Prescribed Medicines (PM) Section
PM01 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
The next questions are about prescription medicines (PERSON)
purchased or received {since (START DATE)/between (START DATE)
and (END DATE)}.
[It would be very helpful for the following questions if we
could look at the bottles, containers, tubes, or bags for each
of the medicines we will be talking about.]
PRESS ENTER TO CONTINUE.
----------------------------------------------------
| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
----------------------------------------------------
----------------------------------------------------
| IF PERSON HAS NO MEDICINES CREATED OR SELECTED |
| DURING THE CURRENT ROUND (ON PERSON’S-PRESCRIBED- |
| MEDICINES-ROSTER), GO TO PM04 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH PM02 |
----------------------------------------------------
----------------------------------------------------
| NOTE: MEDICINES ARE FLAGGED AS ‘CREATED’ ONLY |
| ONCE (I.E., DURING THE ROUND WHERE THE MEDICINE IS|
| INITIALLY REPORTED). MEDICINES ARE FLAGGED AS |
| ‘SELECTED’ WHEN CHOSEN DURING SUBSEQUENT ROUNDS. |
| THUS, FOR ONE ROUND, A MEDICINE CAN ONLY BE |
| FLAGGED AS EITHER ‘CREATED’ OR ‘SELECTED’. |
----------------------------------------------------
PM02 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
While we were talking about (PERSON)'s medical care, we listed
the following prescription(s) as purchased or received {since
(START DATE)/between (START DATE) and (END DATE)}. (READ
MEDICINES BELOW.)
TO SCROLL, USE ARROW KEYS.
TO LEAVE BOX AND GO TO ENTRY FIELD, PRESS ESC.
{NAME OF PRESCRIPTION MEDICINE.}
{NAME OF PRESCRIPTION MEDICINE.}
{NAME OF PRESCRIPTION MEDICINE.}
INFORMATION OKAY ....................... 1 {PM04}
AT LEAST ONE MEDICINE INCORRECT ........ 2
[Code One]
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS ALL |
| MEDICINES IN THE PERSON’S-PRESCRIBED-MEDICINES- |
| ROSTER THAT ARE FLAGGED AS EITHER ‘CREATED’ OR |
| ‘SELECTED’ DURING THE CURRENT ROUND. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
----------------------------------------------------
----------------------------------------------------
| IF CODED '2' (AT LEAST ONE MEDICINE INCORRECT) AND|
| THERE IS ONLY ONE MEDICINE ON PERSON’S-PRESCRIBED-|
| MEDICINES-ROSTER, SELECT THAT MEDICINE |
| AUTOMATICALLY BY CAPI AT PM03 AND GO TO PM04 |
----------------------------------------------------
----------------------------------------------------
| IF CODED '2' (AT LEAST ONE MEDICINE INCORRECT) AND|
| THERE IS MORE THAN ONE MEDICINE ON PERSON’S- |
| PRESCRIBED-MEDICINES-ROSTER, CONTINUE WITH PM03 |
----------------------------------------------------
PM03 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
SELECT MEDICINE(S) THAT WERE RECORDED INCORRECTLY.
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
[1. Prescribed Medicine]
[2. Prescribed Medicine]
[3. Prescribed Medicine]
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS ALL |
| MEDICINES IN THE PERSON’S-PRESCRIBED-MEDICINES- |
| ROSTER THAT ARE FLAGGED AS EITHER ‘CREATED’ OR |
| ‘SELECTED’ DURING THE CURRENT ROUND. |
----------------------------------------------------
----------------------------------------------------
| ROSTER BEHAVIOR SPECIFICATIONS: |
| |
| 1. INTERVIEWER MAY SELECT A MEDICINE(S) ALREADY |
| LISTED ON THE ROSTER. |
| 2. DO NOT ALLOW MEDICINES TO BE ADDED, EDITED OR |
| DELETED. |
----------------------------------------------------
----------------------------------------------------
| FLAG SELECTED MEDICINES AS 'INCORRECT'. THESE |
| MEDICINES WILL NOT BE ELIGIBLE FOR LOOP_01 (I.E., |
| NOT ‘CREATED’ OR ‘SELECTED’ THIS ROUND). |
----------------------------------------------------
PM04 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
{Since (START DATE)/Between (START DATE) and (END DATE)},
(have/has) (PERSON) obtained any medicines [we have not yet
talked about]? For example, (have/has) (PERSON) had any new
prescriptions or a refill of a prescription?
Please include any on-line prescriptions.
YES .................................... 1
NO ..................................... 2 {PM06}
REF ................................... -7 {PM06}
DK .................................... -8 {PM06}
PRESS F1 FOR DEFINITION OF PRESCRIPTIONS AND REFILLS.
----------------------------------------------------
| DISPLAY ‘Since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘Between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
----------------------------------------------------
PM05 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
What were the names of these medicines?
