CMS-P-0015A Telemedicine Questionnaire

2024 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

TLQ-TELEMEDICINE

Question Text/Description

Code List

Routing

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

(01) TELMEDT1
(02) TELAPPT
(-8) TELAPPT
(-9) TELAPPT

(01) TELEPHONE
(02) VIDEO
(03) BOTH
(-8) DON’T KNOW
(-9) REFUSED

TELAPPT

TELEMEDICINE QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007
SPALIVE=1
SEASON= WINTER
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after USQ.
BOX TLBEG

routing

IF RESPONSE AT US1-PLACEPAR^=1, GO TO TELAPPT.
ELSE, GO TO TELMED
Does [your/(SP)’s] usual provider offer telephone or video appointments, so that [you don’t/(SP) doesn't] need to
physically visit their office or facility?

TELMED

TELMED

code one

[IF NEEDED: Did [your/(SP)’s] provider offer to talk to [you/(SP)] about [your/(SP)] symptoms over the phone or
video so that [you/(SP)] wouldn’t have to visit their office or facility?]
[IF NEEDED: Telephone appointments may include “audio-only” appointments.]

TELMEDT1

TELMEDT1

code one

TELAPPT

TELAPPT

code one

Do they offer telephone appointments, video appointments, or both?
FOR “AUDIO-ONLY” APPOINTMENTS, SELECT “TELEPHONE”.

Since (TODAY'S MONTH AND YEAR-12 MONTHS), [have you/has (SP)] had an appointment with a doctor or
other health professional by telephone or video?
[IF NEEDED: Telephone appointments may include “audio-only” appointments.]

TELAPPT1

TELAPPT1

code one

BOX TLEND

routing

Was it a telephone appointment, video appointment or both?
FOR “AUDIO-ONLY” APPOINTMENTS, SELECT “TELEPHONE”.

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) TELEPHONE
(02) VIDEO
(03) BOTH
(-8) DON’T KNOW
(-9) REFUSED

(01) TELAPPT1
(02) BOX TLEND
(-8) BOX TLEND
(-9) BOX TLEND

BOX TLEND

IF 11TH ROUND INTERVIEW AND (INTTYPE IN C001) AND (MREFDATE) IS AFTER (JANUARY 1 (ROUND
YEAR)) GO TO ACQ.
ELSE GO TO DVH.

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