and they are not deceased in the current round
(Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5). Otherwise,
use a null display.
Display “Authorization forms for children under the age of 14 require only a parent or guardian
signature, while forms for children between the ages of 14 and 17 require both the child and a parent or
guardian signature. Should I record that {PERSON} needs only a parent or guardian signature, or
should they sign along with a parent or guardian?” if RU Member is in age category 3, and they are not
deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round
(RF_Person.AFPersonStatus=5). Otherwise, use a null display.
Display “medical providers” if person being looped on has at least one active MPC AF in the current
round [at least one record where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)]] or
[at least one record where [not Round 1 (RndType<>First) and (AF.AFType=MPC) and
(AF.AFSuperceded=Empty)]] or at least one active HCI AF in the current round (AF.AFType=MPCHCI (original) or MPC-HCI (additional)). Otherwise, use a null display.
Display “and” if current round is not the first round of the panel (RndType<>First) and person being
looped on has at least one active MPC or HCI AF, and one active Pharmacy AF in the current round.
Otherwise, use a null display.
Display “pharmacies” if current round is not the first round of the panel (RndType<>First) and person
being looped on has at least one active Pharmacy AF in the current round (AF.AFType=Pharmacy) and
(AF.AFSuperceded=Empty). Otherwise, use a null display.
Display “ADULT RU MEMBERS SHOULD BE THE SIGNER (SELF) UNLESS A PROXY IS
NEEDED.” if RU Member’s age is 18 years old or older or in age categories 5-9 and they are not
deceased in current (Person.CtrlTrackSumm=1) or prior round (RF_Person.AFPersonStatus=5).
Otherwise, use a null display.
Display “RU MEMBERS BETWEEN THE AGES OF 14 AND 17, REQUIRE BOTH RU MEMBER
AND A PARENT OR GUARDIAN AS SIGNERS.” if RU Member’s age is 14-17 years old inclusive
or in age category 4, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or
deceased in a prior round (RF_Person.AFPersonStatus=5). Otherwise, use a null display.
Display “RU MEMBERS 13 YEARS OR YOUNGER REQUIRE A PARENT OR GUARDIAN AS
THE SIGNER.” if RU Member’s age is 13 years old or younger or in age categories 1-2, and they are
not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round
(RF_Person.AFPersonStatus=5). Otherwise, use a null display.
RF - Page 46 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Display “{{PERSON} IS DECEASED. DECEASED RU MEMBERS REQUIRE A PROXY
SIGNATURE.}” if RU member is deceased in the current (Person.CtrlTrackSumm=2) or prior round
(RF_Person.AFPersonStatus=6). Otherwise, use a null display.
Display “RU MEMBERS 13 YEARS OR YOUNGER REQUIRE A PARENT OR GUARDIAN AS
THE SIGNER. RU MEMBERS BETWEEN THE AGES OF 14 AND 17 REQUIRE BOTH TEEN
AND A PARENT OR GUARDIAN AS SIGNERS.” if RU member is in age category 3 and they are not
deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round
(RF_Person.AFPersonStatus=5). Otherwise, use a null display.
Display “{IF INCORRECT, MAKE NECESSARY CORRECTIONS. IF CORRECT, PRESS ENTER
TO CONTINUE./RECORD REQUIRED SIGNATURES.}” if RF105_01 has a prefilled answer in the
answer area. Otherwise, display “RECORD REQUIRED SIGNATURES.”
Use a null display for ‘SELF’, ‘PARENT’, ‘GUARDIAN’, ‘TEEN AND PARENT’, ‘TEEN AND
GUARDIAN’, AND ‘WITNESS’ in the response options if person being asked about is deceased (in
the current round (Person.CtrlTrackSumm=1) or deceased in a prior round
(RF_Person.AFPersonStatus=5). Otherwise, display all response category options.
Display the interviewer instruction 'NAVIGATION: Complete the grid in order of respondent's
answers.' in red text.
RF105_02
Item Type:
(RF1184)
Question
Type Class:
Enumerated
Answer Type:
TAFWHYPROX
Help Available (
BLAISE NAME: AFWhyProx
Field kind: Datafield
ArrayMin:
Min value:
ArrayMax:
Max value:
Field Size:
Answers allowed: 1
)
Show Card (
)
Look Up File (
Question Text:
VERIFY REASON A PROXY IS NEEDED TO SIGN {PERSON}’S AUTHORIZATION FORMS.
NAVIGATION: Complete the grid in order of respondent’s answer.
Responses:
DECEASED
DISABLED
INSTITUTIONALIZED
1
2
3
RF - Page 47 of 77
RF105_03
RF105_03
RF105_03
(RF1185)
(RF1185)
(RF1185)
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
Refused and Don’t Know disallowed.
If person being asked about is deceased in the current round (Person.CtrlTrackSumm= 1) or
deceased in a prior round (RF_Person.AFPersonStatus=5), autocode ‘1’ (DECEASED) for
this person, then go to RF105_03.
If person being asked about is institutionalizing in the current round (Person.CtrlTrackSumm=
2) or institutionalized in a prior round (RF_Person.AFPersonStatus=6), autocode ‘3’
(INSTITUTIONALIZED) for this person, then go to RF105_03.
Otherwise, prefill with option ‘2’ (DISABLED) for FI to verify.
If coded ‘2’ (DISABLED) or ‘3’ (INSTITUTIONALIZED), set AFRsnSecSign as ‘3’ (Patient
Disabled/Institutionalized).
If coded ‘1’ (DECEASED), set AFRsnSecSign as ‘4’ (Patient Deceased).
Display
Instructions:
Display the interviewer instruction 'NAVIGATION: Complete the grid in order of
respondent's answers.' in red text.
RF - Page 48 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF105_03
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1185)
Question
Enumerated
TAFSIGNID
)
BLAISE NAME: AFSignIDRoster
Field kind: Datafield
ArrayMin:
Min value:
Field Size:
Answers allowed: 1
ArrayMax:
Max value:
Show Card (
)
Look Up File (
Question Text:
Who can provide authorization {for/with} {PERSON}?
SELECT {PROXY/PARENT/GUARDIAN} SIGNER.
ENTER ‘98-SIGNER OUTSIDE THE RU’ TO ADD SOMEONE NOT LISTED.
NAVIGATION: Complete the grid in order of respondent’s answer.
Responses:
{FIRST NAME [MIDDLE NAME] LAST
NAME} – {FNAME}’S {RELATION}
{FIRST NAME [MIDDLE NAME] LAST
NAME} – {FNAME}’S {RELATION}
{FIRST NAME [MIDDLE NAME] LAST
NAME} – {FNAME}’S {RELATION}
{FIRST NAME [MIDDLE NAME] LAST
NAME} – {FNAME}’S {RELATION}
{FIRST NAME [MIDDLE NAME] LAST
NAME} – {FNAME}’S {RELATION}
SIGNER OUTSIDE THE RU
1
RF105_04
(RF1187)
2
RF105_04
(RF1187)
3
RF105_04
(RF1187)
4
RF105_04
(RF1187)
5
RF105_04
(RF1187)
98
RF - Page 49 of 77
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
Roster behavior:
1. Single select allowed.
Set AFSignID as the PID for the person selected from the roster at RF105_03. If coded ‘98’
set AFSignID as ‘904’.
Set AFSignRel as the relationship coded at RE900 for the person selected from the roster for
RF105_03.
If coded ‘98’ (SIGNER OUTSIDE THE RU) continue to next RU member on grid. At grid
completion, continue with BOX_90. (NOTE: AFMode and AFMode_AtBox_100 will be set
to paper at Box_100).