PROBE: Any other medicines?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Prescribed Medicine]
[2. Prescribed Medicine]
[3. Prescribed Medicine]
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS PERSON’S- |
| PRESCRIBED-MEDICINES-ROSTER. |
----------------------------------------------------
----------------------------------------------------
| ROSTER BEHAVIOR SPECIFICATIONS: |
| |
| 1. INTERVIEWER MAY SELECT A MEDICINE(S) ALREADY |
| LISTED ON THE ROSTER. |
| 2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF|
| MEDICINES AT THE ROSTER QUESTIONS (I.E., NO |
| LIMIT TO THE NUMBER OF MEDICINES). |
| 3. INTERVIEWER SHOULD BE ABLE TO DELETE A MEDICINE|
| THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS|
| USED. THAT IS, AS LONG AS THE INTERVIEWER HAS |
| NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO |
| DELETE A MEDICINE ENTERED IN ERROR. IF DELETE |
| IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED |
| (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY |
| THE FOLLOWING ERROR MESSAGE: ‘DELETE ALLOWED |
| ONLY WHEN MEDICINE IS FIRST ENTERED.’ |
| 4. ANY MEDICINE ADDED TO THE ROSTER SHOULD BE |
| FLAGGED AS ‘CREATED’ THIS ROUND (WITH THE ROUND|
| STATUS). ANY MEDICINE SELECTED AT THE ROSTER |
| SHOULD BE FLAGGED AS ‘SELECTED’ THIS ROUND |
| (WITH THE ROUND STATUS). THIS FLAGGING SHOULD |
| OCCUR, AT EACH PERSON’S-PRESCRIBED-MEDICINES- |
| ROSTER THROUGHOUT THE INSTRUMENT (UNLESS |
| OTHERWISE SPECIFIED), THE FIRST TIME THE |
| MEDICINE IS ADDED OR SELECTED DURING THE ROUND.|
| FOR EXAMPLE, IF IT IS ROUND 1, ALL MEDICINES |
| ON THE ROSTER WOULD HAVE THE FLAG ‘CREATED - |
| ROUND 1’. IF A MEDICINE IS CREATED IN HS, BUT |
| SELECTED IN MV, ALL DURING ROUND 1, IT WOULD |
| ONLY HAVE THE FLAG ‘CREATED - ROUND 1’. THUS, |
| FOR ANY ONE ROUND, A MEDICINE CAN ONLY BE |
| FLAGGED AS ‘CREATED’ OR ‘SELECTED’. IF IT |
| IS ROUND 2 AND A MEDICINE THAT WAS CREATED IN |
| ROUND 1 IS SELECTED, IT SHOULD BE FLAGGED AS |
| ‘SELECTED - ROUND 2’. THIS FLAG IS IN ADDITION|
| TO THE ORIGINAL ‘CREATED - ROUND 1’ FLAG. |
----------------------------------------------------
----------------------------------------------------
| THE PERSON’S-PRESCRIBED-MEDICINES-ROSTER WILL |
| CONTAIN ALL PREVIOUSLY CREATED PRESCRIBED |
| MEDICINES FROM ALL PREVIOUS ROUNDS, AS WELL AS |
| MEDICINES FROM THE CURRENT ROUND. WHEN A MEDICINE|
| FROM A PREVIOUS ROUND IS SELECTED, A NEW EVENT IS |
| CREATED SINCE IT INVOLVES A NEW PURCHASE. A NEW |
| PURCHASE REQUIRES ASKING CP AND WHAT PHARMACY. |
| THE REASON FOR INCLUDING ALL OF THE PRESCRIBED |
| MEDICINES ON THE ROSTER IS SIMPLY TO AVOID THE |
| INTERVIEWER HAVING TO TYPE THEM IN AGAIN (IF THE |
| PERSON IS GETTING REFILLS OF THE SAME MEDICINE |
| EVERY ROUND). |
----------------------------------------------------
PM06 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
{Since (START DATE)/Between (START DATE) and (END DATE)}, did
(PERSON) get any free samples of prescribed medicines from a
medical or dental provider that we have not yet talked about?
YES .................................... 1
NO ..................................... 2 {BOX_01}
REF ................................... -7 {BOX_01}
DK .................................... -8 {BOX_01}
PRESS F1 FOR DEFINITION OF FREE SAMPLES.
----------------------------------------------------
| DISPLAY ‘Since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘Between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
----------------------------------------------------
PM07 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
What are the names of the medicines (PERSON) got as free
samples?
