Closing (CL) Section
Subsection 1: MPC Authorization Forms (Round 1 through Round 5)
BOX_01 ======
----------------------------------------------------
| IF: |
| AT LEAST ONE PERSON-PROVIDER-PAIR ELIGIBLE (SEE |
| SAMPLING BOXES BELOW) FOR AUTHORIZATION FORM |
| COLLECTION FOR THE CURRENT ROUND, |
| OR |
| AT LEAST ONE PERSON-PROVIDER-PAIR ELIGIBLE FOR |
| AUTHORIZATION FORM COLLECTION DURING THE PREVIOUS |
| ROUND AND CL04 WAS CODED '3' (LEFT WITH R), ‘4’ |
| (MAILED TO R), ‘5’ (REFUSED), OR ‘91’ (OTHER) FOR |
| THIS PERSON-PROVIDER-PAIR IN PREVIOUS ROUND, |
| CONTINUE WITH CL01 |
----------------------------------------------------
----------------------------------------------------
| NOTE: RECEIPT CONTROL WILL UPDATE CAPI INTER- |
| ROUND, USING THE CODE STRUCTURE AT CL04. UPDATES |
| CAN BE EITHER POSITIVE OR NEGATIVE. THIS MEANS |
| THAT INTER-ROUND AN AF CAN EITHER GET UPDATED TO A|
| HIGHER STATUS CODE (FROM UNSIGNED TO SIGNED) OR TO|
| A LOWER STATUS CODE (FROM SIGNED TO UNSIGNED -- |
| I.E., IT WAS NOT SIGNED BY THE RIGHT PERSON). SEE|
| MAPPING SPECIFICATIONS FOR EXACT UPDATES TO STATUS|
| CODES. |
----------------------------------------------------
----------------------------------------------------
| NOTE: DUE TO NEW LEGISLATION THAT WENT INTO |
| EFFECT APRIL 2005, A NEW AUTHORIZATION FORM IS |
| USED TO MAKE IT HIPAA COMPLIANT. |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_02 |
----------------------------------------------------
----------------------------------------------------
| SAMPLING BOX (FOR ROUND 1): |
| PERSON-PROVIDER-PAIRS ELIGIBLE FOR MPC |
| AUTHORIZATION FORM COLLECTION: |
| |
| NOTE: PERSON IS A KEY, ELIGIBLE RU MEMBER (AT |
| TIME OF EVENT). |
| |
| ROUND 1: PERSON-PROVIDER-PAIRS ELIGIBLE FOR |
| AUTHORIZATION FORM COLLECTION ARE THOSE |
| ASSOCIATED WITH A HOSPITAL-BASED EVENT (HS, ER, |
| AND OP EVENTS) AND PROVIDERS ASSOCIATED WITH |
| HOSPITAL-BASED EVENTS AND FLAGGED AS SEPARATELY-|
| BILLING DOCTORS (SBD) AND CARE WAS PROVIDED TO |
| PERSON DURING THE CURRENT REFERENCE PERIOD. |
| |
| ONE AUTHORIZATION FORM IS CREATED FOR EACH |
| PERSON-PROVIDER-PAIR IN WHICH THE PROVIDER IS |
| ASSOCIATED WITH AN HS, ER, OR OP EVENT DURING |
| THE EVENT ROSTER OR EVENT DRIVER SECTION. |
----------------------------------------------------
----------------------------------------------------
| SAMPLING BOX (FOR ROUNDS 2-5): |
| |
| PERSON-PROVIDER-PAIRS ELIGIBLE FOR MPC |
| AUTHORIZATION FORM COLLECTION: |
| |
| NOTE: PERSON IS A KEY, ELIGIBLE RU MEMBER (AT |
| TIME OF EVENT). |
| |
| ROUNDS 2-5: PERSON-PROVIDER-PAIRS ELIGIBLE FOR |
| AUTHORIZATION FORM COLLECTION ARE THOSE |
| ASSOCIATED WITH A HOSPITAL-BASED EVENT (HS, ER, |
| AND OP EVENTS) AND CARE WAS PROVIDED TO PERSON |
| DURING THE CURRENT REFERENCE PERIOD. |
| |
| ADDITIONAL PAIRS ELIGIBLE FOR AUTHORIZATION FORM|
| COLLECTION ARE THOSE ASSOCIATED WITH A HOME |
| HEALTH EVENT (HH EVENT), WHERE THE PROVIDER IS |
| FLAGGED AS AN ‘AGENCY’, AND CARE WAS PROVIDED |
| TO PERSON DURING THE ROUND 1, ROUND 2, ROUND 3, |
| ROUND 4, OR ROUND 5 REFERENCE PERIODS. |
| |
| OTHER PAIRS ELIGIBLE FOR AUTHORIZATION FORM |
| COLLECTION ARE THOSE ASSOCIATED WITH A MEDICAL |
| PROVIDER VISIT EVENT (MV EVENT) WHERE CARE WAS |
| PROVIDED TO PERSON DURING THE ROUND 1, ROUND 2, |
| ROUND 3, ROUND 4, OR ROUND 5 REFERENCE |
| PERIODS, WHERE THE RU IS SELECTED FOR THE MPC |
| SAMPLE, AS DEFINED BELOW, AND EITHER: |
| - A MEDICAL DOCTOR WAS SEEN DURING THE VISIT |
| (MV03 = 1) |
| - MEDICAL DOCTORS WORK AT THE SAME LOCATION AS |
| THE PROVIDER SEEN (MV06 = 1) |
| |
| FINAL PAIRS ELIGIBLE FOR AUTHORIZATION FORM |
| COLLECTION ARE THOSE ASSOCIATED WITH AN |
| INSTITUTIONAL CARE EVENT (IC EVENTS), WHERE CARE|
| WAS PROVIDED TO PERSON DURING THE ROUND 1, ROUND|
| 2, ROUND 3, ROUND 4 OR ROUND 5 REFERENCE |
| PERIODS. |
----------------------------------------------------
----------------------------------------------------
| SAMPLING BOX (FOR ROUNDS 2-5) CONT’D: |
| |
| WHEN DETERMINING IF THE MV EVENTS FOR AN RU |
| REQUIRE AUTHORIZATION FORMS, AN RU IS SELECTED |
| FOR THE MPC SAMPLE AT THE TIME OF THE ROUND 1 |
| INTERVIEW USING THE FOLLOWING RATES: |
| - 100% OF RUs WITH AT LEAST ONE RU MEMBER |
| COVERED BY MEDICAID OR GOV’T HOSPITAL |
| (PHYSICIAN) AT ANY TIME DURING THE REFERENCE |
| PERIOD |
| - 100% OF THE REMAINING RUs (THAT IS, RUs WITH |
| NO RU MEMBER COVERED BY MEDICAID OR GOV’T- |
| HOSPITAL/PHYSICIAN AT ANY TIME DURING THE |
| REFERENCE PERIOD) WITH AT LEAST ONE RU MEMBER |
| WITH HMO COVERAGE AT ANY TIME DURING THE |
| REFERENCE PERIOD. HMO COVERAGE IS DEFINED AS:|
| IF AT LEAST ONE PRIVATE INSURANCE PLAN IN RU|
| MEETS THE FOLLOWING CONDITIONS: |
| - FLAGGED AS ‘PROVIDING HOSPITAL/PHYSICIAN |
| BENEFITS’ (EXCLUDE INSURERS WHERE |
| HOSPITAL/PHYSICIAN BENEFITS ARE PROVIDED |
| SOLELY THROUGH MEDIGAP) |
| - ESTABLISHMENT OR INSURER IS FLAGGED AS |
| ‘HMO’ |
| OR |
| INSURER IS AN HMO (MC01 IS CODED ‘1’ |
| (YES) |
| OR |
| INSURER REQUIRES PERSONS TO SIGN UP WITH |
| PRIMARY PHYSICIAN (MC02 IS CODED ‘1’ (YES)|
| - 100% OF THE REMAINING RUs (THAT IS, RUs WITH |
| NO RU MEMBER COVERED BY MEDICAID OR GOV’T- |
| HOSPITAL/PHYSICIAN AND HMO COVERAGE AT ANY |
| TIME DURING THE REFERENCE PERIOD). |
----------------------------------------------------
----------------------------------------------------
| NOTE: IF THE SAME PROVIDER IS ASSOCIATED MORE |
| THAN ONCE FOR A PARTICULAR PERSON, ONLY ONE |
| AUTHORIZATION FORM IS CREATED FOR THAT PAIR. IF |
| THE SAME PROVIDER IS ASSOCIATED WITH MORE THAN ONE|
| PERSON, AN AUTHORIZATION FORM IS CREATED FOR EACH |
| UNIQUE PERSON-PROVIDER-PAIR. |
----------------------------------------------------
----------------------------------------------------
| NOTE: IF THE PERSON-PROVIDER-PAIR IS OUTSTANDING |
| FROM A PREVIOUS ROUND AND THERE IS A NEW ELIGIBLE |
| EVENT FOR THIS PAIR IN THE CURRENT ROUND, THE PAIR|
| WILL NOT BE TREATED AS IF IT IS OUTSTANDING. THAT|
| IS, THE DISPLAYS FOR PREVIOUS ROUND STATUS WILL |
| NOT BE SHOWN, ETC. |
----------------------------------------------------
CL01 ====
{[As I mentioned during the last interview], it/It} is
important for us to get accurate names and addresses for
medical providers so that we can contact them for more
information about the services they provide. To do this,
we must have written authorization from the family members
receiving these services. I would like to get authorization
from the following people:
TO SCROLL, USE ARROW KEYS. TO LEAVE SCREEN, PRESS ESC.
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[HAND RESPONDENT THE AUTHORIZATION FORM BOOKLET.]
[These materials explain more about why we contact medical
providers and answer questions people sometimes ask about this
part of the study. Please take a minute to review this
information while I prepare the forms.]
----------------------------------------------------
| ROSTER DEFINITION: DISPLAY EACH PERSON ON THE |
| RU-PERSON-PROVIDER-PAIRS-ROSTER WHO MEETS THE |
| FOLLOWING CONDITION(S): |
| |
| - PERSON IS ELIGIBLE FOR MPC AUTHORIZATION FORM |
| COLLECTION FOR THE CURRENT ROUND (SEE BOX_01 |
| SAMPLING SPECIFICATIONS) |
| OR |
| - PERSON WAS ASSOCIATED WITH A PERSON-PROVIDER- |
| PAIR ELIGIBLE FOR AUTHORIZATION FORM COLLECTION |
| IN PREVIOUS ROUND, AND |
| - CL04 WAS CODED '3' (LEFT WITH R), ‘4’ (MAILED |
| TO R), ‘5’ (REFUSED), OR ‘91’ (OTHER) FOR THIS |
| PERSON-PROVIDER-PAIR IN PREVIOUS ROUND |
----------------------------------------------------
----------------------------------------------------
| NOTE: DISPLAY EACH UNIQUE ELIGIBLE PERSON NAME |
| ONLY ONCE. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘[As I mentioned during the last |
| interview], it’ IF NOT ROUND 1 AND AT LEAST ONE |
| PERSON-PROVIDER-PAIR WAS ELIGIBLE FOR MPC |
| AUTHORIZATION FORM COLLECTION DURING THE PREVIOUS |
| ROUND. OTHERWISE, DISPLAY ‘It’. |
----------------------------------------------------
CL02
====
OMITTED.
LOOP_01 =======
----------------------------------------------------
| FOR EACH ELEMENT ON THE RU-PERSON-PROVIDER-PAIRS- |
| ROSTER, ASK CL03 - END_LP01 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_01 PRESENTS EACH UNIQUE |
| PERSON-PROVIDER-PAIR ELIGIBLE FOR AUTHORIZATION |
| FORM COLLECTION (THIS INCLUDES NEW AND OUTSTANDING|
| FORMS) FOR THE INTERVIEWER TO COMPLETE THE |
| AUTHORIZATION FORM. THIS LOOP CYCLES ON RU- |
| PERSON-PROVIDER-PAIRS WITH AN EVENT-PROVIDER- |
| PAIR THAT MEET THE FOLLOWING CONDITION(S): |
| - PAIR IS ELIGIBLE FOR AUTHORIZATION FORM |
| COLLECTION FOR THE CURRENT ROUND (SEE BOX_01 |
| SAMPLING SPECIFICATIONS) |
| OR |
| - PAIR WAS ELIGIBLE FOR AUTHORIZATION FORM |
| COLLECTION IN PREVIOUS ROUND, AND |
| - CL04 WAS CODED '3' (LEFT WITH R), ‘4’ (MAILED |
| TO R), ‘5’ (REFUSED), OR ‘91’ (OTHER) FOR THIS |
| PAIR IN THE PREVIOUS ROUND |
----------------------------------------------------
----------------------------------------------------
| NOTE: LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON- |
| PROVIDER-PAIR. |
----------------------------------------------------
CL03 ====
INTERVIEWER: {COMPLETE AUTHORIZATION FORM/LOCATE APPROPRIATE
PREPRINTED MPC AUTHORIZATION FORM (COMPLETE NEW ONE IF FORM
CANNOT BE LOCATED)} FOR THE FOLLOWING PERSON-PROVIDER-PAIR:
PID: [PID-3] PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PROVIDER ID: [ProvID-4]
PROVIDER NAME: [Provider Full Name-65]
PROVIDER ADDRESS: [Street Address from Provider Directory]
[City Name], [ST] [Zip Code] [Telephone]
{AF STATUS FROM PREVIOUS ROUND: {DISPLAY PREVIOUS ROUND STATUS - 40}}
SIGNATURE DATE ON MPC AF MUST BE ON OR AFTER: {MM/DD/YYYY}
{IF A MPC AF FOR THIS PAIR HAS ALREADY BEEN SIGNED ON OR AFTER THE
ABOVE DATE, DO NOT CREATE A NEW MPC AF.}
PRESS ENTER TO CONTINUE.
PRESS F1 FOR MORE INFORMATION ON MPC AUTHORIZATION FORMS.