If person being asked about died in a prior round (RF_Person.AFPersonStatus=5) or was
institutionalized in a prior round (RF_Person.AFPersonStatus=6) continue to the next RU
member on the grid. At grid completion, continue with BOX_90. (NOTE: AFMode and
AFMode_AtBox_100 will be set to paper at Box_100 ).
Display
Instructions:
Roster 2 – no add/edit/delete Roster Definition:
This item displays RU-members-roster (FULLNAME) for selection. Roster Filter:
Display only RU members who meet the following conditions:
-Person is = or > 18 or in age categories 4-9
-Person is not deceased
-Person is not the patient being looped on
For “FNAME” display the Pers.FName being looped on.
For “RELATION” display the relationship between the RU member listed in the roster to the
person being looped on from RE900. Display RF or DK for relationships coded ‘RF’
(REFUSED) or ‘DK’ (DON’T KNOW). Otherwise, use a null display. For people who died
in a prior round (RF_Person.AFPersonStatus=5) or were institutionalized in a prior round
(RF_Person.AFPersonStatus=6), only display “{FIRST NAME [MIDDLE NAME] LAST
NAME}”.
Display “for” if RF105_01 is coded ‘2’ (PARENT), ‘3’ (GUARDIAN), or ‘6’ (PROXY).
Display “with” if RF105_01 is coded ‘4’ (TEEN AND PARENT) or ‘5’ (TEEN AND
GUARDIAN).
Display “PROXY” if RF105_01 is coded ‘6’ (PROXY).
Display “PARENT” if RF105_01 is coded ‘2’ (PARENT) or ‘4’ (TEEN AND PARENT).
Display “GUARDIAN” if RF105_01 is coded ‘3’ (GUARDIAN) or ‘5’ (TEEN AND
GUARDIAN).
Display the interviewer instruction 'NAVIGATION: Complete the grid in order of
respondent's answers.' in red text.
RF - Page 50 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF105_04
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1187)
Question
Enumerated
TWILLSIGN
)
BLAISE NAME: AFWillSign
Field kind: Datafield
ArrayMin:
Min value:
Field Size:
Answers allowed: 1
ArrayMax:
Max value:
Show Card (
)
Look Up File (
Question Text:
{CODE ‘2’ (SIGNER UNAVAILABLE) UNLESS RESPONDENT VOLUNTEERS THAT A SIGNER IS
UNWILLING TO COMPLETE THE AUTHORIZATION FORM TASK.}
{{Are/Is} {you/{SIGNER 1}} available to sign the {medical} {and} {pharmacy} authorization forms for
{yourself/{himself/herself/{PERSON}}} on my laptop now?}
{{Are both {you/{SIGNER 1}} and {you/{SIGNER 2}} available to sign the {medical} {and} {pharmacy}
authorization forms for {you/{PERSON}} on my laptop now?}
ONLY CODE 1 ‘{BOTH} SIGNER{S} AVAILABLE IN-PERSON’ IF CONDUCTING IN-PERSON
INTERVIEW.
NAVIGATION: Complete the grid in order of respondent’s answer.
Responses:
{BOTH} SIGNER{S} AVAILABLE IN
PERSON (ESIGNATURE)
{AT LEAST ONE} SIGNER
UNAVAILABLE
IF VOLUNTEERED: {AT LEAST ONE}
SIGNER UNWILLING
1
RF105_05
(RF1188)
2
RF105_05
(RF1188)
3
RF - Page 51 of 77
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
If coded ‘3’ (IF VOLUNTEERED: {AT LEAST ONE} SIGNER UNWILLING) continue to
next RU member on grid. At grid completion, continue with BOX_90.
Soft check: If response if coded ‘1’ (SIGNER{S} AVAILABLE IN-PERSON
(ESIGNATURE)) and ST65 <> 1 ‘In-Person’ display the error message: “PLEASE VERIFY
RESPONSE. ONLY CODE 1 ‘{BOTH} SIGNER{S} AVAILABLE IN-PERSON’ IF
CONDUCTING IN-PERSON INTERVIEW.”
Display
Instructions:
Display “CODE ‘2’ (SIGNER UNAVAILABLE) UNLESS RESPONDENT VOLUNTEERS
THAT A SIGNER IS UNWILLING TO COMPLETE THE AUTHORIZATION FORM
TASK.” if ST65 is coded ‘2’ (BY TELEPHONE) or ‘3’ BY VIDEO (CAVI)). Otherwise, use
a null display.
Display “{Are/Is} {you/{SIGNER 1}} available to sign the {medical} {and} {pharmacy}
authorization forms for {yourself/{himself/herself/{PERSON}}} on my laptop now?” if ST65
is coded ‘1’ (IN-PERSON) and RF105_01 is coded ‘1’ (SELF), ‘2’ (PARENT), ‘3’
(GUARDIAN), or ‘6’ (PROXY). Otherwise, use a null display.
Display ‘you’ and ‘yourself’ if person being looped on is the respondent and RF105_01 is
coded ‘1’ (SELF). Display ‘you’ and ‘{PERSON}’ if RF105_01 is coded ‘2’ (PARENT), ‘3’
(GUARDIAN), or ‘6’ (PROXY) and the PID of AFSignID is the respondent.
Display ‘{SIGNER 1}’ and ‘{PERSON}’ if RF105_01 is coded ‘2’ (PARENT), ‘3’
(GUARDIAN), or ‘6’ (PROXY) and the PID of AFSignID is not the respondent. Otherwise,
display ‘{SIGNER 1}’ and ‘himself/herself}’ [RF105_01 is coded ‘1’ (SELF) and person is
not the respondent].
For ‘SIGNER 1’ display the RF_Person.FullName of the person being looped for this row if
RF105_ 01 is coded ‘1’ (SELF). Otherwise, display the RF_Person.FullName of the person
linked to the PID of AFSignID.
Display "Are both {you/{SIGNER 1}} and {you/{SIGNER 2}} available to sign the
{medical} {and} {pharmacy} authorization forms for {you/{PERSON}} on my laptop now?"
if ST65 is coded ‘1’ (IN-PERSON) and RF105_01 is coded ‘4’ (TEEN AND PARENT) or
‘5’ (TEEN AND GUARDIAN). Otherwise, use a null display.
For “{you/{SIGNER 1}}”, display ‘you’ if person for this row is the respondent. Otherwise,
display ‘{SIGNER 1}’. For ‘SIGNER 1’ display the RF_Person.FullName of the RU member.
For “{you/{SIGNER 2}”, display ‘you’ if the PID of AFSignID is the respondent. Otherwise,
display ‘{SIGNER 2}’. For ‘SIGNER 2’, display the RF_Person.FullName linked to the PID
of AFSignID.
For “{you/{PERSON}}”, display ‘you’ if person for this row is the respondent. Otherwise,
display ‘{PERSON}’.
Display “medical” if person being looped on has at least one active MPC AF in the current
round [at least one record where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1
=Yes)]] or [at least one record where [not Round 1 (RndType<>First) and
(AF.AFType=MPC) and (AF.AFSuperceded=Empty)]] or [at least one record where
(AF.AFType=MPC-HCI (original) or HCI (additional)].
Otherwise, use a null display.
Display “and” if current round is not the first round of the panel (RndType<>First) and person
being looped on has at least one active MPC and one active Pharmacy AF in the current
round. Otherwise, use a null display.
RF - Page 52 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Display “pharmacy” if current round is not the first round of the panel (RndType<>First) and
person being looped on has at least one active Pharmacy AF in the current round [at least one
record where (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)]. Otherwise, use a
null display.
Display the interviewer instruction 'NAVIGATION: Complete the grid in order of
respondent's answers.' in red text.