PROBE: Any other free samples?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Prescribed Medicine]
[2. Prescribed Medicine]
[3. Prescribed Medicine]
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS PERSON’S- |
| PRESCRIBED-MEDICINES-ROSTER. |
----------------------------------------------------
----------------------------------------------------
| SEE PM05 FOR PRESCRIBED MEDICINE ROSTER BEHAVIOR |
| SPECIFICATIONS. |
----------------------------------------------------
----------------------------------------------------
| ONLY MEDICINES CREATED AT PM07 DURING THE CURRENT |
| ROUND SHOULD BE FLAGGED AS 'FREE SAMPLE'. |
----------------------------------------------------
BOX_01 ======
----------------------------------------------------
| IF NO MEDICINES FLAGGED AS ‘CREATED’ OR ‘SELECTED’|
| DURING THE CURRENT ROUND, GO TO BOX_06 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH LOOP_01 |
----------------------------------------------------
LOOP_01 =======
----------------------------------------------------
| FOR EACH ELEMENT IN PERSON’S-PRESCRIBED-MEDICINES-|
| ROSTER, ASK BOX_01A-END_LP01 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_01 COLLECTS INFORMATION |
| ABOUT EACH PRESCRIBED MEDICINE CREATED OR SELECTED|
| DURING THE CURRENT ROUND. THIS LOOP CYCLES ON |
| PRESCRIBED MEDICINES THAT MEET ONE OF THE |
| FOLLOWING CONDITIONS: |
| |
| - PRESCRIBED MEDICINE IS FLAGGED AS ‘CREATED’ |
| DURING THE CURRENT ROUND. |
| OR |
| - PRESCRIBED MEDICINE IS FLAGGED AS ‘SELECTED’ |
| DURING THE CURRENT ROUND. |
----------------------------------------------------
BOX_01A =======
----------------------------------------------------
| IF ROUND 5, CONTINUE WITH PM07A |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO PM08 |
----------------------------------------------------
PM07A =====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF PRESCRIPTION
MEDICINE.} {STR-DT}
{END-DT}
Now, let’s talk about (MEDICINE).
Was (MEDICINE) purchased or obtained sometime between (START
DATE) and (END DATE)?
YES .................................... 1
NO ..................................... 2 {END_LP01}
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| IF CODED ‘2’ (NO), FLAG MEDICINE AS ‘INCORRECT’. |
| THIS MEDICINE SHOULD NOT BE FLAGGED AS ‘CREATED’ |
| OR ‘SELECTED’ FOR ROUND 5. |
----------------------------------------------------
PM08 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF PRESCRIPTION
MEDICINE.} {STR-DT}
{END-DT}
{Now, let’s talk about (MEDICINE).}
Is (MEDICINE) used for a specific health problem?
YES .................................... 1
NO ..................................... 2 {BOX_02A}
REF ................................... -7 {BOX_02A}
DK .................................... -8 {BOX_02A}
----------------------------------------------------
| DISPLAY ‘Now let’s talk about (MEDICINE).’ IF NOT |
| ROUND 5. IF ROUND 5, USE A NULL DISPLAY. |
----------------------------------------------------
PM09 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF PRESCRIPTION
MEDICINE.} {STR-DT}
{END-DT}
What health problem is (MEDICINE) prescribed for?
PROBE: Any other health problems?
IF CONDITION IS ALREADY LISTED, ASK: Is this the same (NAME
OF CONDITION) that we have talked about before?
IF SAME EPISODE OF CONDITION, SELECT ENTRY ON ROSTER.
IF NEW EPISODE OF CONDITION, ADD TO ROSTER.
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[1. Medical Condition]
[2. Medical Condition]
[3. Medical Condition]
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS PERSON’S- |
| MEDICAL-CONDITIONS-ROSTER. |
----------------------------------------------------
----------------------------------------------------
| ROSTER BEHAVIOR SPECIFICATIONS: |
| |
| 1. INTERVIEWER MAY SELECT A CONDITION(S) ALREADY |
| LISTED ON THE ROSTER. DOING SO SHOULD NOT |
| IMPACT THE ROUND FLAG OF THE CONDITION. |
| 2. INTERVIEWER SHOULD BE ABLE TO ADD ANY NUMBER OF|
| CONDITIONS AT THE ROSTER QUESTIONS (I.E., NO |
| LIMIT TO THE NUMBER OF CONDITIONS). AS |
| CONDITIONS ARE ENTERED, THEY SHOULD BE FLAGGED |
| WITH THE NUMBER OF THE ROUND IN WHICH THEY WERE|
| FIRST CREATED. THIS ROUND FLAG WILL BE USED |
| LATER IN THE INTERVIEW TO DETERMINE WHICH |
| QUESTIONS SHOULD BE ASKED. |
| 3. INTERVIEWER SHOULD BE ABLE TO DELETE CONDITION |
| THAT WAS RECORDED ON THE SCREEN WHERE DELETE IS|
| USED. THAT IS, AS LONG AS THE INTERVIEWER HAS |
| NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO |
| DELETE A CONDITION ENTERED IN ERROR. IF DELETE|
| IS ATTEMPTED AT A TIME WHEN IT IS NOT ALLOWED |
| (I.E., AFTER THE LINK IS ESTABLISHED), DISPLAY |
| THE FOLLOWING ERROR MESSAGE: ‘DELETE ALLOWED |
| ONLY WHEN CONDITION IS FIRST ENTERED.’ |
----------------------------------------------------
BOX_02A =======
----------------------------------------------------
| IF MEDICINE BEING ASKED ABOUT IS FLAGGED AS |
| ‘SELECTED’ DURING THE CURRENT ROUND, GO TO PM10 |
----------------------------------------------------
----------------------------------------------------
| IF MEDICINE BEING ASKED ABOUT IS FLAGGED AS |
| ‘CREATED’ DURING THE CURRENT ROUND, CONTINUE WITH |
| PM11 |
----------------------------------------------------
PM11 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF PRESCRIPTION
MEDICINE.} {STR-DT}
{END-DT}
In what year did (PERSON) first use (MEDICINE)?