----------------------------------------------------
| DISPLAY ‘COMPLETE AUTHORIZATION FORM ...’ IF |
| PAIR CREATED AND ELIGIBLE DURING CURRENT ROUND. |
| OTHERWISE, DISPLAY ‘LOCATE ... LOCATED)’. |
| |
| DISPLAY ‘AF STATUS ... -40}’ IF CURRENT PERSON- |
| PROVIDER-PAIR IS OUTSTANDING FROM THE PREVIOUS |
| ROUND AND NO ELIGIBLE EVENT WAS CREATED FOR THIS |
| PAIR IN THE CURRENT ROUND. |
| |
| FOR ‘DISPLAY PREVIOUS...-40’, DISPLAY THE CATEGORY|
| ENTRY ASSOCIATED WITH THE PREVIOUS ROUND (OR |
| RECEIPT CONTROL UPDATED) CL04 OUTSTANDING STATUS. |
| THAT IS, IF CL04 WAS CODED ‘3’, DISPLAY ‘LEFT WITH|
| R’; IF CL04 WAS CODED ‘4’, DISPLAY ‘MAILED TO R’; |
| IF CL04 WAS CODED ‘5’, DISPLAY ‘REFUSED’; AND IF |
| CL04 WAS CODED ‘91’, DISPLAY THE FIRST 40 |
| CHARACTERS FROM THE OTHER SPECIFY ENTRY FIELD (OR |
| THE RECEIPT CONTROL UPDATE TEXT GENERATED FOR THE |
| ‘91’ CODE). |
| |
| DISPLAY THE INTERVIEW DATE OF THE MOST RECENT |
| ROUND’S INTERVIEW FOR WHICH PAIR IS/WAS ELIGIBLE |
| FOR AUTHORIZATION FORM COLLECTION FOR |
| ‘MM/DD/YYYY’. |
| |
| DISPLAY ‘IF MPC AF FOR ... NEW MPC AF.’ IF CURRENT|
| PERSON-PROVIDER-PAIR WAS ELIGIBLE FOR MPC IN |
| PREVIOUS ROUND AND FORM WAS NOT SIGNED IN THE |
| PREVIOUS ROUND. |
----------------------------------------------------
END_LP01 ========
----------------------------------------------------
| CYCLE ON NEXT PAIR ON THE RU-PERSON-PROVIDER- |
| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |
| THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END |
| LOOP_01 AND CONTINUE WITH LOOP_02 |
----------------------------------------------------
LOOP_02 =======
----------------------------------------------------
| FOR EACH ELEMENT ON THE RU-PERSON-PROVIDER-PAIRS- |
| ROSTER, ASK CL04 - END_LP02 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_02 COLLECTS THE STATUS OF |
| PERSON-PROVIDER AUTHORIZATION FORMS ELIGIBLE FOR |
| AUTHORIZATION FORM COLLECTION (THIS INCLUDES NEW |
| AND OUTSTANDING FORMS). THIS LOOP CYCLES ON |
| RU-PERSON-PROVIDER-PAIRS WITH AN EVENT-PROVIDER- |
| PAIR THAT MEET THE FOLLOWING CONDITION(S): |
| - PAIR IS ELIGIBLE FOR AUTHORIZATION FORM |
| COLLECTION FOR THE CURRENT ROUND (SEE BOX_01 |
| SAMPLING SPECIFICATIONS) |
| OR |
| - PAIR WAS ELIGIBLE FOR AUTHORIZATION FORM |
| COLLECTION IN PREVIOUS ROUND, AND |
| - CL04 WAS CODED '3' (LEFT WITH R), ‘4’ (MAILED TO|
| R), ‘5’ (REFUSED), OR ‘91’ (OTHER) FOR THIS PAIR|
| IN THE PREVIOUS ROUND |
----------------------------------------------------
----------------------------------------------------
| NOTE: LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON- |
| PROVIDER-PAIR. |
----------------------------------------------------
CL04 ====
INTERVIEWER: ASK APPROPRIATE PERSON(S) TO SIGN AUTHORIZATION FORM.
IF NOT AVAILABLE TO SIGN, LEAVE AF AND BOOKLET WITH RESPONDENT.
RECORD STATUS BELOW AND UPDATE AF LOG IF AF UNSIGNED OR PRE-PRINTED.
PID: [PID-3] PERSON: [First, [Middle], Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PROVIDER ID: [ProvID-4]
PROVIDER NAME: [Provider Full Name-65]
PROVIDER ADDRESS: [Street Address from Provider Directory]
[City Name], [ST] [Zip Code] [Telephone]
SIGNATURE DATE ON MPC AF MUST BE ON OR AFTER: {MM/DD/YYYY}
ENTER THE AUTHORIZATION FORM STATUS:
SIGNED, NO PROBLEM ..................... 1 {CL05}
SIGNED WITH PROBLEM .................... 2
LEFT WITH R ............................ 3 {END_LP02}
MAILED TO R ............................ 4 {END_LP02}
REFUSED ................................ 5 {CL06}
OTHER ................................. 91 {CL04OV2}
PRESS F1 FOR MORE INFORMATION ON MPC AUTHORIZATION FORMS.
[Code One]
----------------------------------------------------
| DISPLAY THE RU END REFERENCE DATE OF THE MOST |
| RECENT ROUND FOR WHICH PAIR IS/WAS ELIGIBLE |
| FOR AUTHORIZATION FORM COLLECTION FOR |
| ‘MM/DD/YYYY’. |
----------------------------------------------------
----------------------------------------------------
| EDIT: CODE ‘4’ (MAILED TO R) MUST BE ENTERED |
| TWICE IF RU IS NOT A STUDENT RU. IF CODE ‘4’ |
| SELECTED AND RU IS NOT A STUDENT RU, DISPLAY THE |
| FOLLOWING MESSAGE: ‘UNLIKELY RESPONSE. VERIFY |
| AND RE-ENTER.’ |
----------------------------------------------------
CL04OV1 =======
ENTER PROBLEM:
[Enter Problem-45] ..................... {CL05}
CL04OV2 =======
ENTER OTHER:
[Enter Other Specify-45] ............... {END_LP02}
CL05 ====
PID: [PID-3] PERSON: [First, [Middle], Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PROVIDER ID: [ProvID-4]
PROVIDER NAME: [Provider Full Name-65]
PROVIDER ADDRESS: [Street Address from Provider Directory]
[City Name], [ST] [Zip Code] [Telephone]
SIGNATURE DATE ON MPC AF MUST BE ON OR AFTER: {MM/DD/YYYY}
ENTER MPC AUTHORIZATION FORM NUMBER:
{NOTE: IF 2 FORMS COLLECTED FOR THE SAME PAIR, ENTER MPC AF NUMBER
FROM THE FORM WITH THE MOST RECENT SIGNATURE DATE. HOWEVER, COLLECT
ALL SIGNED AF(S) AND MAKE A NOTE OF EXTRA AF(S) IN COMMENT AREA OF
THE AF LOG.}
[Enter Number-8] .......................
----------------------------------------------------
| DISPLAY THE RU END REFERENCE DATE OF THE MOST |
| RECENT ROUND FOR WHICH PAIR IS/WAS ELIGIBLE |
| FOR AUTHORIZATION FORM COLLECTION FOR |
| ‘MM/DD/YYYY’. |
| |
| DISPLAY ‘NOTE: ... LOG.’ IF CURRENT PERSON- |
| PROVIDER-PAIR ELIGIBLE FOR MPC IN PREVIOUS ROUND |
| AND FORM WAS NOT SIGNED IN THE PREVIOUS ROUND. |
| OTHERWISE, USE A NULL DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| NOTE: EACH AUTHORIZATION FORM HAS A PRE-ASSIGNED |
| AUTHORIZATION FORM NUMBER. |
----------------------------------------------------
----------------------------------------------------
| EDIT: NUMBER ENTERED MUST BE 8 CHARACTERS LONG |
| AND MUST BEGIN AND END WITH AN ALPHA CHARACTER. |
| THE FIRST ALPHA MUST BE A-M, T, OR Y. THE FIRST |
| NUMERIC DIGIT (SECOND CHARACTER OF ENTRY) MUST |
| BE 0, 1, 2, 3, 4, OR 9. THE LAST ALPHA MUST BE |
| S, T, U, V, OR W. |
----------------------------------------------------
CL05OV ======
ENTER MPC AUTHORIZATION FORM SIGNATURE DATE:
[Enter Month, Day, Year-4] .................. {END_LP02}
----------------------------------------------------
| EDIT: 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. IF DATE IS BEFORE |
| CORRECT DATE, DISPLAY THE FOLLOWING MESSAGE: |
| ‘MPC AF MUST BE SIGNED ON OR AFTER ABOVE DATE. |
| VERIFY AND RE-ENTER DATE OR COMPLETE NEW AF.’ |
----------------------------------------------------
----------------------------------------------------
| NOTE: INTERVIEWERS WILL BE INSTRUCTED TO COLLECT |
| SIGNED MPC AUTHORIZATION FORMS WITH DATES EARLIER |
| THAN THE ONE DISPLAYED, BUT WILL NOT ENTER THE |
| NUMBER IN CAPI SINCE THE CURRENT STATUS FOR THE |
| AUTHORIZATION FORM WITH THE CORRECT DATE MAY BE |
| SOMETHING ELSE. THE CAPI STATUS OF THE MPC |
| AUTHORIZATION FORM SHOULD REFLECT THE FORM WITH |
| THE MOST RECENT DATE. |
----------------------------------------------------
CL06 ====
PID: [PID-3] PERSON: [First, [Middle], Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PROVIDER ID: [ProvID-4]
PROVIDER NAME: [Provider Full Name-65]
PROVIDER ADDRESS: [Street Address from Provider Directory]
[City Name], [ST] [Zip Code] [Telephone]
ENTER MAIN REASON FOR REFUSAL:
DOESN’T WANT TO BOTHER PROVIDER ........ 1 {END_LP02}
CONFIDENTIALITY/SENSITIVE INFORMATION .. 2 {END_LP02}
PAYMENT PROBLEM WITH PROVIDER .......... 3 {END_LP02}
HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP02}
WANTS MORE INFORMATION BEFORE SIGNING .. 5 {END_LP02}
NOT INTERESTED IN STUDY ................ 6 {END_LP02}
NO REASON GIVEN ........................ 7 {END_LP02}
OTHER ................................. 91
[Code One]
CL06OV
======
ENTER OTHER REASON FOR REFUSAL:
[Enter Other Specify-45] ...............
END_LP02 ========
----------------------------------------------------
| CYCLE ON NEXT PAIR ON THE RU-PERSON-PROVIDER- |
| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |
| THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END |
| LOOP_02 AND CONTINUE WITH BOX_02 |
----------------------------------------------------
BOX_02 ======
----------------------------------------------------
| IF NOT ROUND 1 AND ANY KEY RU MEMBER HAD A |
| STATUS OF INSTITUTIONALIZED (IN A HEALTH CARE |
| INSTITUTION) AT THE PREVIOUS ROUND’S INTERVIEW |
| DATE, BUT HAS A DIFFERENT STATUS AS OF THE |
| CURRENT ROUND’S INTERVIEW DATE, CONTINUE WITH |
| LOOP_02A |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_03 |
----------------------------------------------------
LOOP_02A ========
----------------------------------------------------
| FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK |
| CL06A - END_LP02A |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_02A INSTRUCTS THE |
| INTERVIEWER TO COLLECT THE HEALTH CARE INSTITUTION|
| HISTORY AND THE APPROPRIATE NUMBER OF MEDICAL |
| PROVIDER AUTHORIZATION FORMS FOR ALL RU MEMBERS |
| WHO HAS A STATUS OF INSTITUTIONALIZED (IN A HEALTH|
| CARE INSTITUTION) AT THE PREVIOUS ROUND’S |
| INTERVIEW DATE, BUT WHO REJOINED THE COMMUNITY |
| (OR CHANGED STATUS) DURING THE CURRENT ROUND. |
| THIS LOOP CYCLES ON RU MEMBERS WHO MEET THE |
| FOLLOWING CONDITIONS: |
| - PERSON IS AN RU MEMBER |
| - PERSON IS KEY |
| - PERSON DOES NOT HAVE A STATUS OF |
| INSTITUTIONALIZED AS OF THE CURRENT ROUND’S |
| INTERVIEW DATE |
| - PERSON HAD A STATUS OF INSTITUTIONALIZED ON THE |
| PREVIOUS ROUND’S INTERVIEW DATE |
----------------------------------------------------
CL06A =====
PID: [PID-3] PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
DATE ORIGINALLY INSTITUTIONALIZED: [MM/DD/YYYY]
DATE REJOINED COMMUNITY/CHANGED STATUS: [MM/DD/YYYY]
SIGNATURE DATE ON MPC AF MUST BE ON OR AFTER: {MM/DD/YYYY}
INTERVIEWER: THE PERSON NAMED ABOVE WAS INSTITUTIONALIZED IN A
PREVIOUS ROUND AND HAS NOW REJOINED THE COMMUNITY OR CHANGED
STATUS. COMPLETE THE FOLLOWING STEPS:
1. FILL OUT HEALTH CARE INSTITUTION HISTORY.
2. COMPLETE A MPC AF FOR EACH DIFFERENT HEALTH CARE INSTITUTION
LISTED ON HEALTH CARE INSTITUTION HISTORY. WRITE ‘IC’ IN UPPER
LEFT CORNER OF MPC AF. REFER TO SECTION 3 OF HISTORY FOR
INSTRUCTIONS ON COMPLETING THESE AF(S).
3. FOR EACH MPC AF CREATED THIS WAY, RECORD PERSON AND PROVIDER
INFORMATION IN THE AF LOG.
4. REQUEST SIGNATURE(S) ON AF(S).
5. LEAVE UNSIGNED AF(S) AND THE AF BOOKLET WITH RESPONDENT.
6. RECORD AF STATUS FOR EACH MPC AF ON THE AF LOG. CAPI WILL
NOT COLLECT THIS INFORMATION.
PRESS ENTER TO CONTINUE.
END_LP02A =========
----------------------------------------------------
| CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER WHO |
| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|
----------------------------------------------------
----------------------------------------------------
| IF NO OTHER PERSONS MEET THE STATED CONDITIONS, |
| END LOOP_02A AND CONTINUE WITH BOX_03 |
----------------------------------------------------
Subsection 2: HIPS Authorization Forms (In Panel 10, sampling will be done
but Authorizations Forms will not be collected.)