RF105_05
Item Type:
(RF1188)
Question
Type Class:
Enumerated
TYESNO
Answer Type:
Help Available (
)
BLAISE NAME: AFOthNameVerify
Field kind: Datafield
ArrayMin:
Min value:
ArrayMax:
Max value:
Field Size:
Answers allowed: 1
Show Card (
)
Look Up File (
Question Text:
{{Do you/Does {PERSON}} have another name under which records may be filed?/
Previously, we noted that records for {you/{PERSON}} may also be filed under {PL_Person.AFOtherName}. May records
still be filed under this or another name?}
{TO CONFIRM OR UPDATE THIS OTHER NAME, CODE ‘1’.
IF THERE IS NO OTHER NAME, CODE ‘2’.}
NAVIGATION: Complete the grid in order of respondent’s answer.
Responses:
YES
NO
REFUSED
DON'T KNOW
1
2
RF
DK
RF - Page 53 of 77
RF105_06
(RF1189)
)
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Programmer
Instructions:
Display
Instructions:
If coded ‘2’, ‘RF’, or ‘DK’, continue to next RU
member on grid. At grid completion, continue with BOX_90.
Display ‘{Do you/Does {PERSON}} have another name under which records may be filed?’ if RU
member does not have a preloaded AF other name (PL_Person.AFOtherName=Empty). Otherwise,
display ‘Previously, we noted that records for {you/{PERSON}} may also be filed under
{PL_Person.AFOtherName}. May records still be filed under this or another name?’
Display ‘TO CONFIRM OR UPDATE THIS OTHER NAME, CODE ‘1’. IF THERE IS NO OTHER
NAME, CODE ‘2’.’ if RU member has a preloaded AF other name (PL_Person.AFOtherName<>
Empty). Otherwise, use a null display.
Display the interviewer instruction 'NAVIGATION: Complete the grid in order of respondent's
answers.' in red text.
BLAISE NAME: AFOtherName
RF105_06
Item Type:
Type Class:
(RF1189)
Question
String
Answer Type:
{Continuous Answer.} Answers allowed: 1
Help Available (
)
Field kind: Datafield
Field Size: 75
Show Card (
ArrayMin:
Min value:
ArrayMax:
Max value:
)
Look Up File (
Context Header:
Question Text:
{What is {your/{PERSON}’s} other name?/
EDIT OTHER NAME AS NEEDED. IF OTHER NAME IS CORRECT, PRESS ENTER TO CONTINUE WITHOUT
MAKING EDITS.}
NAVIGATION: Complete the grid in order of respondent’s answer.
Responses:
1
RF - Page 54 of 77
)
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Programmer
Instructions:
If RF105_05 was coded ‘1’ (YES) and RU member has a preloaded AF other name
(PL_Person.AFOtherName<>Empty), display the preloaded other name in the RF105_06
response field for editing.
Refused and Don’t Know disallowed.
Continue to next RU member on grid. At grid completion, continue with BOX_90.
Display
Instructions:
BOX_90
Display ‘What is {your/{PERSON}’s} other name?’ if RU member does not have a preloaded AF other
name (PL_Person.AFOtherName=Empty). Otherwise, display ‘IF INCORRECT MAKE NECESSARY
CORRECTIONS. IF CORRECT, PRESS ENTER TO CONTINUE.’
Display the interviewer instruction 'NAVIGATION: Complete the grid in order of respondent's
answers.' in red text.
(RF1190)
Item Type: Route
Type Class: If Then
Route Details:
Continue with BOX_100.
Programmer
Instructions:
Before leaving the grid, CAPI should verify that all eligible fields per row of the grid have a
valid answer entered. If not, display error message “ONE OR MORE QUESTIONS HAVE
NOT BEEN ANSWERED. PRESS TO GO TO THE FIRST UNANSWERED
QUESTION: {Question Tag} FOR {PERSON’S FIRST, MIDDLE AND LAST NAME}”.
CAPI will move to the first unanswered item/field, starting from the top left of the grid and
moving to the next unanswered item, left to right by row, until all are complete.
RF - Page 55 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Rout
Full Detail Spec
BOX_100
Route Details:
(RF1195)
Item Type: Route
Type Class: If Then
Go to RF115
Set AFMode = ‘1’ (ESIGNATURE) for all AFs for the RU member being looped on, if:
⦁ RF105_04 is coded ‘1’ (YES, {BOTH} SIGNER{S} AVAILABLE).
Set AFMode = ‘2’ (DOCUSIGN) for all AFs for the RU member being looped on, if:
⦁ RF105_04 is coded ‘2’ (NO, {AT LEAST ONE} SIGNER UNAVAILABLE) and
RF105_01 is coded ‘1’ (SELF) and contact information is available for the RU
member being looped on (either Person.EmailAddr is not empty or (Person.Cellphone
is not empty and (Person.CMTextCell=1 (YES) or Person.CMTextCell=3
(PENDING))))
⦁ RF105_04 is coded ‘2’ (NO, {AT LEAST ONE} SIGNER UNAVAILABLE) and
RF105_01 is coded ‘2’ (PARENT) or ‘3’ (GUARDIAN) and contact information is
available for the PID stored at AFSignID (either Person.EmailAddr is not empty or
(Person.Cellphone is not empty and (Person.CMTextCell=1 (YES) or
Person.CMTextCell=3 (PENDING))) for the PersID linked to AFSignID)
⦁ RF105_04 is coded ‘2’ (NO, {AT LEAST ONE} SIGNER UNAVAILABLE) and
RF105_01 is coded ‘4’ (TEEN AND PARENT) or ‘5’ (TEEN AND GUARDIAN)
and contact information is available for the PID stored at AFSignID (either
Person.EmailAddr is not empty or (Person.Cellphone is not empty and
(Person.CMTextCell=1 (YES) or Person.CMTextCell=3 (PENDING))) for the PersID
linked to AFSignID)
⦁ RF105_04 is coded ‘2’ (NO, {AT LEAST ONE} SIGNER UNAVAILABLE) and
RF105_01 is coded ‘6’ (Proxy) and contact information is available for the PID stored
at AFSignID (either Person.EmailAddr is not empty or (Person.Cellphone is not empty
and (Person.CMTextCell=1 (YES) or Person.CMTextCell=3 (PENDING))) for the
PersID linked to AFSignID)
Otherwise, set AFMode = ‘3’ (PAPER) for all AFs for the RU member being looped on.
Note: AFMode_AtBox_100 is also set according to the same rules above. AFMode_AtBox_
100 will control the launching of the eSignature app. The values of AFMode_AtBox_100
may or may not be updated by backing up and changing answers at the RF105 grid.
AFMode may be updated in the eSignature app when requesting paper. The values of
AFMode are initialized at RF115 and may or may not be updated by backing up and
changing answers at the RF105 grid.
Note: Please see the Backing up and Ctrl-S in RF document below on Sharepoint for
information on which AF array variables may be impacted by backing up and when those
variables need to be updated by.
https://mepspm.westat.com/FinalDesignDocsbyGroup/Respondent%20Form%20(RF)%
20Section%20Supporting%20Documents/RF%20Reference%20Documents/Backing%
20up%20and%20Ctrl-S%20in%20RF.xlsx
RF - Page 56 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Instr
Full Detail Spec
RF115
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1200)
Instruction
Enumerated
BLAISE NAME: AFModeSum
Field kind: Datafield
TContinue
Answers allowed: 1
)
Show Card (
)
Look Up File (
Question Text:
AF COLLECTION MODE SUMMARY.