BOX_03 ======
----------------------------------------------------
| SAMPLING BOX FOR ROUNDS 2 AND 3: (TO BASE ON |
| ROUND 1 CRITERIA FOR COLLECTION OF AFs IN ROUND 2 |
| AND ROUND 3): |
| RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS |
| AUTHORIZATION FORM COLLECTION: |
| |
| - ALL PAIRS WHERE THE PERSON IS THE POLICYHOLDER |
| OF THIS INSURANCE ON THE DATE OF THE ROUND 1 |
| INTERVIEW AND THE ESTABLISHMENT IS A PRIVATE |
| SOURCE OF INSURANCE (DEFINED LATER) HELD ON THE |
| DATE OF THE ROUND 1 INTERVIEW (DEFINED LATER) |
| WITH FOUR EXCEPTIONS: |
| 1. ESTABLISHMENT IS FLAGGED AS ‘EMPLOYER’ AND |
| EMPLOYER IS THE FEDERAL GOVERNMENT (EM96=2 |
| OR HP13=1) |
| 2. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF- |
| EMPLOYED’ WITH ONE EMPLOYEE (EM91=1) AND ONE|
| LOCATION (EM93=2) |
| 3. PERSON IS THE POLICYHOLDER OF THIS INSURANCE|
| AND IS FLAGGED AS ‘POLICYHOLDER NOT LISTED |
| IN RU’ |
| 4. ESTABLISHMENT ONLY PROVIDES LONG TERM CARE |
| IN A NURSING HOME, EXTRA CASH FOR HOSPITAL |
| STAYS, SERIOUS DISEASE OR DREAD DISEASE, |
| DISABILITY, WORKER’S COMPENSATION, OR |
| ACCIDENT INSURANCE (HX48 IS CODED ONLY |
| COMBINATIONS OF CODES ‘6’, ‘7’, ‘8’, ‘9’, |
| ‘10’, AND ‘11’). |
----------------------------------------------------
----------------------------------------------------
| SAMPLING BOX FOR ROUNDS 2 AND 3: (TO BASE ON |
| ROUND 1 CRITERIA FOR COLLECTION OF AFs IN ROUND 2 |
| AND ROUND 3): |
| RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS |
| AUTHORIZATION FORM COLLECTION: |
| |
| - ALL PAIRS WHERE THE ESTABLISHMENT IS FLAGGED AS |
| ‘EMPLOYER’ AND THE JOB SUBTYPE OF THAT EMPLOYER |
| IS FLAGGED AS ‘CURRENT MAIN’ AND THE JOB IS NOT |
| FLAGGED AS ‘PROVIDES HEALTH INSURANCE’ (PERSON |
| IS THE JOBHOLDER OF THIS CURRENT MAIN JOB ON THE|
| DATE OF THE ROUND 1 INTERVIEW) AS OF THE ROUND 1|
| INTERVIEW DATE WITH THREE EXCEPTIONS: |
| 1. ESTABLISHMENT IS THE FEDERAL GOVERNMENT |
| (EM96 = 2) |
| 2. ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’ |
| WITH A FIRM-SIZE=1 |
| 3. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF- |
| EMPLOYED’ WITH ONE EMPLOYEE (EM91=1) AND ONE|
| LOCATION (EM93=2) |
----------------------------------------------------
----------------------------------------------------
| NOTE: PRIVATE INSURANCE IS DEFINED AS: |
| - ESTABLISHMENTS FLAGGED AS ‘EMPLOYER’ AND |
| FLAGGED AS ‘PROVIDES HEALTH INSURANCE’ |
| (ESTABLISHMENTS FLAGGED AS ‘SELF-EMPLOYED’ WITH |
| A FIRM-SIZE-1 ARE TREATED AS DIRECT PURCHASED, |
| SEE NOTE BELOW) |
| - DIRECT PURCHASED INSURANCE, THAT IS, |
| ESTABLISHMENTS CREATED FROM THE HX23 SERIES |
----------------------------------------------------
----------------------------------------------------
| NOTE: HELD ON THE DATE OF THE ROUND 1 INTERVIEW: |
| - FOR PRIVATE SOURCES -- POLICYHOLDER HELD |
| INSURANCE AT THE TIME OF THE ROUND 1 INTERVIEW |
| DATE (HQ01 IS CODED ‘1’ (WHOLE TIME) OR HQ02 IS |
| CODED ‘1’ (YES, COVERED NOW) FOR THE |
| POLICYHOLDER) |
| - FOR PRIVATE SOURCES WHERE POLICYHOLDER IS |
| DECEASED -- AT LEAST ONE DEPENDENT (SELECTED AT |
| HP16) IS COVERED BY THE INSURANCE AT THE TIME OF|
| THE ROUND 1 INTERVIEW DATE (HQ01 IS CODED ‘1’ |
| (WHOLE TIME) OR HQ02 IS CODED ‘1’ (YES, COVERED |
| NOW) FOR THE COVERED PERSON) |
----------------------------------------------------
----------------------------------------------------
| NOTE: ESTABLISHMENTS THAT ARE EMPLOYERS AND |
| PROVIDE HEALTH INSURANCE AND ARE FLAGGED AS ‘SELF-|
| EMPLOYED’ WITH A FIRM-SIZE=1 ARE TREATED AS DIRECT|
| PURCHASED INSURANCE, THAT IS, HIPS WILL CONTACT |
| THE ESTABLISHMENT PROVIDING THE INSURANCE, (I.E., |
| CREATED FROM THE HX03 SERIES) NOT THE EMPLOYER. |
----------------------------------------------------
----------------------------------------------------
| NOTE: FOR ESTABLISHMENTS WHICH ARE CURRENT MAIN |
| EMPLOYERS (ON THE ROUND 1 INTERVIEW DATE) AND |
| PROVIDE HEALTH INSURANCE, WHERE THE HEALTH |
| INSURANCE IS ONLY FROM A UNION (EM117=2), A HIPS |
| AUTHORIZATION FORM IS REQUIRED FOR BOTH THE |
| EMPLOYER AND THE UNION. IN THESE CASES, BOTH |
| ESTABLISHMENT-PERSON-PAIRS ARE ELIGIBLE FOR HIPS |
| AUTHORIZATION FORM COLLECTION. |
----------------------------------------------------
----------------------------------------------------
| NOTE: IF A CURRENT MAIN JOB IS FLAGGED AS |
| ‘PREVIOUS HEALTH INSURANCE’ BUT THAT INSURANCE IS |
| ONLY LONG TERM CARE IN A NURSING HOME, EXTRA CASH |
| FOR HOSPITAL STAYS, SERIOUS DISEASE OR DREAD |
| DISEASE, DISABILITY, WORKER’S COMPENSATION, AND/OR|
| ACCIDENT INSURANCE, THE JOB IS PROCESSED AS IF IT |
| DOES NOT PROVIDE HEALTH INSURANCE BUT IS ELIGIBLE |
| FOR HEALTH INSURANCE PROVIDER AUTHORIZATION FORM |
| COLLECTION (AS LONG AS OTHER REQUIREMENTS ARE |
| MET). |
----------------------------------------------------
----------------------------------------------------
| NOTE: ‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW) |
| RESPONSES AT ANY QUESTION LISTED ABOVE DOES NOT |
| MEET THE CRITERIA. |
----------------------------------------------------
----------------------------------------------------
| NOTE: IN ROUND 4, A NEW HIPS FLAG WILL BE SET AND|
| NEW HIPS AUTHORIZATION FORMS WILL BE COLLECTED FOR|
| ALL ESTABLISHMENT-PERSON-PAIRS BASED ON THE SAME |
| SAMPLING CRITERIA AND NOTES AS ABOVE, BUT USING |
| ROUND 3 DATA INSTEAD OF ROUND 1 DATA, AS DESCRIBED|
| IN THE FOLLOWING BOXES. |
----------------------------------------------------
----------------------------------------------------
| SAMPLING BOX FOR ROUNDS 4 AND 5 (TO BASE ON |
| ROUND 3 CRITERIA, FOR COLLECTION OF AFs IN |
| ROUNDS 4 AND 5): |
| RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS |
| AUTHORIZATION FORM COLLECTION: |
| |
| - ALL PAIRS WHERE THE PERSON IS THE POLICYHOLDER |
| OF THIS INSURANCE ON THE DATE OF THE ROUND 3 |
| INTERVIEW AND THE ESTABLISHMENT IS A PRIVATE |
| SOURCE OF INSURANCE (DEFINED LATER) HELD ON THE |
| DATE OF THE ROUND 3 INTERVIEW (DEFINED LATER) |
| WITH FOUR EXCEPTIONS: |
| 1. ESTABLISHMENT IS FLAGGED AS ‘EMPLOYER’ AND |
| EMPLOYER IS THE FEDERAL GOVERNMENT (EM96=2 |
| OR HP13=1) |
| 2. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF- |
| EMPLOYED’ WITH ONE EMPLOYEE (EM91=1) AND ONE|
| LOCATION (EM93=2) |
| 3. PERSON IS THE POLICYHOLDER OF THIS INSURANCE|
| AND IS FLAGGED AS ‘POLICYHOLDER NOT LISTED |
| IN DU’ |
| 4. ESTABLISHMENT ONLY PROVIDES LONG TERM CARE |
| IN A NURSING HOME, EXTRA CASH FOR HOSPITAL |
| STAYS, SERIOUS DISEASE OR DREAD DISEASE, |
| DISABILITY, WORKER’S COMPENSATION, OR |
| ACCIDENT INSURANCE (HX48, OE10, OE24, OR |
| OE37 IS CODED ONLY COMBINATIONS OF CODES |
| ‘6’, ‘7’, ‘8’, ‘9’, ‘10’, AND ‘11’). |
----------------------------------------------------
----------------------------------------------------
| SAMPLING BOX FOR ROUNDS 4 AND 5 (TO BASE ON |
| ROUND 3 CRITERIA, FOR COLLECTION OF AFs IN |
| ROUNDS 4 AND 5): |
| RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS |
| AUTHORIZATION FORM COLLECTION: |
| |
| - ALL PAIRS WHERE THE ESTABLISHMENT IS FLAGGED AS |
| ‘EMPLOYER’ AND THE JOB SUBTYPE OF THAT EMPLOYER |
| IS FLAGGED AS ‘CURRENT MAIN’ AND THE JOB IS NOT |
| FLAGGED AS ‘PROVIDES HEALTH INSURANCE’ (PERSON |
| IS THE JOBHOLDER OF THIS CURRENT MAIN JOB ON THE|
| DATE OF THE ROUND 3 INTERVIEW) AS OF THE ROUND 3|
| INTERVIEW DATE WITH THREE EXCEPTIONS: |
| 1. ESTABLISHMENT IS THE FEDERAL GOVERNMENT |
| (EM96 = 2) |
| 2. ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’ |
| WITH A FIRM-SIZE=1 |
| 3. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF- |
| EMPLOYED’ WITH ONE EMPLOYEE (EM91=1) AND ONE|
| LOCATION (EM93=2) |
----------------------------------------------------
----------------------------------------------------
| NOTE: PRIVATE INSURANCE IS DEFINED AS: |
| - ESTABLISHMENTS FLAGGED AS ‘EMPLOYER’ AND |
| FLAGGED AS ‘PROVIDES HEALTH INSURANCE’ |
| (ESTABLISHMENTS FLAGGED AS ‘SELF-EMPLOYED’ WITH |
| A FIRM-SIZE-1 ARE TREATED AS DIRECT PURCHASED, |
| SEE NOTE BELOW) |
| - DIRECT PURCHASED INSURANCE, THAT IS, |
| ESTABLISHMENTS CREATED FROM THE HX23 SERIES |
----------------------------------------------------
----------------------------------------------------
| NOTE: HELD ON THE DATE OF THE ROUND 3 INTERVIEW: |
| - FOR PRIVATE SOURCES -- POLICYHOLDER HELD |
| INSURANCE AT THE TIME OF THE ROUND 3 INTERVIEW |
| DATE [(HQ01 IS CODED ‘1’ (WHOLE TIME) OR HQ02 IS|
| CODED ‘1’ (YES, COVERED NOW) FOR THE |
| POLICYHOLDER) OR (OE01, OE12, OE26 IS CODED ‘1’ |
| (YES) FOR THE POLICYHOLDER) |
| - FOR PRIVATE SOURCES WHERE POLICYHOLDER IS |
| DECEASED -- AT LEAST ONE DEPENDENT [(SELECTED AT|
| HP16 OR OE45) OR (CONFIRMED AS STILL COVERED AT |
| OE29 OR OE30)] IS COVERED BY THE INSURANCE AT |
| THE TIME OF THE ROUND 3 INTERVIEW DATE [(HQ01 |
| IS CODED ‘1’ (WHOLE TIME) OR HQ02 IS CODED ‘1’ |
| (YES, COVERED NOW) FOR THE COVERED PERSON) OR |
| (OE26 IS CODED ‘1’ (YES) FOR THE COVERED |
| PERSON)] |
----------------------------------------------------
----------------------------------------------------
| NOTE: ESTABLISHMENTS WHICH ARE EMPLOYERS AND |
| PROVIDE HEALTH INSURANCE AND ARE FLAGGED AS |
| ‘SELF-EMPLOYED’ WITH A FIRM-SIZE=1 ARE TREATED AS |
| DIRECT PURCHASED INSURANCE, THAT IS, HIPS WILL |
| CONTACT THE ESTABLISHMENT PROVIDING THE INSURANCE,|
| (I.E., CREATED FROM THE HX03 SERIES) NOT THE |
| EMPLOYER. |
----------------------------------------------------
----------------------------------------------------
| NOTE: FOR ESTABLISHMENTS WHICH ARE CURRENT MAIN |
| EMPLOYERS (ON THE ROUND 3 INTERVIEW DATE) AND |
| PROVIDE HEALTH INSURANCE, WHERE THE HEALTH |
| INSURANCE IS ONLY FROM A UNION (EM117=2), A HIPS |
| AUTHORIZATION FORM IS REQUIRED FOR BOTH THE |
| EMPLOYER AND THE UNION. IN THESE CASES, BOTH |
| ESTABLISHMENT-PERSON-PAIRS ARE ELIGIBLE FOR HIPS |
| AUTHORIZATION FORM COLLECTION. |
----------------------------------------------------
----------------------------------------------------
| NOTE: IF A CURRENT MAIN JOB IS FLAGGED AS |
| ‘PREVIOUS HEALTH INSURANCE’ BUT THAT INSURANCE IS |
| ONLY LONG TERM CARE IN A NURSING HOME, EXTRA CASH |
| FOR HOSPITAL STAYS, SERIOUS DISEASE OR DREAD |
| DISEASE, DISABILITY, WORKER’S COMPENSATION, AND/OR|
| ACCIDENT INSURANCE, THE JOB IS PROCESSED AS IF IT |
| DOES NOT PROVIDE HEALTH INSURANCE BUT IS ELIGIBLE |
| FOR HEALTH INSURANCE PROVIDER AUTHORIZATION FORM |
| COLLECTION (AS LONG AS OTHER REQUIREMENTS ARE |
| MET). |
----------------------------------------------------
----------------------------------------------------
| NOTE: ‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW) |
| RESPONSES AT ANY QUESTION LISTED ABOVE DOES NOT |
| MEET THE CRITERIA. |
----------------------------------------------------
----------------------------------------------------
| GO TO BOX_05 |
----------------------------------------------------
BOX_04A
=======
OMITTED.
BOX_04
======
OMITTED.
CL07
====
OMITTED.
LOOP_03
=======
OMITTED.
CL08
====
OMITTED.
CL09
====
OMITTED.
CL09OV1
=======
OMITTED.
CL09OV2
=======
OMITTED.
CL10
====
OMITTED.
CL11
====
OMITTED.
CL11OV
======
OMITTED.
END_LP03
========
OMITTED.
Subsection 3: HIPS Policy Booklets (Not collected in Panel 10)
BOX_05 ======
----------------------------------------------------
| GO TO BOX_10 |
----------------------------------------------------
BOX_06
======
OMITTED.
CL12
====
OMITTED.
CL13
====
OMITTED.
CL14
====
OMITTED.
LOOP_04
=======
OMITTED.
CL15
====
OMITTED.
CL15OV
======
OMITTED.
CL16
====
OMITTED.
CL17
====
OMITTED.
CL17OV
======
OMITTED.
END_LP04
========
OMITTED.
BOX_07
======
OMITTED.
CL18
====
OMITTED.
CL18OV
======
OMITTED.
CL19
====
OMITTED.
CL20
====
OMITTED.
CL20OV
======
OMITTED.
BOX_08
======
OMITTED.
LOOP_04A
========
OMITTED.
CL21
====
OMITTED.
END_LP04A
=========
OMITTED.
BOX_09
======
OMITTED.
CL22
====
OMITTED.
Subsection 4: Pharmacy Requests and Authorization Forms (Round 3 and Round 5)
BOX_10 ======
----------------------------------------------------
| AS A PHARMACY WAS ENTERED OR SELECTED DURING THE |
| PRESCRIBED MEDICINES SECTION, THE PERSON-PHARMACY-|
| PAIR WAS FLAGGED WITH THE CURRENT ROUND (I.E., THE|
| MOST RECENT ROUND IT WAS ENTERED/SELECTED). THIS |
| ROUND FLAG IS USED TO DETERMINE WHETHER THE |
| PHARMACY IS ELIGIBLE FOR PHARMACY AUTHORIZATION |
| FORM COLLECTION FOR THIS RU MEMBER. |
----------------------------------------------------
----------------------------------------------------
| IF ROUND 3 OR ROUND 5, CONTINUE WITH BOX_11 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_14 |
----------------------------------------------------
BOX_11 ======
----------------------------------------------------
| IF AT LEAST ONE PERSON-PHARMACY-PAIR ELIGIBLE |
| (SEE SAMPLING BOX BELOW) FOR PHARMACY |
| AUTHORIZATION FORM COLLECTION, CONTINUE |
| WITH CL29 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_14 |
----------------------------------------------------
----------------------------------------------------
| SAMPLING BOX (FOR ROUND 3): |
| PERSON-PHARMACY-PAIRS ELIGIBLE FOR PHARMACY |
| AUTHORIZATION FORM COLLECTION IN ROUND 3: |
| |
| - PERSON IS A KEY, ELIGIBLE RU MEMBER |
| - PERSON ASSOCIATED WITH THE PHARMACY |
| - PHARMACY COLLECTED DURING ROUND 1, 2, OR 3 |
| |
| NOTE: FORMS ASSOCIATED WITH DECEASED AND |
| INSTITUTIONALIZED PERSONS IN ROUNDS 1 AND 2 |
| WILL BE REQUESTED. |
----------------------------------------------------
----------------------------------------------------
| SAMPLING BOX (FOR ROUND 5): |
| PERSON-PHARMACY-PAIRS ELIGIBLE FOR PHARMACY |
| AUTHORIZATION FORM COLLECTION IN ROUND 5: |
| |
| - PERSON IS A KEY, ELIGIBLE RU MEMBER |
| - PERSON ASSOCIATED WITH THE PHARMACY |
| - PHARMACY COLLECTED OR USED DURING ROUND 3, 4, |
| OR 5 |
| |
| NOTE: FORMS ASSOCIATED WITH DECEASED AND |
| INSTITUTIONALIZED PERSONS IN ROUNDS 3 AND 4 |
| WILL BE REQUESTED. |
----------------------------------------------------
----------------------------------------------------
| NOTE: IF THE SAME PHARMACY IS ASSOCIATED MORE |
| THAN ONCE FOR A PARTICULAR PERSON, ONLY ONE |
| AUTHORIZATION FORM IS ASKED ABOUT FOR THAT PAIR. |
| IF THE SAME PHARMACY IS ASSOCIATED WITH MORE THAN |
| ONE PERSON, A AUTHORIZATION FORM IS ASKED FOR |
| EACH UNIQUE PERSON-PHARMACY-PAIR. |
----------------------------------------------------
CL23
====
OMITTED.
CL24
====
OMITTED.
LOOP_05
=======
OMITTED.
CL25
====
OMITTED.
END_LP05
========
OMITTED.
CL26
====
OMITTED.
BOX_12
======
OMITTED.
CL27
====
OMITTED.
LOOP_06
=======
OMITTED.
CL28
====
OMITTED.
END_LP06
========
OMITTED.
BOX_13
======
OMITTED.
CL29 ====
As you know, the U.S. Public Health Service is very interested
in obtaining the most complete and accurate information about
health care use and expenditures, including prescription medicines.
Many pharmacies now offer their customers a summary of their
prescription medicine charges. People sometimes request these
summaries to help in preparing their taxes or insurance claims.
To help us get the best information about the family’s
prescriptions, we would like to obtain a printed summary
from each pharmacy used by this family during the past year. To
do this, we must have written authorization.
PRESS ENTER TO CONTINUE.
CL30 ====
From the information I have, I would like to get a signed
authorization form for:
(READ PERSON BELOW)’s prescriptions filled at (READ PHARMACY
BELOW).
TO SCROLL, USE ARROW KEYS. TO LEAVE SCREEN, PRESS ESC.
| ROSTER. PERSON | CL30_01. PHARMACY |
|---|---|
| [First, [Middle], Last Name-35] | [Name of Pharmacy.............-30] |
| [First, [Middle], Last Name-35] | [Name of Pharmacy.............-30] |
| [First, [Middle], Last Name-35] | [Name of Pharmacy.............-30] |
[HAND RESPONDENT THE AUTHORIZATION FORM BOOKLET.]
[These materials explain more about why we contact pharmacies
and answer questions people sometimes ask about this part of
the study. Please take a minute to review this information
while I gather the forms.]
----------------------------------------------------
| ROSTER DEFINITION: DISPLAY EACH PAIR ON THE |
| RU-PERSON-PHARMACY-PAIRS-ROSTER THAT MEET THE |
| FOLLOWING CONDITION: |
| |
| - PAIR IS ELIGIBLE FOR PHARMACY AUTHORIZATION FORM|
| COLLECTION (SEE BOX_11 SAMPLING SPECIFICATIONS) |
| FOR ROUNDS 1, 2, OR 3 IF ROUND 3 OR FOR ROUNDS |
| 3, 4, OR 5 IF ROUND 5. |
----------------------------------------------------
----------------------------------------------------
| NOTE: DISPLAY EACH UNIQUE ELIGIBLE PERSON- |
| PHARMACY-PAIR ONLY ONCE. |
----------------------------------------------------
LOOP_07 =======
----------------------------------------------------
| FOR EACH ELEMENT ON THE RU-PERSON-PHARMACY-PAIRS- |
| ROSTER, ASK CL31 - END_LP07 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_07 PRESENTS EACH UNIQUE |
| PERSON-PHARMACY-PAIR ELIGIBLE FOR PHARMACY |
| AUTHORIZATION FORM COLLECTION FOR THE INTERVIEWER |
| TO COMPLETE THE AUTHORIZATION FORM. THIS LOOP |
| CYCLES ON THE RU-PERSON-PHARMACY-PAIRS THAT MEET |
| THE FOLLOWING CONDITION: |
| |
| - PAIR IS ELIGIBLE FOR PHARMACY AUTHORIZATION FORM|
| COLLECTION (SEE BOX_11 SAMPLING SPECIFICATIONS) |
| FOR ROUNDS 1, 2, OR 3 IF ROUND 3 OR FOR ROUNDS |
| 3, 4, OR 5 IF ROUND 5. |
----------------------------------------------------
----------------------------------------------------
| NOTE: LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON- |
| PHARMACY-PAIR. |
----------------------------------------------------
CL31 ====
INTERVIEWER: {LOCATE APPROPRIATE PREPRINTED PHARMACY AUTHORIZATION
FORMS (COMPLETE NEW ONE IF FORM CANNOT BE LOCATED)/COMPLETE
PHARMACY AUTHORIZATION FORM} FOR THE FOLLOWING PERSON-PHARMACY-PAIR:
PID: [PID] PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PHARMID: [PharmID-4]
PHARMACY NAME: [Pharmacy Name-35]
PHARMACY ADDRESS: [Street Address for Pharmacy]
[City Name], [ST] [Zip Code] [Telephone]
PRESS ENTER TO CONTINUE.
PRESS F1 FOR MORE INFORMATION ON PHARMACY AUTHORIZATION FORMS.
----------------------------------------------------
| DISPLAY ‘LOCATE ... LOCATED)’ IF PERSON-PHARMACY- |
| PAIR WAS ELIGIBLE FROM ROUNDS 1 OR 2 IF ROUND 3 |
| OR FROM ROUNDS 3 OR 4 IF ROUND 5. OTHERWISE, |
| DISPLAY ‘COMPLETE ... FORM’. |
----------------------------------------------------
END_LP07 ========
----------------------------------------------------
| CYCLE ON NEXT PAIR ON THE RU-PERSON-PHARMACY- |
| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |
| THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END |
| LOOP_07 AND CONTINUE WITH LOOP_08 |
----------------------------------------------------
LOOP_08 =======
----------------------------------------------------
| FOR EACH ELEMENT ON THE RU-PERSON-PHARMACY-PAIRS- |
| ROSTER, ASK CL32 - END_LP08 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_08 PRESENTS EACH UNIQUE |
| PERSON-PHARMACY-PAIR ELIGIBLE FOR PHARMACY |
| AUTHORIZATION FORM COLLECTION FOR THE INTERVIEWER |
| TO RECORD THE STATUS OF THE AUTHORIZATION FORM. |
| THIS LOOP CYCLES ON THE RU-PERSON-PHARMACY-PAIRS |
| THAT MEET THE FOLLOWING CONDITION: |
| |
| - PAIR IS ELIGIBLE FOR PHARMACY AUTHORIZATION FORM|
| COLLECTION (SEE BOX_11 SAMPLING SPECIFICATIONS) |
| FOR ROUNDS 1, 2, OR 3 IF ROUND 3 OR FOR ROUNDS |
| 3, 4, OR 5 IF ROUND 5. |
----------------------------------------------------
----------------------------------------------------
| NOTE: LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON- |
| PHARMACY-PAIR. |
----------------------------------------------------
CL32 ====
INTERVIEWER: ASK APPROPRIATE PERSON(S) TO SIGN AUTHORIZATION FORM.
IF NOT AVAILABLE TO SIGN, LEAVE AUTHORIZATION FORM AND BOOKLET WITH
RESPONDENT. RECORD STATUS BELOW AND UPDATE AF LOG IF AF UNSIGNED OR
PRE-PRINTED.
PID: [PID] PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PHARMID: [PharmID-4]
PHARMACY NAME: [Pharmacy Name-35]
PHARMACY ADDRESS: [Street Address for Pharmacy]
[City Name], [ST] [Zip Code] [Telephone]
ENTER THE PHARMACY AUTHORIZATION FORM STATUS:
SIGNED, NO PROBLEM ..................... 1 {CL33}
SIGNED WITH PROBLEM .................... 2
LEFT WITH R ............................ 3 {END_LP08}
MAILED TO R ............................ 4 {END_LP08}
REFUSED ................................ 5 {CL34}
OTHER ................................. 91 {CL32OV2}
[Code One]
PRESS F1 FOR MORE INFORMATION ON PHARMACY AUTHORIZATION FORMS.
----------------------------------------------------
| EDIT: CODE ‘4’ (MAILED TO R) MUST BE ENTERED |
| TWICE IF RU IS NOT A STUDENT RU. IF CODE ‘4’ |
| SELECTED AND RU IS NOT A STUDENT RU, DISPLAY THE |
| FOLLOWING MESSAGE: ‘UNLIKELY RESPONSE. VERIFY |
| AND RE-ENTER.’ |
----------------------------------------------------
CL32OV1 =======
ENTER PROBLEM:
[Enter Problem-45] ..................... {CL33}
CL32OV2 =======
ENTER OTHER:
[Enter Other Specify-45] ............... {END_LP08}
CL33 ====
PID: [PID] PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PHARMID: [PharmID-4]
PHARMACY NAME: [Pharmacy Name-35]
PHARMACY ADDRESS: [Street Address for Pharmacy]
[City Name], [ST] [Zip Code] [Telephone]
ENTER PHARMACY AUTHORIZATION FORM NUMBER:
[Enter Number-8] ....................... {END_LP08}
----------------------------------------------------
| NOTE: EACH PHARMACY AUTHORIZATION FORM HAS A |
| PRE-ASSIGNED PHARMACY AUTHORIZATION FORM NUMBER. |
----------------------------------------------------
----------------------------------------------------
| EDIT: NUMBER ENTERED MUST BE 8 CHARACTERS LONG |
| AND MUST BEGIN AND END WITH AN ALPHA CHARACTER. |
| THE FIRST ALPHA MUST BE R-S, Z, OR Y. THE FIRST |
| NUMERIC DIGIT (SECOND CHARACTER OF ENTRY) MUST |
| BE 7, 8, OR 9. THE LAST ALPHA MUST BE S, T, U, |
| V, OR W. |
----------------------------------------------------
CL34 ====
PID: [PID] PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
PHARMID: [PharmID-4]
PHARMACY NAME: [Pharmacy Name-35]
PHARMACY ADDRESS: [Street Address for Pharmacy]
[City Name], [ST] [Zip Code] [Telephone]
ENTER MAIN REASON FOR REFUSAL:
DOESN’T WANT TO BOTHER PHARMACY ........ 1 {END_LP08}
CONFIDENTIALITY/SENSITIVE ISSUE ........ 2 {END_LP08}
PAYMENT PROBLEM WITH PHARMACY .......... 3 {END_LP08}
HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP08}
WANTS MORE INFORMATION BEFORE SIGNING .. 5 {END_LP08}
NOT INTERESTED ......................... 6 {END_LP08}
NO REASON GIVEN ........................ 7 {END_LP08}
OTHER ................................. 91
[Code One]
CL34OV
======
ENTER OTHER REASON FOR REFUSAL:
[Enter Other Specify-45] ...............
END_LP08 ========
----------------------------------------------------
| CYCLE ON NEXT PAIR ON THE RU-PERSON-PHARMACY- |
| PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN |
| THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END |
| LOOP_08 AND CONTINUE WITH BOX_14 |
----------------------------------------------------
Subsection 5: Self-Administered Questionnaire (Collected in Rounds 2 through 5)
BOX_14 ======
----------------------------------------------------
| IF ROUND 2 OR 4, CONTINUE WITH BOX_15 |
----------------------------------------------------
----------------------------------------------------
| IF ROUND 3 OR 5, GO TO BOX_16 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_16A |
----------------------------------------------------
BOX_15 ======
----------------------------------------------------
| IF ROUND 2 OR 4 AND AT LEAST ONE RU MEMBER |
| ELIGIBLE FOR SAQ (I.E., AT LEAST ONE CURRENT RU |
| MEMBER WHO IS NOT DECEASED OR INSTITUTIONALIZED |
| AND IS IN THE RU AT THE ROUND 2 OR 4 INTERVIEW |
| DATE AND IS 18 YEARS OF AGE OR OLDER (OR IN AGE |
| CATEGORIES 4-9) ON JULY 1, 2005 IF ROUND 2 OR ON |
| JULY 1, 2006 IF ROUND 4 OR HAS TURNED 18 BETWEEN |
| JULY 1, 2005 IF ROUND 2 OR JULY 1, 2006 IF ROUND 4|
| AND THE DATE OF INTERVIEW), CONTINUE WITH CL35 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO CL41 |
----------------------------------------------------
----------------------------------------------------
| NOTE: DETERMINING WHICH ADULTS IN THE RU RECEIVE |
| AN SAQ AND WHICH ADULTS ARE FOLLOWED-UP IN ROUND |
| 3 OR 5 WILL BE BASED ONLY ON ROUND 2 OR 4 |
| INFORMATION. THAT IS, NO RU MEMBERS ADDED IN |
| ROUND 3 OR 5 WILL BE ASKED TO COMPLETE AN SAQ. |
----------------------------------------------------
CL35 ====
Now I would like to ask (READ PERSON NAMES BELOW) to complete
a brief survey about health and health opinions.