RU Member
Signer
{PERSON
FIRST NAME}
{PERSON
FIRST NAME}
{PERSON
FIRST NAME}
{PERSON
FIRST NAME}
{PERSON
FIRST NAME}
{PERSON
FIRST NAME}
{SIGNER 1
/SIGNER 2}
{ SIGNER 1
/SIGNER 2}
{ SIGNER 1
/SIGNER 2}
{ SIGNER 1
/SIGNER 2}
{ SIGNER 1
/SIGNER 2}
{ SIGNER 1
/SIGNER 2}
Collection Mode
Number of AFs
{Text}
XX
{Text}
XX
{Text}
XX
{Text}
XX
{Text}
XX
{Text}
XX
PRESS 1 AND ENTER TO CONTINUE.
Responses:
CONTINUE
1
RF - Page 57 of 77
LOOP_30
(RF1205)
)
MEPSSpring2024
Full Detail Spec
Display
Instructions:
Respondent Forms (RF) Section
(Instr
Roster 1- Report
This item uses the RF array to display RU-members. (RF_Person.FullName)
Column Header #1: RU Member
Display the first name (Pers. FName) of the Person.
Column Header #2: Signer
If AFReqSign=1 or 2, display only {SIGNER 1}. If AFReqSign=3, display both {SIGNER 1}
and {SIGNER 2} separated by a comma.
For ‘SIGNER 1’ display the RF_Person.FullName linked to the PID of the Person if
AFReqSign is coded ‘1’ (Patient only) or ‘3’ (BOTH). Display the RF_Person.FullName
linked to the PID of AFSignID if AFReqSign is coded ‘2’ (Proxy/Parent only) and
AFSignID<>904. Otherwise, display “SIGNER OUTSIDE THE RU” if AFSignID=904.
For ‘SIGNER 2’ display the RF_Person.FullName linked to the PID of AFSignID when
AFReqSign=3 (BOTH) and AFSignID<>904. Otherwise, display “SIGNER OUTSIDE THE
RU” if AFSignID=904.
Column Header #3: Collection Mode
Display the collection mode for AFMode_AtBox_100.
Column Header #4: Number of AFs
Display the total number of all active AFs on the AF array for this person, where (Round 1)
and (AF.AFType=MPC) and (AF.RequestRd1=Yes)] or [(RndType<>First) and
(AF.AFType=MPC or Pharmacy or HCI) and (AFSuperceded=empty). Note this count
should include all outstanding MPC, Pharmacy and HCI AFs.
RF - Page 58 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Rout
Full Detail Spec
LOOP_30
(RF1205)
Route Details:
Item Type: Route
Type Class: Begin Loop
For each person, ask RF125- END_LP30.
Loop definition: Loop collects the status and signatures of all eligible MPC, Pharmacy, and
HCI Authorization Forms. This loop cycles on RU members that meet one of the following
conditions:
⦁ Round 1 and person eligible for MPC authorization form collection for the current round
[person has at least one record where (AF.AFType=MPC) and (AF.RequestRd1
=Yes)]
OR
⦁ Not Round 1 (RndType<>First) and person eligible for MPC or Pharmacy authorization
form collection for the current round [person has at least one record where
(AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]
OR
Not Round 1 (RndType<>First) and person that is part of this RU
(MostRecentRU=RUUnit) rejoined the community this round from previously being
institutionalized in a health care setting [person has record where (AF.AFType=MPC-HCI
(original) or HCI (additional)) and (AF.AFInstStatus=1 or 2)]
RF125
Item Type:
(RF1215)
Question
Type Class:
Enumerated
Answer Type:
TContinue
Help Available (
BLAISE NAME: AFAccess
Field kind: Datafield
ArrayMin:
Min value:
ArrayMax:
Max value:
Field Size:
Answers allowed: 1
)
Show Card (
)
Look Up File (
Question Text:
[In this next section, we will be {collecting electronic signatures}{{and} collecting hardcopy authorization forms} {{and}
discussing how to access Docusign authorization forms}.] {Let’s start with {you/{PERSON}}./Now {let’s collect the
electronic signatures for{your/{PERSON}}’s authorization forms.} /{I have some hardcopy authorization forms for
{you/{PERSON}}.}/ {let’s discuss {your/{PERSON}}’s Docusign authorization forms.}}
CTRL-S: SWITCH TO A DIFFERENT RU MEMBER.
PRESS 1 AND ENTER TO CONTINUE.
Responses:
CONTINUE
1
RF - Page 59 of 77
BOX_110
(RF1217)
)
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Display
Instructions:
Display “In this next section, we will be {collecting electronic signatures}{{and} collecting
hardcopy authorization forms} {{and} discussing how to access Docusign authorization
forms}.” in bold black text if first cycle of LOOP_30. Otherwise, always display in brackets
and “grayed-out” text.
Display “collecting electronic signatures”if there is at least one person in the RU with
AFMode coded as ‘1’ (ESignature).
Display “{and} collecting hardcopy authorization forms” if there is at least one person in the
RU with AFMode coded as ‘3’ (Paper). Display “and” if at least one person in the RU with
AFMode coded as’1’ (ESignature).
Display “{and} discussing how to access Docusign authorization forms” if there is at least one
person in the RU with AFMode coded as ‘2’ (Docusign). Display “and” if there is at least one
person in the RU with AFMode coded as ‘2’ (Docusign) or ‘3’ (Paper).
Display “Let’s start with {you/{PERSON}}.” if first cycle of LOOP_30. Otherwise, display
“Now {let’s collect the electronic signature for{your/{PERSON}}’s authorization forms.}/{I
have some hardcopy authorization forms for {you/{PERSON}}.}/{let’s discuss
{your/{PERSON}}’s Docusign authorization forms.}”
Display “let’s collect the electronic signatures for{your/{PERSON}}’s authorization forms.”
if RU member being looped upon has AFMode coded as ‘1’ (Esignature).
Display “I have some hardcopy authorization forms for {you/{PERSON}}” if RU member
being looped upon has AFMode coded as ‘3’ (Paper).
Display “let’s discuss {your/{PERSON}}’s Docusign authorization forms.” if RU member
being looped upon has AFMode coded as ‘2’ (Docusign).
BOX_110
Route Details:
(RF1217)
Item Type: Route
Type Class: If Then
If at least one AF for the RU member being looped on has AFMode coded as ‘1’
(ESignature), continue with RF135.
Otherwise, go to BOX_120.
RF - Page 60 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF135
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1220)
Question
Enumerated
TContinue
BLAISE NAME: AFSignApp
Field kind: Datafield
ArrayMin:
Min value:
Field Size:
Answers allowed: 1
ArrayMax:
Max value:
)
Show Card (
)
Look Up File (
Question Text:
{ONLY LAUNCH ESIGNATURE APP IF IN-PERSON. BACK-UP AND RE-CODE RF105_04 IF CAVI OR
TELEPHONE INTERVIEW.}
{Now I would like {you/{SIGNER 1}} to sign the {medical} {and} {pharmacy} authorization forms for
{yourself/himself/herself/{PERSON}} on my laptop.}
{Now I would like both {you/{SIGNER 1}} and {you/{SIGNER 2}} to sign the {medical} {and} {pharmacy} authorization
forms for {PERSON} on my laptop.}
CTRL-S: SWITCH TO A DIFFERENT RU MEMBER.
{ONCE ESIGNATURE APP IS LAUNCHED, TURN THE LAPTOP TOWARDS THE SIGNER{S} AND HAND THEM A
STYLUS SO THEY CAN SIGN./THE ESIGNATURE APP FOR {PERSON} HAS ALREADY BEEN COMPLETED AND
CANNOT BE REOPENED.}
PRESS 1 AND ENTER TO {LAUNCH THE ESIGNATURE APP/CONTINUE}.