TO SCROLL, USE ARROW KEYS. TO LEAVE SCREEN, PRESS ESC.
| ROSTER. PERSON | CL35_01. PID |
|---|---|
| [First Name, [Middle Name], Last Name-65] | [PID] |
| [First Name, [Middle Name], Last Name-65] | [PID] |
| [First Name, [Middle Name], Last Name-65] | [PID] |
AS APPROPRIATE, PREPARE AN SAQ FOR EACH PERSON LISTED ABOVE.
----------------------------------------------------
| ROSTER DEFINITION: DISPLAY ALL PERSONS ON THE RU-|
| MEMBERS-ROSTER WHO MEET THE FOLLOWING CONDITIONS: |
| - PERSON DOES NOT HAVE A STATUS OF DECEASED OR |
| INSTITUTIONALIZED ON ROUND 2 OR 4 INTERVIEW DATE|
| - PERSON CURRENTLY IN RU ON ROUND 2 OR 4 INTERVIEW|
| DATE |
| - PERSON IS 18 YEARS OF AGE OR OLDER (OR IN AGE |
| CATEGORIES 4-9) ON JULY 1, 2005 IF ROUND 2 OR |
| ON JULY 1, 2006 IF ROUND 4 OR HAS TURNED 18 |
| BETWEEN JULY 1, 2005 IF ROUND 2 OR JULY 1, 2006 |
| IF ROUND 4 AND THE DATE OF INTERVIEW |
----------------------------------------------------
----------------------------------------------------
| DISPLAY THE ROW PERSON’S PID AT CL35_01. |
----------------------------------------------------
LOOP_09 =======
----------------------------------------------------
| FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK |
| CL36 – END_LP09 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_09 COLLECTS THE SAQ STATUS |
| FOR EACH PERSON ELIGIBLE TO COMPLETE THE SAQ. |
| THIS LOOP CYCLES ON EACH PERSON ON THE RU-MEMBERS-|
| ROSTER WHO MEETS THE FOLLOWING CONDITIONS: |
| - PERSON DOES NOT HAVE A STATUS OF DECEASED OR |
| INSTITUTIONALIZED ON ROUND 2 OR 4 INTERVIEW DATE|
| - PERSON CURRENTLY IN RU ON ROUND 2 OR 4 INTERVIEW|
| DATE |
| - PERSON IS 18 YEARS OF AGE OR OLDER (OR IN AGE |
| CATEGORIES 4-9) ON JULY 1, 2005 IF ROUND 2 OR |
| ON JULY 1, 2006 IF ROUND 4 OR HAS TURNED 18 |
| BETWEEN JULY 1, 2005 IF ROUND 2 OR JULY 1, 2006 |
| IF ROUND 4 AND THE DATE OF INTERVIEW |
----------------------------------------------------
CL36 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
PID: {PID}
COLLECT (PERSON)’S COMPLETED SAQ AND EXPLAIN THAT THEY WILL
RECEIVE $5.00 FOR EACH COMPLETED SAQ.
IF (PERSON) NOT AVAILABLE OR NOT ABLE TO COMPLETE SAQ AT
THIS TIME, LEAVE SAQ WITH (PERSON) OR RESPONDENT AND EXPLAIN
INSTRUCTIONS.
ENTER THE STATUS OF THE SAQ.
COMPLETED AND GIVEN TO INTERVIEWER ..... 1 {END_LP09}
NOT COMPLETED, WILL PICK UP AT
LATER DATE ........................... 2 {END_LP09}
NOT COMPLETED, WILL MAIL TO OFFICE ..... 3 {END_LP09}
MAILED TO SAQ RESPONDENT ............... 4 {END_LP09}
REFUSED TO COMPLETE .................... 5 {CL37}
OTHER ................................. 91
[Code One]
----------------------------------------------------
| AT PID, DISPLAY THE PERSON’S 3 DIGIT PID. |
----------------------------------------------------
----------------------------------------------------
| EDIT: CODE ‘4’ (MAILED TO SAQ RESPONDENT) MUST BE|
| ENTERED TWICE IF RU IS NOT A STUDENT RU. IF CODE |
| ‘4’ SELECTED AND RU IS NOT A STUDENT RU, DISPLAY |
| THE FOLLOWING MESSAGE: ‘UNLIKELY RESPONSE. |
| VERIFY AND RE-ENTER.’ |
----------------------------------------------------
CL36OV ======
ENTER OTHER:
[Enter Other Specify-45] ............... {END_LP09}
CL37 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
ENTER MAIN REASON FOR REFUSAL:
TOO BUSY/NOT INTERESTED ................ 1 {END_LP09}
TOO PERSONAL/SENSITIVE INFORMATION ..... 2 {END_LP09}
TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP . 3 {END_LP09}
HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP09}
WANTS MORE INFORMATION ................. 5 {END_LP09}
NOT INTERESTED ......................... 6 {END_LP09}
NO REASON GIVEN ........................ 7 {END_LP09}
OTHER ................................. 91
[Code One]
CL37OV ======
ENTER OTHER REASON FOR REFUSAL:
[Enter Other Specify-45] ...............
END_LP09 ========
----------------------------------------------------
| CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER WHO |
| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|
----------------------------------------------------
----------------------------------------------------
| IF NO OTHER PERSONS MEET THE STATED CONDITIONS, |
| END LOOP_09 AND GO TO BOX_16A |
----------------------------------------------------
BOX_16 ======
----------------------------------------------------
| IF AT LEAST ONE PERSON WITH AN SAQ DISPOSITION OF |
| ‘2’ (NOT COMPLETED, WILL PICK UP AT LATER DATE), |
| ‘3’ (NOT COMPLETED, WILL MAIL TO OFFICE), ‘4’ |
| (MAILED TO SAQ RESPONDENT), ‘5’ (REFUSED TO |
| COMPLETE SAQ), OR ‘91’ (OTHER) RECORDED AT CL36 |
| DURING ROUND 2 OR 4 AND NOT UPDATED BY RECEIPT |
| CONTROL TO ‘1’ (COMPLETE), ‘2’ (PARTIAL COMPLETE),|
| ‘4’ (PROBLEM), OR ‘6’ (WRONG SAQ TYPE) ((I.E., |
| RECEIPT CONTROL IS EQUAL TO ‘3’ (REFUSED) OR ‘5’ |
| (NOT HERE/BLANK)), CONTINUE WITH CL38 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_16A |
----------------------------------------------------
CL38 ====
During the last interview a short survey about health and
health opinions was left with (READ PERSON NAMES BELOW) to
complete.
I would like to check to see if I could pick these surveys
up or if they were already mailed back to the home office.}
TO SCROLL, USE ARROW KEYS. TO LEAVE SCREEN, PRESS ESC.
| ROSTER. PERSON | CL38_01. PID |
|---|---|
| [First Name, [Middle Name], Last Name-65] | [PID] |
| [First Name, [Middle Name], Last Name-65] | [PID] |
| [First Name, [Middle Name], Last Name-65] | [PID] |
1. COLLECT SAQs, IF AVAILABLE.
2. IF ANY REPORTED AS LOST, RE-DISTRIBUTE APPROPRIATE
NUMBER AND TYPE OF SAQs TO THE RESPONDENT.
----------------------------------------------------
| ROSTER DEFINITION: DISPLAY ALL PERSONS ON THE RU-|
| MEMBERS-ROSTER WHO MEET THE FOLLOWING CONDITIONS: |
| - PERSON DID NOT HAVE A STATUS OF DECEASED OR |
| INSTITUTIONALIZED ON ROUND 2 OR 4 INTERVIEW DATE|
| - PERSON WAS CURRENTLY IN RU ON ROUND 2 OR 4 |
| INTERVIEW DATE |
| - PERSON IS 18 YEARS OF AGE OR OLDER (OR IN AGE |
| CATEGORIES 4-9) ON JULY 1, 2005 IF ROUND 2 OR |
| ON JULY 1, 2006 IF ROUND 4 OR HAS TURNED 18 |
| BETWEEN JULY 1, 2005 IF ROUND 2 OR JULY 1, 2006 |
| IF ROUND 4 AND THE DATE OF INTERVIEW |
| - CL36 WAS CODED ‘1’ (COMPLETED AND GIVEN TO |
| INTERVIEWER), ‘2’ (NOT COMPLETED, WILL PICK UP |
| AT LATER DATE), ‘3’ (NOT COMPLETED, WILL MAIL |
| TO OFFICE),‘4’ (MAILED TO SAQ RESPONDENT), ‘5’ |
| (REFUSED TO COMPLETE SAQ), OR ‘91’ (OTHER) |
| DURING ROUND 2 OR 4 FOR PERSON AND NOT UPDATED |
| BY RECEIPT CONTROL TO ‘1’ (COMPLETE), ‘2’ |
| (PARTIAL COMPLETE), ‘4’ (PROBLEM), OR ‘6’ (WRONG|
| SAQ TYPE) ((I.E., RECEIPT CONTROL IS EQUAL TO |
| ‘3’ (REFUSED) OR ‘5’ (NOT HERE/BLANK)) |
----------------------------------------------------
----------------------------------------------------
| DISPLAY THE ROW PERSON’S PID AT CL38_01. |
----------------------------------------------------
LOOP_10 =======
----------------------------------------------------
| FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK |
| CL39 - END_LP10 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_10 COLLECTS THE SAQ STATUS |
| FOR EACH PERSON ELIGIBLE TO COMPLETE THE SAQ. |
| THIS LOOP CYCLES ON EACH PERSON ON THE RU-MEMBERS-|
| ROSTER WHO MEETS THE FOLLOWING CONDITIONS: |
| - PERSON DID NOT HAVE A STATUS OF DECEASED OR |
| INSTITUTIONALIZED ON ROUND 2 OR 4 INTERVIEW DATE|
| - PERSON WAS CURRENTLY IN RU ON ROUND 2 OR 4 |
| INTERVIEW DATE |
| - PERSON IS 18 YEARS OF AGE OR OLDER (OR IN AGE |
| CATEGORIES 4-9) ON JULY 1, 2005 IF ROUND 2 OR |
| ON JULY 1, 2006 IF ROUND 4 OR HAS TURNED 18 |
| BETWEEN JULY 1, 2005 IF ROUND 2 OR JULY 1, 2006 |
| IF ROUND 4 AND THE DATE OF INTERVIEW |
| - CL36 WAS CODED ‘1’ (COMPLETED AND GIVEN TO |
| INTERVIEWER), ‘2’ (NOT COMPLETED, WILL PICK UP |
| AT LATER DATE), ‘3’ (NOT COMPLETED, WILL MAIL |
| TO OFFICE),‘4’ (MAILED TO SAQ RESPONDENT), ‘5’ |
| (REFUSED TO COMPLETE SAQ), OR ‘91’ (OTHER) |
| DURING ROUND 2 OR 4 FOR PERSON AND NOT UPDATED |
| BY RECEIPT CONTROL TO ‘1’ (COMPLETE), ‘2’ |
| (PARTIAL COMPLETE), ‘4’ (PROBLEM), OR ‘6’ |
| (WRONG SAQ TYPE) ((I.E., RECEIPT CONTROL IS |
| EQUAL TO ‘3’ (REFUSED) OR ‘5’ (NOT HERE/BLANK)) |
----------------------------------------------------
CL39 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
PID: {PID}
{SAQ STATUS FROM PREVIOUS ROUND: {PREVIOUS ROUND STATUS -40}}
COLLECT (PERSON)'s COMPLETED SAQ AND EXPLAIN THAT THEY WILL RECEIVE
$5.00 FOR EACH COMPLETED SAQ.
ENTER THE STATUS OF THE SAQ:
COMPLETED AND GIVEN TO INTERVIEWER ..... 1 {END_LP10}
NOT COMPLETED, WILL PICK UP AT
LATER DATE ........................... 2 {END_LP10}
NOT COMPLETED, WILL MAIL TO OFFICE ..... 3 {END_LP10}
ALREADY MAILED TO HOME OFFICE .......... 4 {END_LP10}
REFUSED TO COMPLETE .................... 5 {CL40}
OTHER ................................. 91
[Code One]
----------------------------------------------------
| AT PID, DISPLAY THE PERSON’S 3 DIGIT PID. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘SAQ STATUS FROM PREVIOUS ROUND’ {PREVIOUS|
| ROUND STATUS -40}’. OTHERWISE, USE A NULL |
| DISPLAY. |
| |
| FOR ‘PREVIOUS ROUND STATUS-40’, DISPLAY THE TEXT |
| ASSOCIATED WITH THE ROUND 2 OR 4 (OR RECEIPT |
| CONTROL UPDATED STATUS) STATUS ENTERED AT CL36. |
----------------------------------------------------
CL39OV ======
ENTER OTHER:
[Enter Other Specify-45] ............... {END_LP10}
CL40 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
ENTER MAIN REASON FOR REFUSAL:
TOO BUSY/NOT INTERESTED ................ 1 {END_LP10}
TOO PERSONAL/SENSITIVE INFORMATION ..... 2 {END_LP10}
TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP . 3 {END_LP10}
HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP10}
WANTS MORE INFORMATION ................. 5 {END_LP10}
NOT INTERESTED ......................... 6 {END_LP10}
NO REASON GIVEN ........................ 7 {END_LP10}
OTHER ................................. 91
[Code One]
CL40OV ======
ENTER OTHER REASON FOR REFUSAL:
[Enter Other Specify-45] ...............
END_LP10 ========
----------------------------------------------------
| CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER WHO |
| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|
----------------------------------------------------
----------------------------------------------------
| IF NO OTHER PERSONS MEET THE STATED CONDITIONS, |
| END LOOP_10 AND CONTINUE WITH BOX_16A |
----------------------------------------------------
Subsection 5a: Diabetes Care Supplement (DCS) Questionnaire (Rounds 3 and 5)
BOX_16A =======
----------------------------------------------------
| IF ROUND 3 OR 5, CONTINUE WITH BOX_16B |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO CL41 |
----------------------------------------------------
BOX_16B =======
----------------------------------------------------
| IF ROUND 3 OR 5 AND AT LEAST ONE RU MEMBER |
| ELIGIBLE FOR DIABETES CARE SUPPLEMENT (I.E., AT |
| LEAST ONE RU MEMBER WHO IS CODED ‘1’ (YES) AT |
| PC02), CONTINUE WITH CL40A |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO CL41 |
----------------------------------------------------
CL40A =====
SELF DIABETES CARE SUPPLEMENT (DCS):
Earlier we asked (READ SELF NAMES BELOW) to complete
a few questions about the care received for diabetes.
PROXY DCS:
Earlier we asked that someone knowledgeable about
(READ PROXY NAMES BELOW) diabetes complete a few
questions about the care received.
TO SCROLL, USE ARROW KEYS. TO LEAVE SCREEN, PRESS ESC.
| ROSTER. PERSON | CL40A_01. PID |
CL40A_02. TYPE OF DCS |
|---|---|---|
| [First Name, [Middle Name], Last Name-65] | [PID] |
{SELF/PROXY} |
| [First Name, [Middle Name], Last Name-65] | [PID] |
{SELF/PROXY} |
| [First Name, [Middle Name], Last Name-65] | [PID] |
{SELF/PROXY} |
AS APPROPRIATE, COLLECT DCS FOR EACH PERSON LISTED ABOVE.
----------------------------------------------------
| ROSTER DEFINITION: DISPLAY ALL PERSONS ON THE RU-|
| MEMBERS-ROSTER WHO MEET THE FOLLOWING CONDITION: |
| - PC02 IS CODED ‘1’ (YES) FOR THE PERSON |
----------------------------------------------------
----------------------------------------------------
| DISPLAY THE ROW PERSON’S PID AT CL40A_01 |
----------------------------------------------------
----------------------------------------------------
| DISPLAY THE TYPE OF DCS FOR THE PERSON AT |
| CL40A_02. IF PC03 FOR THE ROW PERSON IS CODED |
| ‘1’ (SELF), DISPLAY ‘SELF.’ IF PC03 FOR THE ROW |
| PERSON IS CODED ‘2’ (PROXY), DISPLAY ‘PROXY.’ |
----------------------------------------------------
LOOP_10A =======
----------------------------------------------------
| FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK |
| CL40B – END_LP10A |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_10A COLLECTS THE DCS STATUS|
| FOR EACH PERSON ELIGIBLE TO COMPLETE THE DCS. |
| THIS LOOP CYCLES ON EACH PERSON ON THE RU- |
| MEMBERS-ROSTER WHO MEETS THE FOLLOWING CONDITION: |
| |
| - PC02 IS CODED ‘1’ (YES) FOR THE PERSON |
----------------------------------------------------
CL40B =====
{PERSON’S FIRST MIDDLE AND LAST NAME}
PID: {PID} TYPE OF DCS: {SELF/PROXY}
COLLECT (PERSON)’S COMPLETED DIABETES CARE SUPPLEMENT
IF (PERSON) NOT AVAILABLE OR NOT ABLE TO COMPLETE DCS AT
THIS TIME, LEAVE DCS WITH (PERSON) OR RESPONDENT AND EXPLAIN
INSTRUCTIONS.
ENTER THE STATUS OF THE DCS:
COMPLETED AND GIVEN TO INTERVIEWER ..... 1 {END_LP10A}
NOT COMPLETED, WILL PICK UP AT
LATER DATE ........................... 2 {END_LP10A}
NOT COMPLETED, WILL MAIL TO OFFICE ..... 3 {END_LP10A}
MAILED TO DCS RESPONDENT ............... 4 {END_LP10A}
REFUSED TO COMPLETE .................... 5 {CL40C}
OTHER ................................. 91
[Code One]
----------------------------------------------------
| AT PID, DISPLAY THE PERSON’S 3 DIGIT PID. |
----------------------------------------------------
----------------------------------------------------
| AT TYPE OF DCS, DISPLAY ‘SELF’ IF THE PERSON |
| BEING LOOPED ON IS CODED ‘1’ (SELF) AT PC03. |
| DISPLAY ‘PROXY’ IF THE PERSON BEING LOOPED ON |
| IS CODED ‘2’ (PROXY) AT PC03. |
----------------------------------------------------
----------------------------------------------------
| EDIT: CODE ‘4’ (MAILED TO DCS RESPONDENT) MUST BE|
| ENTERED TWICE IF RU IS NOT A STUDENT RU. IF CODE |
| ‘4’ SELECTED AND RU IS NOT A STUDENT RU, DISPLAY |
| THE FOLLOWING MESSAGE: ‘UNLIKELY RESPONSE. |
| VERIFY AND RE-ENTER.’ |
----------------------------------------------------
CL40BOV =======
ENTER OTHER:
[Enter Other Specify-45] ............... {END_LP10A}
CL40C =====
{PERSON’S FIRST MIDDLE AND LAST NAME}
ENTER MAIN REASON FOR REFUSAL:
TOO BUSY/NOT INTERESTED ................ 1 {END_LP10A}
TOO PERSONAL/SENSITIVE INFORMATION ..... 2 {END_LP10A}
TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP . 3 {END_LP10A}
HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP10A}
WANTS MORE INFORMATION ................. 5 {END_LP10A}
NOT INTERESTED ......................... 6 {END_LP10A}
NO REASON GIVEN ........................ 7 {END_LP10A}
OTHER ................................. 91
[Code One]
CL40COV =======
ENTER OTHER REASON FOR REFUSAL:
[Enter Other Specify-45] ...............
END_LP10A =========
----------------------------------------------------
| CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER WHO |
| MEETS THE CONDITION STATED IN THE LOOP DEFINITION |
----------------------------------------------------
----------------------------------------------------
| IF NO OTHER PERSONS MEET THE STATED CONDITION, |
| END LOOP_10A AND GO TO CL41 |
----------------------------------------------------
Subsection 6: Collecting/Updating Locating Information (Round 1 through Round 5)
CL41 ====
{Thank you for your cooperation and for taking the time to
participate in this important study.}
{In the coming months, we will be contacting this family again
to collect information on health care use and expenses./We are
nearing the end of this study. I’d like to thank you for your
participation in this important study. Just in case my
supervisor needs to reach you to verify that I was here and
collected this information correctly, I’d like to verify a few
pieces of information.}
{Just to make sure I can reach you for the next interview, I’d
like to ask a few questions about how to find the family./Let
me quickly review and update the information we have for
locating the family that was collected during the last
interview.}
PRESS ENTER TO CONTINUE.
----------------------------------------------------
| DISPLAY ‘Thank you ... important study.’ IF ROUNDS|
| 1 OR 2 OR 3 OR 4. OTHERWISE, USE A NULL DISPLAY. |
| |
| DISPLAY ‘In the coming months, ... use and |
| expenses.’ IF ROUNDS 1 OR 2 OR 3 OR 4. OTHERWISE,|
| DISPLAY ‘We are nearing ... of information.’ |
| |
| DISPLAY ‘Just ... family.’ IF ROUND 1. OTHERWISE,|
| DISPLAY ‘Let ... interview.’ |
----------------------------------------------------
----------------------------------------------------
| IF NOT ROUND 5, CONTINUE WITH CL42 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE (I.E., IF ROUND 5), GO TO BOX_17 |
----------------------------------------------------
CL42 ====
What is the best time of day and day of the week to get in
touch with you?
ENTER BEST TIME TO CONTACT RESPONDENT/PROXY.
[Enter Text] ...........................
----------------------------------------------------
| NOTE: FOUR LINES OF 45 CHARACTERS SHOULD BE |
| AVAILABLE FOR ENTRY OF FREE FORM TEXT. |
----------------------------------------------------
CL42OV1 =======
ENTER WHO BEST TIME RECORDED FOR:
CURRENT RESPONDENT ..................... 1 {BOX_17}
CURRENT PROXY .......................... 2 {BOX_17}
ENTIRE RU .............................. 3 {BOX_17}
OTHER ................................. 91
[Code One]
CL42OV2 =======
ENTER OTHER:
[Enter Other Specify] ..................
BOX_17 ======
----------------------------------------------------
| IF NO CURRENT RU MEMBER PART OF THE RU ON THE |
| CURRENT INTERVIEW DATE (I.E., ALL RU MEMBERS |
| DECEASED, INSTITUTIONALIZED, OR OUT OF THE COUNTRY|
| ON CURRENT INTERVIEW DATE), GO TO BOX_18 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH CL43 |
----------------------------------------------------
CL43 ====
ITEM: SECOND PHONE (WORK, FRIEND, RELATIVE, OTHER) WHERE
FAMILY COULD BE REACHED.
INTERVIEWER: IF AVAILABLE, VERIFY CURRENT SECOND PHONE SHOWN
BELOW.
IF NO CURRENT INFORMATION, PROBE:
Do you have a second phone number where you can
be reached such as a work number, the number of
a friend or relative?
Current Info: [2ND_TELEPHONE]
ENTER NEW SECOND PHONE ................. 1
SECOND PHONE CORRECT ................... 2 {CL46}
SECOND PHONE NEEDS CORRECTION .......... 3
NO CURRENT SECOND PHONE ................ 4 {CL46}
REF ................................... -7 {CL46}
DK .................................... -8 {CL46}
----------------------------------------------------
| EDIT: CODES ‘2’ (SECOND PHONE CORRECT) AND ‘3’ |
| (SECOND PHONE NEEDS CORRECTION) CANNOT BE SELECTED|
| IF NO CURRENT SECOND PHONE INFORMATION AVAILABLE. |
| IF CODES ‘2’ OR ‘3’ SELECTED WHEN NO CURRENT |
| SECOND PHONE, DISPLAY THE FOLLOWING MESSAGE: ‘CODE|
| NOT AVAILABLE. NO CURRENT SECOND PHONE. VERIFY |
| AND RE-ENTER.’ |
----------------------------------------------------
----------------------------------------------------
| ASSUMPTION: THE QUESTIONS IN CLOSING IN WHICH |
| CONTACT AND LOCATING INFORMATION IS PRE-RECORDED |
| IN CAPI (CL43-CL64) ARE SPECIFIED WITH THE |
| FOLLOWING BASIC ASSUMPTIONS: |
| 1. LOCATING AND CONTACTING INFORMATION WILL NOT BE|
| WRITTEN OVER FROM ROUND TO ROUND. |
| 2. ONLY THE MOST CURRENT INFORMATION WILL APPEAR |
| IN THE TEXT OF THESE QUESTIONS AND NO HISTORY |
| OF CONTACT AND LOCATING INFORMATION WILL APPEAR|
| ON THE CAPI SCREEN FOR THE INTERVIEWER. |
| 3. IF INFORMATION STAYS THE SAME, IT WILL BE |
| CARRIED FORWARD. |
| 4. WHETHER OR NOT PREVIOUS ROUND’S INFORMATION OR |
| ANY CONTACT HISTORY WILL BE PRINTED ON THE FACE|
| SHEET FOR ANY OF THE CONTACTING AND LOCATING |
| QUESTIONS IS STILL NOT KNOWN. |
----------------------------------------------------
CL44 ====
[What is that telephone number?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT SECOND PHONE.
IF UNAVAILABLE, ENTER COMPLETE SECOND TELEPHONE NUMBER.
TO VERIFY CURRENT INFORMATION OR TO LEAVE A FIELD BLANK, PRESS
ENTER. TO CORRECT OR ENTER INFORMATION, TYPE ENTIRE FIELD.
Current Info: [2ND_TELEPHONE]
[Enter Area Code,Exchange,Local] .......
----------------------------------------------------
| EDIT: DISALLOW LEADING ZEROS AS AN ENTRY. |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF NO CURRENT SECOND PHONE AVAILABLE, AN |
| ENTRY MUST BE MADE FOR EVERY FIELD (REF AND DK ARE|
| ALLOWED). |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF CURRENT SECOND PHONE AVAILABLE, AT LEAST|
| ONE FIELD MUST BE UPDATED. |
----------------------------------------------------
----------------------------------------------------
| FLAG SECOND PHONE INFORMATION FOR THE RU WITH THE |
| NUMBER ENTERED OR CORRECTED AT CL44 FOR THE |
| CURRENT ROUND. |
----------------------------------------------------
CL45 ====
Where is that telephone located?
OFFICE/PLACE OF BUSINESS ............... 1 {CL45OV2}
RELATIVE ............................... 2 {CL45OV2}
NEIGHBOR ............................... 3 {CL45OV2}
FRIEND ................................. 4 {CL45OV2}
OTHER ..................................91
REF ................................... -7 {CL45OV2}
DK .................................... -8 {CL45OV2}
[Code One]
CL45OV1 =======
ENTER OTHER:
[Enter Other Specify-45] ..............
REF ................................... -7
DK .................................... -8
CL45OV2 =======
What is the name of that location?
ENTER NAME AND/OR DESCRIPTION. ALSO, INCLUDE ANY SPECIAL
INSTRUCTIONS FOR CALLING AT THE ALTERNATE TELEPHONE NUMBER (FOR
EXAMPLE, CALL ONLY IN EMERGENCY).
[Enter Description] ...................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| NOTE: ALLOW 2 LINES OF 45 CHARACTERS FOR |
| DESCRIPTION. |
----------------------------------------------------
CL46 ====
ITEM: MAILING ADDRESS DIFFERENT FROM LOCATING (STREET) ADDRESS.
INTERVIEWER: IF AVAILABLE, VERIFY CURRENT MAILING ADDRESS SHOWN
BELOW.
IF NO CURRENT INFORMATION, PROBE:
Do you have a mailing address that is different from
your physical address, such as a P.O. Box?
Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY]
[STATE]
[ZIP CODE]
ENTER NEW MAILING ADDRESS .............. 1
MAILING ADDRESS CORRECT ................ 2 {BOX_17A}
MAILING ADDRESS NEEDS CORRECTION ....... 3
NO CURRENT MAILING ADDRESS ............. 4 {BOX_17A}
REF ................................... -7 {BOX_17A}
DK .................................... -8 {BOX_17A}
----------------------------------------------------
| EDIT: CODES ‘2’ (MAILING ADDRESS CORRECT) AND ‘3’|
| (MAILING ADDRESS NEEDS CORRECTION) CANNOT BE |
| SELECTED IF NO CURRENT MAILING ADDRESS INFORMATION|
| AVAILABLE. IF CODES ‘2’ OR ‘3’ SELECTED WHEN NO |
| CURRENT MAILING ADDRESS, DISPLAY THE FOLLOWING |
| MESSAGE: ‘CODE NOT AVAILABLE. NO CURRENT MAILING|
| ADDRESS. VERIFY AND RE-ENTER.’ |
----------------------------------------------------
CL47 ====
[What is that address?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT MAILING ADDRESS.
IF UNAVAILABLE, ENTER COMPLETE MAILING ADDRESS.
TO VERIFY CURRENT INFORMATION OR TO LEAVE A FIELD BLANK, PRESS
ENTER. TO CORRECT OR ENTER INFORMATION, TYPE ENTIRE FIELD.
Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY]
[STATE]
[ZIP CODE]
1ST_STR_ADDRESS (CL47_01): [_____________]
2ND_STR_ADDRESS (CL47_02): [_____________]
CITY (CL47_03): [_____________]
STATE (CL47_04): [_____________]
ZIP CODE (CL47_05): [_____________]
PRESS F1 FOR LIST OF STATE ABBREVIATIONS.