Responses:
CONTINUE
1
RF - Page 61 of 77
BOX_120
(RF1225)
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
For the ESignature App specs, see Sharepoint:
https://mepspm.westat.com/FinalDesignDocsbyGroup/Respondent%20Form%20(RF)%
20Section%20Supporting%20Documents/Electronic%20Signature%
20Specification/Esignature%20spec_113021_prod_v1_4.docx
The ESignature App should not relaunch if all the AFs for the person being looped upon were
assigned an eSignStatus by the app (RF_Person.eSigAppDone=Yes).
Display
Instructions:
Display “ONLY LAUNCH ESIGNATURE APP IF IN-PERSON. BACK-UP AND RECODE RF105_04 IF CAVI OR TELEPHONE INTERVIEW.” in red text if ST65 is coded
‘2’ (BY TELEPHONE) or ‘3’ BY VIDEO (CAVI)) and RF_Person.eSigAppDone=Empty.
Otherwise, use a null display.
Display “Now I would like {you/{SIGNER 1}} to sign the {medical} {and} {pharmacy}
authorization forms for {yourself/{himself/herself/{PERSON}}} on my laptop.” if
AFReqSign =’1’ (Patient Only) or ‘2’ (Proxy/Parent Only) and
RF_Person.eSigAppDone=Empty. Otherwise, use a null display.
Display ‘you’ and ‘yourself’ if person being looped on is the respondent and RF105_01 is
coded ‘1’ (SELF). Display ‘you’ and ‘{PERSON}’ if RF105_01 is coded ‘2’ (PARENT), ‘3’
(GUARDIAN), or ‘6’ (PROXY) and the PID of AFSignID is the respondent. Display
‘{SIGNER 1}’ and ‘{PERSON}’ if RF105_01 is coded ‘2’ (PARENT), ‘3’ (GUARDIAN),
or ‘6’ (PROXY) and the PID of AFSignID is not the respondent. Otherwise, display
‘{SIGNER 1}’ and ‘himself/herself/{PERSON}}’ [RF105_01 is coded ‘1’ (SELF) and
person is not the respondent].
For ‘SIGNER 1’ display the RF_Person.FullName of the person being looped on if RF105_
01 is coded ‘1’ (SELF). Otherwise, display the RF_Person.FullName of the person linked to
the PID of AFSignID.
Display “Now I would like both {you/{SIGNER 1}} and {you/{SIGNER 2}} to sign the
{medical} {and} {pharmacy} authorization forms for {you/{PERSON}} on my laptop.” if
AFReqSign coded as ‘3’ (Both) and RF_Person.eSigAppDone=Empty. Otherwise, use a null
display.
For “{you/{SIGNER 1}}”, display ‘you’ if person being looped on is the respondent.
Otherwise, display ‘{SIGNER 1}’. For ‘SIGNER 1’ display the RF_Person.FullName of the
RU member.
For “{you/{SIGNER 2}”, display ‘you’ if the PID of AFSignID is the respondent. Otherwise,
display ‘{SIGNER 2}’. For ‘SIGNER 2’, display the RF_Person.FullName linked to the PID
of AFSignID.
For “{you/{PERSON}}”, display ‘you’ if the person being looped on is the respondent.
Otherwise, display ‘{PERSON}’.
Display “medical” if person being looped on has at least one active MPC AF in the current
round [at least one record where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1
=Yes)]] or [at least one record where [not Round 1 (RndType<>First) and
(AF.AFType=MPC) and (AF.AFSuperceded=Empty)]]. Or has at least one active HCI AF in
the current round (AF.AFType=MPC-HCI (original).
Otherwise, use a null display.
RF - Page 62 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Display “and” if current round is not the first round of the panel (RndType<>First) and person
being looped on has at least at least one active MPC or HCI AF and one active Pharmacy AF
in the current round. Otherwise, use a null display.
Display “pharmacy” if current round is not the first round of the panel (RndType<>First) and
person being looped on has at least one active Pharmacy AF in the current round [at least one
record where (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)]. Otherwise, use a
null display.
Display “ONCE ESIGNATURE APP IS LAUNCHED, TURN THE LAPTOP TOWARDS
THE SIGNER{S} AND HAND THEM A STYLUS SO THEY CAN SIGN.” (in the standard
blue interviewer instruction font color) if RF_Person.eSigAppDone=Empty. Otherwise,
display “THE ESIGNATURE APP FOR {PERSON} HAS ALREADY BEEN
COMPLETED AND CANNOT BE REOPENED.” in bold, red text.
Display “LAUNCH THE ESIGNATURE APP” if RF_Person.eSigAppDone=Empty.
Otherwise, display “CONTINUE”.
BOX_120
Route Details:
(RF1225)
Item Type: Route
Type Class: If Then
If at least one AF for the RU member being looped on has AFMode coded as ‘1’
(eSignature) and the eSignStatus for that AF is empty, update the AFMode for those AFs
where (AF.AFMode=1 and AF.eSignStatus=empty) to ‘3’ (Paper).
If at least one AF for the RU member being looped on has AFMode coded as ‘3’ (Paper),
then continue with RF140_01.
Otherwise, go to BOX_130.
Note: AFMode will be updated to '3' (Paper) by the eSignature app if eSignStatus=3
(Paper).
RF - Page 63 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF140_01
Item Type:
Type Class:
Answer Type:
(RF1230)
Question
Enumerated
BLAISE NAME: AFInfo
TAFFORMPREP
Field kind: Datafield
ArrayMin:
Min value:
Field Size:
Answers allowed: 1
ArrayMax:
Max value:
Help Available (AFInfoHelp)
Show Card (
)
Look Up File (
Question Text:
INTERVIEWER: {COMPLETE A NEW AF FOR THIS PAIR./TAKE OUT PREPRINTED AF FOR THIS PAIR. IF NOT
AVAILABLE, FILL OUT A BLANK AF.} {ON TOP LEFT CORNER OF FORM, PRINT “HCI”.}
{AF STATUS FROM PREVIOUS ROUND: {DISPLAY RECEIPT CONTROL STATUS}}
PROVIDER NAME: {Provider/Pharmacy Full Name}
ADDRESS: {Combined Street Address}
{City}, {ST} {Zip Code} {Telephone}
PATIENT: {First,[Middle],Last Name}
DOB: {MM/DD/YYYY} AGE: {XXX} {ACTION: {Status Action}} {OTHER NAMES:{Other Names}}
RU ID: {RUID} REGION: {Reg ID} PROVIDER ID: {ProvID} PID: {PID}
SIGNATURE DATE ON AF MUST BE ON OR AFTER: {MM/DD/YYYY}
{IF NECESSARY, SAY: Since {LINKED PROV NAMES} (is/are) associated with a larger practice, we will ask for
authorization for just {PROVIDER FULL NAME}.}
CTRL-S: SWITCH TO A DIFFERENT RU MEMBER.
PRESS 1 AND ENTER WHEN FORM IS PREPARED.
Responses:
AF FORM PREPARED
1
RF - Page 64 of 77
)
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Programmer
Instructions:
Preloaded grid type 2 – flexible navigation including RF140_01, RF140_02, RF140_03,
RF140_04, RF140_N, as well as RF150_01, RF150_02, RF150_03, RF150_04, RF150_05,
and RF150_06.
At grid completion, continue with BOX_130.
Display
Instructions:
Roster 1 – Report
Col #1 Header: Provider
Instructions: Display the name of the medical, pharmacy, or institution provider for this row.
This column is protected and uneditable. (Use AF.ProvName from the AF array. Variable
may need to be truncated for display in grid.)