----------------------------------------------------
| EDIT: IF NO CURRENT MAILING ADDRESS AVAILABLE, |
| AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT |
| SECOND STREET ADDRESS (REF AND DK ARE ALLOWED). |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF CURRENT MAILING ADDRESS AVAILABLE, AT |
| LEAST ONE FIELD MUST BE UPDATED. |
----------------------------------------------------
----------------------------------------------------
| FLAG MAILING ADDRESS INFORMATION FOR THE RU WITH |
| THE ADDRESS ENTERED OR CORRECTED AT CL47 FOR THE |
| CURRENT ROUND. |
----------------------------------------------------
BOX_17A =======
----------------------------------------------------
| IF NOT ROUND 5, CONTINUE WITH CL48 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE (I.E., IF ROUND 5), GO TO CL62 |
----------------------------------------------------
CL48 ====
ITEM: ANOTHER HOME SUCH AS SECOND HOME OR VACATION HOME WHERE
FAMILY CAN SOMETIMES BE CONTACTED.
INTERVIEWER: IF AVAILABLE, VERIFY CURRENT SECOND HOME
INFORMATION SHOWN BELOW.
IF NO CURRENT INFORMATION, PROBE:
Do you have a second home, such as a vacation home
where we could contact you if you’re not available
at your usual address?
Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
ENTER NEW SECOND HOME ADDRESS AND
TELEPHONE ............................ 1
SECOND HOME ADDRESS AND TELEPHONE
CORRECT .............................. 2 {CL50}
SECOND HOME ADDRESS OR TELEPHONE
NEEDS CORRECTION ..................... 3
NO CURRENT SECOND HOME ................. 4 {CL50}
REF ................................... -7 {CL50}
DK .................................... -8 {CL50}
----------------------------------------------------
| EDIT: CODES ‘2’ (SECOND HOME ADDRESS AND |
| TELEPHONE CORRECT) AND ‘3’ (SECOND HOME ADDRESS |
| OR TELEPHONE NEEDS CORRECTION) CANNOT BE |
| SELECTED IF NO CURRENT SECOND HOME ADDRESS |
| INFORMATION AVAILABLE. IF CODES ‘2’ OR ‘3’ |
| SELECTED WHEN NO CURRENT SECOND HOME ADDRESS, |
| DISPLAY THE FOLLOWING MESSAGE: ‘CODE NOT |
| AVAILABLE. NO CURRENT SECOND HOME ADDRESS. |
| VERIFY AND RE-ENTER.’ |
----------------------------------------------------
CL49 ====
[What is the address and phone number of that home?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT SECOND HOME ADDRESS.
IF UNAVAILABLE, ENTER COMPLETE SECOND HOME ADDRESS.
TO VERIFY CURRENT INFORMATION OR TO LEAVE A FIELD BLANK, PRESS
ENTER. TO CORRECT OR ENTER INFORMATION, TYPE ENTIRE FIELD.
Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
1ST_STR_ADDRESS (CL49_01): [_____________]
2ND_STR_ADDRESS (CL49_02): [_____________]
CITY (CL49_03): [_____________]
STATE (CL49_04): [_____________]
ZIP CODE (CL49_05): [_____________]
TELEPHONE (CL49_06): [_____________]
PRESS F1 FOR LIST OF STATE ABBREVIATIONS.
----------------------------------------------------
| EDIT: IF NO CURRENT SECOND HOME ADDRESS AVAILABLE,|
| AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT |
| SECOND STREET ADDRESS (REF AND DK ARE ALLOWED). |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF CURRENT SECOND HOME ADDRESS AVAILABLE, |
| AT LEAST ONE FIELD MUST BE UPDATED. |
----------------------------------------------------
----------------------------------------------------
| FLAG SECOND HOME ADDRESS FOR THE RU WITH THE |
| ADDRESS AND PHONE ENTERED OR CORRECTED AT CL49 |
| FOR THE CURRENT ROUND. |
----------------------------------------------------
CL50 ====
ITEM: LOCATING CONTACT - RELATIVE OR FRIEND WHO DOES NOT LIVE
HERE WHO WILL ALWAYS KNOW HOW TO GET IN TOUCH WITH FAMILY.
INTERVIEWER: IF AVAILABLE, VERIFY CURRENT CONTACT INFORMATION
SHOWN BELOW.
IF NO CURRENT INFORMATION, PROBE:
Do you have a friend or relative who does not live
here who will always know how to get in touch with
the family?
Current Info: [CONTACT_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
ENTER NEW CONTACT PERSON/ADDRESS ....... 1
CONTACT PERSON/ADDRESS CORRECT ......... 2 {CL52}
CONTACT PERSON/ADDRESS NEEDS
CORRECTION ........................... 3
NO CURRENT CONTACT PERSON .............. 4 {CL53}
REF ................................... -7 {CL53}
DK .................................... -8 {CL53}
----------------------------------------------------
| EDIT: CODES ‘2’ (CONTACT PERSON/ADDRESS CORRECT) |
| AND ‘3’ (CONTACT PERSON/ADDRESS NEEDS CORRECTION) |
| CANNOT BE SELECTED IF NO CURRENT CONTACT PERSON |
| INFORMATION AVAILABLE. IF CODES ‘2’ OR ‘3’ |
| SELECTED WHEN NO CURRENT CONTACT INFORMATION, |
| DISPLAY THE FOLLOWING MESSAGE: ‘CODE NOT |
| AVAILABLE. NO CURRENT CONTACT INFORMATION. |
| VERIFY AND RE-ENTER.’ |
----------------------------------------------------
CL51 ====
[What is the name, address, and phone number of that person?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT CONTACT INFORMATION.
IF UNAVAILABLE, ENTER COMPLETE CONTACT INFORMATION.
TO VERIFY CURRENT INFORMATION OR TO LEAVE A FIELD BLANK, PRESS
ENTER. TO CORRECT OR ENTER INFORMATION, TYPE ENTIRE FIELD.
ENTER ‘NMN’ IF NO MIDDLE NAME.
Current Info: [CONTACT_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
CONTACT_NAME (CL51_01): [_____________]
1ST_STR_ADDRESS (CL51_02): [_____________]
2ND_STR_ADDRESS (CL51_03): [_____________]
CITY (CL51_04): [_____________]
STATE (CL51_05): [_____________]
ZIP CODE (CL51_06): [_____________]
TELEPHONE (CL51_07): [_____________]
PRESS F1 FOR LIST OF STATE ABBREVIATIONS.
----------------------------------------------------
| EDIT: IF NO CURRENT CONTACT ADDRESS AVAILABLE, |
| AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT |
| SECOND STREET ADDRESS (REF AND DK ARE ALLOWED). |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF CURRENT CONTACT ADDRESS AVAILABLE, AT |
| LEAST ONE FIELD MUST BE UPDATED. |
----------------------------------------------------
----------------------------------------------------
| FLAG CONTACT PERSON INFORMATION FOR THE RU WITH |
| THE NAME, ADDRESS, AND PHONE ENTERED OR CORRECTED |
| AT CL51 FOR THE CURRENT ROUND. |
----------------------------------------------------
CL52 ====
CONTACT PERSON: {NAME OF CONTACT PERSON FROM CL51_01}
REFERENCE PERSON: {NAME OF REFERENCE PERSON}
[What is (CONTACT PERSON)’s relationship to (REFERENCE PERSON)?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT CONTACT RELATIONSHIP.
IF UNAVAILABLE, ENTER COMPLETE CONTACT RELATIONSHIP.
TO VERIFY CURRENT INFORMATION OR TO LEAVE A FIELD BLANK, PRESS
ENTER. TO CORRECT OR ENTER INFORMATION, TYPE ENTIRE FIELD.
Current Info: [CONTACT_RELATIONSHIP]
CONTACT_RELATIONSHIP (CL52_01): [_____________]
----------------------------------------------------
| DISPLAY THE NAME ENTERED AT CL51_01 FOR ‘NAME OF |
| CONTACT PERSON FROM CL51_01’. |
| |
| DISPLAY THE NAME OF THE REFERENCE PERSON FOR THE |
| RU FOR ‘NAME OF REFERENCE PERSON’. |
----------------------------------------------------
----------------------------------------------------
| THE ENTRY FIELD FOR CL52_01 SHOULD BE 45 |
| CHARACTERS OF FREE FORM TEXT IN LENGTH. |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF NO CURRENT CONTACT RELATIONSHIP |
| AVAILABLE, AN ENTRY MUST BE MADE (REF AND DK ARE |
| ALLOWED). |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF CURRENT CONTACT RELATIONSHIP AVAILABLE, |
| ACCEPT AN ENTRY, REF OR DK, OR NO UPDATE. |
----------------------------------------------------
----------------------------------------------------
| FLAG CONTACT PERSON RELATIONSHIP FOR THE RU WITH |
| THE RELATIONSHIP ENTERED OR CORRECTED AT CL52 FOR |
| THE CURRENT ROUND. |
----------------------------------------------------
CL53 ====
ITEM: ALTERNATE RESPONDENT - BEST PERSON TO PROVIDE HEALTH CARE
AND EXPENSES INFORMATION FOR THIS FAMILY IF CURRENT
RESPONDENT IS UNAVAILABLE DURING NEXT INTERVIEW.
INTERVIEWER: IF AVAILABLE, VERIFY CURRENT ALTERNATE RESPONDENT
INFORMATION SHOWN BELOW. IF NO CURRENT INFORMATION,
PROBE:
If you are not available for the next interview, who
would be the best person to provide information about
the family for the next interview?
Current Info: [ALTERNATE_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
ENTER NEW ALTERNATE RESPONDENT
INFORMATION .......................... 1
ALTERNATE RESPONDENT INFORMATION
CORRECT .............................. 2 {CL56}
ALTERNATE RESPONDENT INFORMATION NEEDS
CORRECTION ........................... 3
NO CURRENT ALTERNATE RESPONDENT ........ 4 {CL57}
REF ................................... -7 {CL57}
DK .................................... -8 {CL57}
----------------------------------------------------
| EDIT: CODES ‘2’ (ALTERNATE RESPONDENT INFORMATION|
| CORRECT) AND ‘3’ (ALTERNATE RESPONDENT INFORMATION|
| NEEDS CORRECTION) CANNOT BE SELECTED IF NO CURRENT|
| ALTERNATE RESPONDENT INFORMATION AVAILABLE. IF |
| CODES ‘2’ OR ‘3’ SELECTED WHEN NO CURRENT |
| ALTERNATE RESPONDENT INFORMATION, DISPLAY THE |
| FOLLOWING MESSAGE: ‘CODE NOT AVAILABLE. NO |
| NO CURRENT ALTERNATE INFORMATION. VERIFY AND |
| RE-ENTER.’ |
----------------------------------------------------
----------------------------------------------------
| NOTE: IF CURRENT ALTERNATE RESPONDENT IS A DU |
| MEMBER, DO NOT DISPLAY CURRENT ADDRESS AND PHONE |
| INFORMATION. ONLY DISPLAY CURRENT ADDRESS AND |
| PHONE INFORMATION IF CURRENT ALTERNATE RESPONDENT |
| IS OUTSIDE OF THE DU. |
----------------------------------------------------
CL54 ====
INTERVIEWER: SELECT PERSON NAMED FROM ROSTER.
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
----------------------------------------------------
| ROSTER DEFINITION: DISPLAY ALL PERSONS ON DU- |
| MEMBERS-ROSTER WHO MEET THE FOLLOWING CONDITIONS: |
| - PERSON IS NOT CURRENT RESPONDENT |
| - PERSON IS NOT DECEASED |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘SOMEONE OUTSIDE DU’ AS LAST ENTRY ON |
| ROSTER. |
----------------------------------------------------
----------------------------------------------------
| IF DU MEMBER SELECTED, FLAG ALTERNATE RESPONDENT |
| INFORMATION FOR THE RU WITH THE PERSON SELECTED AT|
| CL54 FOR THE CURRENT ROUND. |
----------------------------------------------------
----------------------------------------------------
| IF ‘SOMEONE OUTSIDE DU’ SELECTED, CONTINUE WITH |
| CL55 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO CL57 |
----------------------------------------------------
CL55 ====
[What is the name, address, and phone number of that person?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT ALTERNATE RESPONDENT.
IF UNAVAILABLE, ENTER COMPLETE ALTERNATE RESPONDENT INFORMATION.
TO VERIFY CURRENT INFORMATION OR TO LEAVE A FIELD BLANK, PRESS
ENTER. TO CORRECT OR ENTER INFORMATION, TYPE ENTIRE FIELD.
ENTER ‘NMN’ IF NO MIDDLE NAME.
Current Info: [ALTERNATE_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
ALTERNATE_NAME (CL55_01): [_____________]
1ST_STR_ADDRESS (CL55_02): [_____________]
2ND_STR_ADDRESS (CL55_03): [_____________]
CITY (CL55_04): [_____________]
STATE (CL55_05): [_____________]
ZIP CODE (CL55_06): [_____________]
TELEPHONE (CL55_07): [_____________]
PRESS F1 FOR LIST OF STATE ABBREVIATIONS.
----------------------------------------------------
| EDIT: IF NO CURRENT ALTERNATE ADDRESS AVAILABLE, |
| AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT |
| SECOND STREET ADDRESS (REF AND DK ARE ALLOWED). |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF CURRENT ALTERNATE ADDRESS AVAILABLE, AT |
| LEAST ONE FIELD MUST BE UPDATED. |
----------------------------------------------------
----------------------------------------------------
| FLAG ALTERNATE RESPONDENT INFORMATION FOR THE RU |
| WITH THE NAME, ADDRESS, AND PHONE ENTERED OR |
| CORRECTED AT CL55 FOR THE CURRENT ROUND. |
----------------------------------------------------
CL56 ====
ALTERNATE RESPONDENT: {NAME OF ALTERNATE RESPONDENT CL55_01}
REFERENCE PERSON: {NAME OF REFERENCE PERSON}
[What is (ALTERNATE RESPONDENT)’s relationship to (REFERENCE
PERSON)?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT ALTERNATE RESPONDENT.
IF UNAVAILABLE, ENTER COMPLETE ALTERNATE RESPONDENT RELATIONSHIP.
TO VERIFY CURRENT INFORMATION OR TO LEAVE A FIELD BLANK, PRESS
ENTER. TO CORRECT OR ENTER INFORMATION, TYPE ENTIRE FIELD.
Current Info: [ALTERNATE_RELATIONSHIP]
ALTERNATE_RELATIONSHIP (CL56_01): [_____________]
----------------------------------------------------
| DISPLAY THE NAME ENTERED AT CL55_01 FOR ‘NAME OF |
| ALTERNATE RESPONDENT CL55_01’. |
| |
| DISPLAY THE NAME OF THE REFERENCE PERSON FOR THE |
| RU FOR ‘NAME OF REFERENCE PERSON’. |
----------------------------------------------------
----------------------------------------------------
| THE ENTRY FIELD FOR CL56_01 SHOULD BE 45 |
| CHARACTERS OF FREE FORM TEXT IN LENGTH. |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF NO CURRENT ALTERNATE RELATIONSHIP |
| AVAILABLE, AN ENTRY MUST BE MADE (REF AND DK ARE |
| ALLOWED). |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF CURRENT ALTERNATE RELATIONSHIP AVAILABLE,|
| ACCEPT AN ENTRY, REF OR DK, OR NO UPDATE. |
----------------------------------------------------
----------------------------------------------------
| FLAG ALTERNATE RESPONDENT RELATIONSHIP FOR THE RU |
| WITH THE RELATIONSHIP ENTERED OR CORRECTED AT CL56|
| FOR THE CURRENT ROUND. |
----------------------------------------------------
CL57 ====
Is anyone in the family planning to move within the next 3
months?
YES .................................... 1
NO ..................................... 2 {BOX_18}
REF ................................... -7 {BOX_18}
DK .................................... -8 {BOX_18}
CL58 ====
Who is that?
PROBE: Anyone else?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS|
| ON THE RU-MEMBERS-ROSTER WHO MEET THE FOLLOWING |
| CONDITION: |
| - PERSON IS A CURRENT RU MEMBER (I.E., PERSON PART|
| OF THE RU ON INTERVIEW DATE) |
----------------------------------------------------
LOOP_11 =======
----------------------------------------------------
| FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK |
| CL59 - END_LP11 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_11 COLLECTS ADDRESS |
| INFORMATION FOR POTENTIAL FUTURE MOVERS. THIS |
| LOOP CYCLES ON PERSONS ON THE RU-MEMBERS-ROSTER |
| WHO MEET THE FOLLOWING CONDITIONS: |
| - PERSON IS A CURRENT RU MEMBER (I.E., PERSON PART|
| OF THE RU ON INTERVIEW DATE) |
| - PERSON SELECTED AS A FUTURE MOVER (I.E., |
| SELECTED AT CL58) |
| - PERSON NOT FLAGGED AS ‘PROCESSED FUTURE MOVER’ |
----------------------------------------------------
CL59 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Please give me the address and telephone number of the place
where (PERSON) is planning to move.
1ST_STR_ADDRESS (CL59_01): [_____________]
2ND_STR_ADDRESS (CL59_02): [_____________]
CITY (CL59_03): [_____________]
STATE (CL59_04): [_____________]
ZIP CODE (CL59_05): [_____________]
TELEPHONE (CL59_06): [_____________]
PRESS F1 FOR LIST OF STATE ABBREVIATIONS.
----------------------------------------------------
| REFUSED AND DON’T KNOW ALLOWED FOR EACH FIELD. |
----------------------------------------------------
----------------------------------------------------
| FLAG PERSON AS ‘PROCESSED FUTURE MOVER’. |
----------------------------------------------------
----------------------------------------------------
| IF ALL PERSONS SELECTED AS FUTURE MOVERS (I.E., |
| SELECTED AT CL58) ARE FLAGGED AS ‘PROCESSED FUTURE|
| MOVER’, GO TO END_LP11 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH CL60 |
----------------------------------------------------
CL60 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
IF KNOWN, CODE WITHOUT ASKING.
Is (PERSON) planning to move with anyone in the family?
YES .................................... 1
NO ..................................... 2 {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}
CL61 ====
{PERSON’S FIRST MIDDLE AND LAST NAME}
IF KNOWN, CODE WITHOUT ASKING.
Who is (PERSON) planning to move with?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS ALL PERSONS|
| IN THE RU-MEMBERS-ROSTER WHO MEET THE FOLLOWING |
| CONDITIONS: |
| - PERSON IS A CURRENT RU MEMBER (I.E., PERSON PART|
| OF THE RU ON INTERVIEW DATE) |
| - PERSON SELECTED AS A FUTURE MOVER (I.E., |
| SELECTED AT CL58) |
| - PERSON NOT FLAGGED AS ‘PROCESSED FUTURE MOVER’ |
----------------------------------------------------
----------------------------------------------------
| FLAG ALL SELECTED PERSONS AS ‘PROCESSED FUTURE |
| MOVER’. |
----------------------------------------------------
END_LP11 ========
----------------------------------------------------
| CYCLE ON NEXT PERSON ON THE RU-MEMBERS-ROSTER WHO |
| MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION|
----------------------------------------------------
----------------------------------------------------
| IF NO OTHER PERSONS MEET THE STATED CONDITIONS, |
| END LOOP_11 AND CONTINUE WITH BOX_18 |
----------------------------------------------------
BOX_18 ======
----------------------------------------------------
| IF CURRENT RESPONDENT IS A PROXY, CONTINUE WITH |
| BOX_18A |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO CL62 |
----------------------------------------------------
BOX_18A =======
----------------------------------------------------
| IF NOT ROUND 5, CONTINUE WITH CL61A |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE (I.E., IF ROUND 5), GO TO CL62 |
----------------------------------------------------
CL61A =====
ITEM: PROXY INFORMATION - NEED ADDRESS AND PHONE NUMBER OF
CURRENT PROXY.
INTERVIEWER: IF AVAILABLE, VERIFY CURRENT PROXY ADDRESS SHOWN
BELOW.
IF NO CURRENT INFORMATION, PROBE FOR NEW PROXY
ADDRESS (IF AVAILABLE).
Current Info: [PROXY_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
ENTER NEW PROXY ADDRESS AND TELEPHONE... 1
PROXY ADDRESS AND TELEPHONE CORRECT .... 2 {CL62}
PROXY ADDRESS OR TELEPHONE NEEDS
CORRECTION ........................... 3
NO CURRENT PROXY ADDRESS ............... 4 {CL62}
REF ................................... -7 {CL62}
DK .................................... -8 {CL62}
----------------------------------------------------
| EDIT: CODES ‘2’ (PROXY ADDRESS AND TELEPHONE |
| CORRECT) AND ‘3’ (PROXY ADDRESS OR TELEPHONE NEEDS|
| CORRECTION) CANNOT BE SELECTED IF NO CURRENT PROXY|
| ADDRESS INFORMATION AVAILABLE. IF CODES ‘2’ OR |
| ‘3’ SELECTED WHEN NO CURRENT PROXY ADDRESS, |
| DISPLAY THE FOLLOWING MESSAGE: ‘CODE NOT |
| AVAILABLE. NO CURRENT PROXY ADDRESS. VERIFY AND |
| RE-ENTER.’ |
----------------------------------------------------
CL61B =====
[What is your address and phone number?]
IF AVAILABLE, VERIFY AND UPDATE CURRENT PROXY ADDRESS.
IF UNAVAILABLE, ENTER COMPLETE PROXY ADDRESS.
TO VERIFY CURRENT INFORMATION OR TO LEAVE A FIELD BLANK, PRESS
ENTER. TO CORRECT OR ENTER INFORMATION, TYPE ENTIRE FIELD.
Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
1ST_STR_ADDRESS (CL61B_01): [_____________]
2ND_STR_ADDRESS (CL61B_02): [_____________]
CITY (CL61B_03): [_____________]
STATE (CL61B_04): [_____________]
ZIP CODE (CL61B_05): [_____________]
TELEPHONE (CL61B_06): [_____________]
PRESS F1 FOR LIST OF STATE ABBREVIATIONS.
----------------------------------------------------
| EDIT: IF NO CURRENT PROXY ADDRESS AVAILABLE, AN |
| ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT SECOND |
| STREET ADDRESS (REF AND DK ARE ALLOWED). |
----------------------------------------------------
----------------------------------------------------
| EDIT: IF CURRENT PROXY ADDRESS AVAILABLE, AT |
| LEAST ONE FIELD MUST BE UPDATED. |
----------------------------------------------------
----------------------------------------------------
| FLAG PROXY ADDRESS INFORMATION FOR THE RU WITH THE|
| ADDRESS AND PHONE ENTERED OR CORRECTED AT CL61B |
| FOR THE CURRENT ROUND. |
----------------------------------------------------
CL62 ====
INTERVIEWER: DID YOU COMPLETE THIS INTERVIEW IN-PERSON OR BY
TELEPHONE? (YOU MUST HAVE SUPERVISOR APPROVAL PRIOR TO
INTERVIEWING BY TELEPHONE.)
IN-PERSON .............................. 1
BY TELEPHONE ........................... 2
[Code One]
CL62A =====
INTERVIEWER: WHAT LANGUAGE WAS THIS INTERVIEW COMPLETED IN?
ENGLISH ................................ 1 {CL63}
SPANISH ................................ 2 {CL63}
BOTH ENGLISH AND SPANISH ............... 3 {CL63}
OTHER LANGUAGE ........................ 91
[Code One]
CL62AOV =======
ENTER OTHER LANGUAGE:
[Enter Other Specify-45] ...............
CL63 ====
INTERVIEWER: WAS ANYONE OTHER THAN THE {RESPONDENT/PROXY}
PRESENT FOR ALL OR PART OF THE INTERVIEW?
NO ONE ELSE PRESENT .................... 1 {CL65}
SOMEONE ELSE PRESENT FOR ALL OF
INTERVIEW ........................... 2
SOMEONE ELSE PRESENT FOR PART OF
INTERVIEW ........................... 3
[Code One]
----------------------------------------------------
| DISPLAY ‘RESPONDENT’ IF CURRENT RESPONDENT IS AN |
| RU MEMBER. DISPLAY ‘PROXY’ IF CURRENT RESPONDENT |
| IS A PROXY. |
----------------------------------------------------
CL64 ====
INTERVIEWER: CODE ALL OTHER PERSONS PRESENT DURING INTERVIEW.
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS PERSONS |
| ON THE DU-MEMBERS-ROSTER WHO MEET THE FOLLOWING |
| CONDITION(S): |
| - PERSON IS ON THE DU ROSTER, BUT NOT THE RU |
| ROSTER |
| OR |
| - PERSON ON THE RU ROSTER AND WAS ELIGIBLE AT THE |
| END OF RE-ENUMERATION AND IS PHYSICALLY IN THE |
| RU ON THE INTERVIEW DATE |
| AND |
| - PERSON IS NOT IDENTIFIED AS CURRENT RESPONDENT |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘SOMEONE OUTSIDE DU’ AS LAST ENTRY ON THE |
| ROSTER. |
----------------------------------------------------
CL65 ====
INTERVIEWER: USE BLACK BALL POINT PEN TO COMPLETE CHECKS AND
FORMS.
{1a. FILL OUT SAQ CHECK(S) WITH SAQ RESPONDENT NAME(S).}
1b. FILL OUT INTERVIEW CHECK FOR PARTICIPATION WITH RESPONDENT'S
NAME.
{2a. COMPLETE THE RECEIPT AND AGREEMENT FORM AND RECORD THE SAQ
CHECK(S).}
2b. COMPLETE THE RECEIPT AND AGREEMENT FORM AND RECORD THE INTERVIEW
PARTICIPATION CHECK AND HAVE RESPONDENT SIGN IT.
{3a. COMPLETE SAQ CHECK LOG.}
3b. COMPLETE THE RESPONDENT PAYMENT CHECK LOG.
PRESS ENTER TO CONTINUE.
----------------------------------------------------
| DISPLAY ‘1a. FILL ... NAME(S).’ AND ‘2a. |
| COMPLETE ... SAQ CHECK(S)’ AND ‘3a. COMPLETE |
| SAQ CHECK LOG.’ IF ROUNDS 2-5 AND IF ANY CL36 |
| OR CL39 IS CODED ‘1’ (COMPLETED AND GIVEN TO |
| INTERVIEWER.) OTHERWISE, USE A NULL DISPLAY. |
----------------------------------------------------
CL66 ====
INTERVIEWER:
4. GIVE RESPONDENT CHECK(S) AND READ STATEMENTS BELOW:
Thank you again for your cooperation in this important research.
{This check is payment in advance for keeping records from today
until the next interview. This next interview will take place in
{the fall of 2005/early 2006/the fall of 2006/early 2007}./This
check is for your efforts in keeping records and participating in
this survey.}
5. THANK RESPONDENT FOR THIS INTERVIEW.
6. {ASK RESPONDENT TO KEEP RECORDS FOR NEXT INTERVIEW AND GIVE
RESPONDENT GIFT./GIVE RESPONDENT CERTIFICATE:
I would also like to thank you on behalf of the two Public Health
Service agencies that sponsor this study -- the Agency for Healthcare
Research and Quality and the National Center for Health statistics.
As a token of their appreciation, they would like you to have this
certificate of commendation recognizing your contributions of time
and effort in a research project to help enlighten Americans about
our health care system.}
PRESS ENTER TO CONTINUE.
----------------------------------------------------
| DISPLAY ‘This ... /early 2007}.’ IF ROUNDS 1-4. |
| OTHERWISE, DISPLAY ‘This check ... this survey.’ |
| |
| DISPLAY ‘the fall of 2005’ IF ROUND 1. DISPLAY |
| ‘early 2006’ IF ROUND 2. DISPLAY ‘the fall of |
| 2006’ IF ROUND 3. DISPLAY ‘early 2007’ IF ROUND 4.|
| |
| DISPLAY ‘ASK ... GIFT.’ IF ROUNDS 1-4. |
| DISPLAY ‘GIVE RESPONDENT ... health care system.’ |
| IF ROUND 5. |
----------------------------------------------------
CL67 ====
INTERVIEWER: WERE ANY OF THE FOLLOWING MEMORY AIDS USED BY THE
RESPONDENT(S) DURING THE INTERVIEW?
Yes No
CL67_01 =======
MONTHLY PLANNER
WITH ENTRIES 1 2
CL67_02 =======
MONTHLY PLANNER
WITHOUT ENTRIES 1 2
CL67_03 =======
HEALTH EVENTS RECORD
WORKSHEET 1 2
CL67_04 =======
RECORD FILE 1 2
CL67_05 =======
OTHER CALENDAR 1 2
CL67_06 =======
CHECK BOOK 1 2
CL67_07 =======
BILL/STATEMENT FROM
PROVIDER 1 2
CL67_08 =======
INSURANCE PAYMENT
STATEMENT 1 2
CL67_09 =======
MEDICINE
BOTTLE/RECEIPT 1 2
CL67_10 =======
OTHER 1 2
----------------------------------------------------
| IF CL67_10 IS CODED '1' (YES), CONTINUE WITH |
| CL68 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_20 |
----------------------------------------------------
CL68 ====
WHICH OTHER MEMORY AIDS?
Yes No
CL68_01 =======
DOCTOR'S CARD OR
APPOINTMENT SLIP 1 2
CL68_02 =======
INSURANCE POLICY 1 2
CL68_03 =======
INSURANCE CARDS 1 2
CL68_04 =======
TELEPHONE BOOK 1 2
CL68_05 =======
OTHER 1 2
----------------------------------------------------
| IF CL68_01 THROUGH CL68_05 ARE ALL CODED `2’ (NO),|
| CAPI DISPLAYS THE FOLLOWING MESSAGE: `AT LEAST |
| ONE FIELD SHOULD BE CODED 1.’ THE INTERVIEWER |
| MUST RE-ENTER RESPONSES TO CL68_01 THROUGH |
| CL68_05. |
----------------------------------------------------
----------------------------------------------------
| IF CL68_05 IS CODED '1' (YES), CONTINUE WITH |
| CL68OV |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_20 |
----------------------------------------------------
CL68OV ======
ENTER OTHER:
[Enter Other Specify] ..................
BOX_20 ======
----------------------------------------------------
| END INTERVIEW. |
----------------------------------------------------