Roster Filter:
Display only MPC, Pharmacy, and HCI authorization forms that are active for this person for
this round, records where:
⦁ [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)] or
⦁ [Not Round 1 (RndType<>First) and (AF.AFType=MPC or Pharmacy) and
(AF.AFSuperceded=Empty)]].
or
⦁ Not Round 1 (RndType<>First) and person that is part of this RU
(MostRecentRU=RUUnit) rejoined the community this round from previously being
institutionalized in a health care setting [person has record where (AF.AFType=MPC-HCI
(original) or HCI(additional)) and (AF.AFInstStatus=1 or 2)]
Col #2 Header: Type
Instructions: Display the Authorization form type – either “MPC”,“Pharmacy”, or “MPCHCI”. This column is protected and uneditable. (use AF.AFType)
Col #3 Header: Color
Instructions: Display the color linked to this authorization form. (see BOX_10 rules)
Col #4 Header: Prep
Instructions: RF140_01, RF140_02, RF140_03, RF140_04, RF140_N entry field.
Display “COMPLETE A NEW AF FOR THIS PAIR.” if no preprinted AF exists for this
record (AF.AFPreprinted=Empty). Otherwise display, “TAKE OUT PREPRINTED AF FOR
THIS PAIR. IF NOT AVAILABLE, FILL OUT A BLANK AF.”
Display “ON TOP LEFT CORNER OF FORM, PRINT “HCI”.” if AF.AFType=MPC-HCI
(original) or MPC-HCI (additional).
Display “AF STATUS FROM PREVIOUS ROUND: {DISPLAY RECEIPT CONTROL
STATUS}”
if this AF record was outstanding from the previous round and not replaced by a new personprovider pair record [(AF.AFSuperceded=Empty) and (AF.OrigRnd< > current round) and
(AF.PL_AFRecCtrlStatus<>Empty)]. Otherwise, use a null display.
For “{DISPLAY RECEIPT CONTROL STATUS}”, display the label associated with the
receipt control status. If the receipt control status is “Other, specify”, display the other specify
status text entry field. (Use AF.PL_AFRecCtrlStatus and AF.PL_AFRecCtrlStatusOS)
The labels PROVIDER NAME:, ADDRESS:, PATIENT:, DOB:, AGE:, RU ID:, REGION:,
PROVIDER ID:, PID, AND SIGNATURE DATE…: should be displayed in the traditional
RF - Page 65 of 77
MEPSSpring2024
Full Detail Spec
Respondent Forms (RF) Section
(Ques
blue font and size of interviewer instructions. However, display the contents after that label
(i.e., the provider/pharmacy name, person name, etc.) in bold black. This will make the screen
easier to read.
The label ACTION: should be displayed in the traditional interviewer instruction font size –
but in red. However, display the contents after that label (i.e., status action) in bold black.
For "{Other Names}" display the text string entered at RF105_06 (AF.OtherNames). If this
field is empty, leave the field blank and do not display the label "OTHER NAMES".
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for
this AF record. (Use AF.ProvName with no truncation).
For “{Combined Street Address}” display the street address of the provider or pharmacy for
this AF record. (Concatenate AF.StrtAddr1 and AF.StrtAddr2 into one line separated with a
space)
For “{City}, {ST} {Zip Code} {Telephone}” display the rest of the address of the provider or
pharmacy for this AF record. (Use AF.City, AF.State, AF.Zip and AF.Phone)
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record.
(Use AF.FName, AF.MName, and AF.LName)
For (DOB) “{MM/DD/YYYY}” display the DOB of the RU member for this AF record. (Use
AF.DOBM, AF.DOBD, AF.DOBY). If complete DOB is RF/DK/empty, leave the display
empty. If part of the DOB is RF/DK/empty, display "RF" or "DK" or leave empty as
appropriate for that field.
For “{XXX}” display the age or age range of the RU member for this AF record. (Use
AF.Age. If Age=RF/DK/empty, use AF.AgeCat. If AF.AgeCat= RF/DK/empty, use
AF.AgeGuess.)
Display “ACTION: {Status Action}” if (AF.AFPersonStatus=3, 4, 5, or 6) or if
[(AF.AFPersonStatus=1 or 2) and [(AF.Age <=17) or (AF.AgeCat or AF.AgeGuess=1-4)]].
Otherwise, use a null display.
For “{Status Action}”:
Display “ Child <=13. Need Parent/Guardian Signature” if [(AF.AFPersonStatus=1 or 2)
and [(AF.Age <=13) or (AF.Age is RF/DK/empty and AF.AgeCat or AF.AgeGuess= 1-3)
and AFReqSign=2 (Proxy/Parent only)]]. Otherwise, use a null display.
Display “ Child 14-17. Need Patient and Parent/Guardian Signature” if
[(AF.AFPersonStatus= 1 or 2) and [(AF.Age 14-17) or (AF.Age is RF/DK/empty and
AF.AgeCat or AF.AgeGuess= 3 or 4) and AFReqSign=3 (Both)]]. Otherwise, use a null
display.
Display “Patient Deceased {In Prior Round}. Need Proxy Signature” if
AF.AFPersonStatus=3 or 5. Display “In Prior Round” if AF.AFPersonStatus=5.
Otherwise, use a null display.
Display “Patient {Still} Institutionalized. Need Proxy Signature” if AF.AFPersonStatus=
4 or 6 and AFReqSign=2 (Proxy/Parent only). Display “Still” if AF.AFPersonStatus=6.
Otherwise, use a null display.
For “{RUID}”, display the CaseID.
For “{Reg ID}”, display the region of this CaseID. (May need to get from BFOS?)
For “{ProvID}”, display the provider ID of the provider or pharmacy for this AF record
(ProvID). For “{PID}”, display the AF.PersID of the RU member for this AF record.
RF - Page 66 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
For (SIGNATURE DATE) “{MM/DD/YYYY}”, display the required signature date for this
AF record (Use AF.ReqSignDt).
Display “IF NECESSARY, SAY: Since {LINKED PROV NAMES} (is/are) associated with a
larger practice, we will ask for authorization for just {PROV NAME}.” if there are linked
provider names for this AF record (AF.LinkedAF.ProvNames < > Empty). Otherwise, use a
null display.
For “{LINKED PROV NAMES}” display the text entry associated with this field for this AF
record. This will be a string of provider first and last names. (Use AF.LinkedAF.ProvNames).
For “{PROVIDER FULL NAME}” display the full name of the provider for this AF record.
(Use AF.ProvName).
RF150_01
Item Type:
Type Class:
Answer Type:
(RF1234)
Question
Enumerated
TFORMSTAT2
BLAISE NAME: AFStat
Field kind: Datafield
ArrayMin:
Min value:
Field Size:
Answers allowed: 1
ArrayMax:
Max value:
Help Available (AFStatHelp)
Show Card (
)
Look Up File (
)
Question Text:
PROVIDER NAME: {Provider/Pharmacy Full Name}
PATIENT: {First,[Middle],Last Name}
REQUEST SIGNATURE AND THEN ENTER THE AUTHORIZATION FORM STATUS.
{IF NECESSARY, SAY: Since {LINKED PROV NAMES} (is/are) associated with a larger practice, we will ask for
authorization for just {PROVIDER FULL NAME}.}
HELP: F1
Responses:
SIGNED
LEFT WITH RESPONDENT
MAILED TO RESPONDENT
REFUSED (NO FORM LEFT)
OTHER (NOT SIGNED)
1
2
3
4
91
RF - Page 67 of 77
RF150_03
(RF1236)
RF150_05
RF150_02
(RF1238)
(RF1235)
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Programmer
Instructions:
Preloaded Grid type 2 – flexible navigation, including items RF150_01, RF150_02, RF150_
03, RF150_04, RF150_05, and RF150_06, as well as RF140_01, RF140_02, RF140_03,
RF140_04, RF140_N.
Refused and Don’t Know disallowed.
If RF150_01 is coded ‘2’ (LEFT WITH RESPONDENT) or ‘3’ (MAILED TO
RESPONDENT), return to RF140_01 for next authorization form on grid. At grid
completion, go to BOX_130.
Display
Instructions:
Roster 1 – Report
Col #1 Header: Provider
Instructions: Display the name of the medical, pharmacy, or institution provider for this row. This
column is protectedand uneditable. (use AF.ProvName from the AF array. Variable may need to be
truncated for display in grid.)
Roster Filter:
Display only MPC, Pharmacy, and HCI authorization forms that are active for this person for this
round, records where:
⦁ [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)]
or
⦁ [Not Round 1 (RndType<>First) and (AF.AFType=MPC or Pharmacy) and
(AF.AFSuperceded=Empty)]].
or
⦁ Not Round 1 (RndType<>First) and person that is part of this RU (MostRecentRU=RUUnit)
rejoined the community this round from previously being institutionalized in a health care setting
[person has record where (AF.AFType=MPC-HCI (original) or HCI (additional)) and
(AF.AFInstStatus=1 or 2)]
Col #2 Header: Type
Instructions: Display the Authorization form type – either “MPC”,“Pharmacy”, or “MPC-HCI”. This
column is protected and uneditable. (use AF.AFType)
Col #3 Header: Color
Instructions: Display the color linked to this authorization form. (see BOX_10 rules)
Col #4 Header: Prep
Instructions: Display the entered responses from RF140_01-RF140_N for each authorization form in a
protected, uneditable field.
Col #5 Header: Status
Instructions: Item RF150_01. Always an active cell for every row.
Col #6 Header: Specify Status
Instructions: Item RF150_02. Display as an active cell if RF150_01 is coded ‘91’ (OTHER).
Col #7 Header: AF Number
Instructions: Item RF150_03. Display as an active cell if RF150_01 is coded ‘1’ (SIGNED).
RF - Page 68 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Col #8 Header: Signature Date
Instructions: Item RF150_04. Display as an active cell if RF150_01 is coded ‘1’ (SIGNED).
Col #9 Header: Refusal Reason
Instructions: Item RF150_05. Display as an active cell if RF150_01 is coded ‘4’ (REFUSED).
Col #10 Header: Specify Refusal
Instructions: Item RF150_06. Display as an active cell if RF150_01 is coded ‘91’ (OTHER SPECIFY).
Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for this AF
record as grayed out text. (Use AF.ProvName with no truncation).
BLAISE NAME: AFStatOS
RF150_02
Item Type:
(RF1235)
Question
Type Class:
String
Answer Type:
{Continuous Answer.} Answers allowed: 1
Help Available (
Field kind: Datafield
ArrayMin:
Min value:
ArrayMax:
Max value:
Field Size: 1000
)
Show Card (
)
Look Up File (
Question Text:
PROVIDER NAME: {Provider/Pharmacy Full Name}
PATIENT: {First,[Middle],Last Name}
SPECIFY OTHER AUTHORIZATION FORM STATUS:
Responses:
1
RF - Page 69 of 77
)
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Programmer
Instructions:
Return to RF140_01 for next authorization form on grid.
Refused and Don’t Know disallowed.
Set AF.AFCAPIStatusOS=RF150_02.
Display
Instructions:
Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for this AF
record as grayed out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as grayed out
text. (Use AF.FName, AF.MName, and AF.LName)
Testing/Editing
Notes:
Variable collected at
MEPS(Fall/Spring)YYYY.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
Variable stored at
MEPS(Fall/Spring)YYYY_PersSect.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
BLAISE NAME: AFNum
RF150_03
Item Type:
(RF1236)
Question
Type Class:
String
Field Size: 8
{Continuous Answer.} Answers allowed: 1
Answer Type:
Help Available (
Field kind: Datafield
)
Show Card (
ArrayMin:
Min value:
ArrayMax:
Max value:
)
Look Up File (
Question Text:
PROVIDER NAME: {Provider/Pharmacy Full Name}
PATIENT: {First,[Middle],Last Name}
ENTER AUTHORIZATION FORM NUMBER:
Responses:
1
RF - Page 70 of 77
RF150_04
(RF1237)
)
MEPSSpring2024
Full Detail Spec
Programmer
Instructions:
Respondent Forms (RF) Section
(Ques
Refused and Don’t Know disallowed.
Set AF.AFFormID=RF150_03.
Note: Each authorization form has a pre-assigned authorization form number. This number
is linked to the authorization form type, panel and round.
Hard check: Exactly 8 digit alpha-numeric entry required. If less than 8 characters entered,
display the following message: "AUTHORIZATION FORM NUMBER REQUIRES EXACTLY 8
LETTERS/NUMBERS. VERIFY FORM NUMBER AND FORM TYPE AND RE-ENTER."
Hard Check – MPC/Pharmacy/HCI Authorization Forms: The Authorization form number
entered must follow the conventions noted below for the panel and AF type. If an
authorization form number is entered that does not meet the conventions, display the
following message: “INVALID AUTHORIZATION FORM NUMBER ENTERED. VERIFY FORM
NUMBER AND FORM TYPE AND RE-ENTER.”
MPC AND PHARMACY AUTHORIZATION FORM NUMBER CONVENTIONS
For the MPC and Pharmacy AF numbering conventions, see the MEPS AF Numbering Memo
Folder on Sharepoint:
https://mepspm.westat.com/FinalDesignDocsbyGroup/Forms/AllItems.aspx?RootFolder=%
2FFinalDesignDocsbyGroup%2FRespondent%20Form%20%28RF%29%20Section%
20Supporting%20Documents%2FAF%20Numbering%20Memos&FolderCTID=
0x012000CE0FAA87D31EF94CB16570AFD8729C46&View=%7BB0F5D183%2DE0BB%
2D4DB4%2DB308%2DB130405E7963%7D
Display
Instructions:
Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for
this AF record as grayed out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as
grayed out text. (Use AF.FName, AF.MName, and AF.LName)
Testing/Editing
Notes:
Variable collected at MEPS(Fall/Spring)
YYYY.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
Variable stored at MEPS(Fall/Spring)
YYYY_PersSect.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
RF - Page 71 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF150_04
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1237)
Question
Date
BLAISE NAME: AFDate
Field kind: Datafield
Field Size:
{Continuous Answer.} Answers allowed: 1
)
Show Card (
ArrayMin:
Min value:
ArrayMax:
Max value:
)
Look Up File (
)
Question Text:
PROVIDER NAME: {Provider/Pharmacy Full Name}
PATIENT: {First,[Middle],Last Name}
SIGNATURE DATE ON AF MUST BE ON OR AFTER: {MM/DD/YYYY}
ENTER AUTHORIZATION FORM SIGNATURE DATE:
1
Responses:
Programmer
Instructions:
Return to RF140_01 for next authorization form on grid.
Refused and Don’t Know disallowed.
Hard check: Date entered must be on or after the interview date of the most recent round’s
interview for which the pair is/was eligible for authorization form collection (use
AF.ReqSignDt), but cannot be after ‘Today’s’ Date’ (the current date set on the laptop,
which may be different from RU reference period end date). If date is before correct date,
display the following message: “AUTHORIZATION FORM MUST BE SIGNED ON OR
AFTER ABOVE DATE. VERIFY AND RE-ENTER DATE OR COMPLETE NEW AF.”
Display
Instructions:
Display the date field for the signature date here.
Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for this AF
record as grayed out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as grayed out
text. (Use AF.FName, AF.MName, and AF.LName)
For (SIGNATURE DATE) “{MM/DD/YYYY}”, display the required signature date for this AF record
(Use AF.ReqSignDt). This date should be displayed in bold black.
Testing/Editing
Notes:
Variable collected at
MEPS(Fall/Spring)YYYY.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
Variable stored at
MEPS(Fall/Spring)YYYY_PersSect.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
RF - Page 72 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RF150_05
Item Type:
Type Class:
Answer Type:
Help Available (
(RF1238)
Question
Enumerated
TREFUSAL
BLAISE NAME: AFRfRESN
Field kind: Datafield
ArrayMin:
Min value:
Field Size:
Answers allowed: 1
ArrayMax:
Max value:
)
Show Card (
)
Look Up File (
)
Question Text:
PROVIDER NAME: {Provider/Pharmacy Full Name}
PATIENT: {First,[Middle],Last Name}
SELECT MAIN REASON FOR REFUSAL:
Responses:
Programmer
Instructions:
DOESN'T WANT TO BOTHER PROVIDER
CONFIDENTIALITY/SENSITIVE INFO
PAYMENT PROBLEM WITH PROVIDER
HAS ALREADY GIVEN ENOUGH
INFORMATION
WANTS MORE INFO BEFORE SIGNING
NOT INTERESTED IN STUDY
NO REASON GIVEN
OTHER SPECIFY
1
2
3
4
5
6
7
91
RE150_06
(RF1239)
If coded ‘1’, ‘2’, ‘3’, ‘4’, ‘5’, ‘6’, or ‘7’, go to RF140_01 for next authorization form on grid.
Refused and Don’t Know disallowed
Display
Instructions:
Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for this AF
record as grayed out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as grayed out
text. (Use AF.FName, AF.MName, and AF.LName)
Testing/Editing
Notes:
Variable collected at
MEPS(Fall/Spring)YYYY.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
Variable stored at
MEPS(Fall/Spring)YYYY_PersSect.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
RF - Page 73 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
RE150_06
Item Type:
(RF1239)
Question
String
Type Class:
Answer Type:
BLAISE NAME: AFRfOS
Field kind: Datafield
Field Size: 45
{Continuous Answer.} Answers allowed: 1
Help Available (
)
Show Card (
ArrayMin:
Min value:
ArrayMax:
Max value:
)
Look Up File (
)
Question Text:
PROVIDER NAME: {Provider/Pharmacy Full Name}
PATIENT: {First,[Middle],Last Name}
SPECIFY OTHER REASON FOR REFUSAL:
1
Responses:
Programmer
Instructions:
Display
Instructions:
Return to RF140_01 for next authorization form on grid.
Refused and Don’t Know disallowed.
Display the labels PROVIDER NAME: and PATIENT: as grayed out text.
For “{Provider/Pharmacy Full Name}” display the full name of the provider or pharmacy for this AF
record as grayed out text. (Use AF.ProvName with no truncation).
For “{First,[Middle],Last Name}” display the name of the RU member for this AF record as grayed out
text. (Use AF.FName, AF.MName, and AF.LName)
Testing/Editing
Notes:
Variable collected at
MEPS(Fall/Spring)YYYY.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
Variable stored at
MEPS(Fall/Spring)YYYY_PersSect.RF_Main.RF_Loop10.RF50Table.RF50Grid[1..100]
BOX_130
Route Details:
(RF1241)
Item Type: Route
Type Class: If Then
If at least one AF for the RU member being looped on has AFMode coded as ‘2’
(Docusign), continue with RF160.
Otherwise, go to END_LP30.
RF - Page 74 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Rout
Full Detail Spec
RF160
Item Type:
(RF1248)
Question
Type Class:
Enumerated
Answer Type:
TContinue
Help Available (
BLAISE NAME: AFDocusign
Field kind: Datafield
ArrayMin:
)
Min value:
Field Size:
Answers allowed: 1
Show Card (
ArrayMax:
Max value:
)
Look Up File (
Question Text:
In a few days, {{SIGNER 1}/{SIGNER 2}} will receive {an email} {and} {a text} from MEPS inviting
{you/them} to review and sign some authorization forms for {yourself/{PERSON}} through a secure electronic
signature website called DocuSign.
Please {remind them to} review and sign the authorization forms as soon as possible after {you/they} receive
{your/their} invitation.
PRESS 1 AND ENTER TO CONTINUE.
Responses:
CONTINUE
1
RF - Page 75 of 77
END_LP30
(RF1249)
)
MEPSSpring2024
Respondent Forms (RF) Section
(Ques
Full Detail Spec
Display
Instructions:
Display ‘{SIGNER 1}’ if AFReqSign is coded ‘1’ (Patient Only) substituting ‘you’ for
SIGNER 1 if RF105_01 is coded ‘1’ (SELF) and the person being looped on is the
respondent. Otherwise, display RF_Person.FullName linked to the PID of the person being
looped on.
Display ‘{SIGNER 1}’ if AFReqSign is coded ‘2’ (Proxy/Parent only) substituting ‘you’ if
the PID of AFSignID is the respondent. Otherwise, display the RF_Person.FullName linked to
the PID of AFSignID.
Display ‘{SIGNER 2}’ if AFReqSign is coded ‘3’ (Both) substituting ‘you’ if the PID of
AFSignID is the respondent. Otherwise, display the RF_Person.FullName linked to the PID of
AFSignID.
Display ‘an email’ if an email is available for the PID stored at AFSignID and AFReqSign is
coded ‘2’ (Proxy/Parent) or ‘3’ (Both), or if AFReqSign is coded ‘1’ (Patient Only) and an
email is available for the RU member being looped on (Person.EmailAddr is not empty).
Otherwise, use a null display.
Display ‘and’ if an email and phone with permission to text given or pending is available for
the PID stored at AFSignID and AFReqSign is coded ‘2’ (Proxy/Parent) or ‘3’ (Both), or if
AFReqSign is coded ‘1’ (Patient Only) and an email and phone with permission to text given
or pending is available for the RU member being looped on (Person.EmailAddr is not empty
and (Person.CMTextCell=1 or Person.CMTextCell=3)). Otherwise, use a null display.
Display ‘a text’ if a phone with permission to text given or pending is available for the PID
stored at AFSignID and AFReqSign is coded ‘2’ (Proxy/Parent) or ‘3’ (Both), or if
AFReqSign is coded ‘1’ (Patient Only) and a phone with permission to text given or pending
is available for the RU member being looped on (either Person.CMTextCell=1 or
Person.CMTextCell=3). Otherwise, use a null display.
For “{yourself/{PERSON}}”, display ‘yourself’ if the person being looped on is the
respondent. Otherwise, display ‘{PERSON}’.
Display ‘remind them to’ if AFReqSign is coded ‘1’ (Patient Only) and the person being
looped on is not the respondent or if AFReqSign is coded ‘2’ (Proxy/Parent only) and the PID
of AFSignID is the not respondent Otherwise, use a null display.
END_LP30
Route Details:
(RF1249)
Item Type: Route
Type Class: If Then
Cycle on next person that meets the condition stated in the loop definition.
If no more people meet the stated conditions, end LOOP_30 and continue with BOX_140.
RF - Page 76 of 77
MEPSSpring2024
Respondent Forms (RF) Section
(Rout
Full Detail Spec
BOX_140
Route Details:
(RF1250)
Item Type: Route
Type Class: If Then
Go to next questionnaire section.
[End of RF]
RF - Page 77 of 77
| File Type | application/pdf |
| File Title | rptFullDetail_Item |
| Author | hughes_r |
| File Modified | 2023-06-23 |
| File Created | 2023-06-23 |