[Enter Year-4] ........................
HAS NOT YET TAKEN/USED ................ XX
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| IF YEAR IS REFERENCE YEAR OR REFERENCE YEAR |
| MINUS 1, CONTINUE WITH PM11OV1 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO PM10 |
----------------------------------------------------
PM11OV1 =======
[Enter Month-2] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV2 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO PM1O |
----------------------------------------------------
PM11OV2 =======
[Enter Day-2] .........................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| EDIT/RANGE CHECK: |
| |
| ENTRIES FOR MONTH AND DAY FIELDS MUST CORRESPOND |
| TO CALENDAR MONTHS AND DAYS. THAT IS, |
| - IF MONTH, ALLOWABLE VALUES = 01 - 12. |
| - IF DAY: |
| - ALLOWABLE VALUES = 01 - 31 IF MONTH CODED |
| ‘01’, ‘03’, ‘05’, ‘07’, ‘08’, ‘10’, ‘12’; |
| - ALLOWABLE VALUES = 01 - 30 IF MONTH CODED |
| ‘04’, ‘06’, ‘09’, ‘11’; |
| - ALLOWABLE VALUES = 01 - 29 IF MONTH CODED |
| ‘02’ AND YEAR IS 1996, 2000, 2004, 2008, |
| OR 2010 (LEAP YEAR); |
| - ALLOWABLE VALUES = 01 - 28 IF MONTH CODED |
| ‘02’ AND YEAR IS NOT 1996, 2000, 2004, |
| 2008, OR 2010 (I.E., NOT LEAP YEAR). |
| |
| MISSING VALUES = -7 AND -8 ALLOWED FOR MONTH AND |
| DAY FIELDS. |
----------------------------------------------------
----------------------------------------------------
| THE COMPLETE DATE CANNOT BE BEFORE THE PERSON’S |
| DATE OF BIRTH OR AFTER THE REFERENCE PERIOD END |
| DATE FOR THIS PERSON. |
----------------------------------------------------
PM10 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF PRESCRIPTION
MEDICINE.} {STR-DT}
{END-DT}
How many times was (MEDICINE) obtained or purchased for
(PERSON) {since (START DATE)/between (START DATE) and (END
DATE)}?
[Enter Number of Times] ................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
----------------------------------------------------
BOX_02B =======
----------------------------------------------------
| IF ROUND 3 AND PM10 -7 OR –8, CONTINUE WITH |
| PM10A |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_02 |
----------------------------------------------------
PM10A =====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF PRESCRIPTION
MEDICINE.} {STR-DT}
{END-DT}
NUMBER OF TIMES OBTAINED/PURCHASED SINCE (START DATE):
{NUMBER OF TIMES}
Of these times, how many were in 2005?
[Enter Number of Times] ................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| EDIT: NUMBER OF TIMES IN 2005 NUMBER OF TIMES |
| OBTAINED/PURCHASED. |
----------------------------------------------------
----------------------------------------------------
| FOR ‘NUMBER OF TIMES,’ DISPLAY THE NUMBER ENTERED |
| AT PM10. |
----------------------------------------------------
BOX_02 ======
----------------------------------------------------
| IF THE CHARGE/PAYMENT (CP) SECTION HAS NOT BEEN |
| ASKED FOR THIS MEDICINE, ASK THE CHARGE/PAYMENT |
| (CP) SECTION |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH END_LP01 |
----------------------------------------------------
END_LP01 ========
----------------------------------------------------
| CYCLE ON NEXT MEDICINE IN PERSON’S-PRESCRIBED- |
| MEDICINES-ROSTER THAT MEETS THE CONDITIONS STATED |
| IN THE LOOP DEFINITION. |
----------------------------------------------------
----------------------------------------------------
| IF NO OTHER MEDICINES MEET THE STATED CONDITIONS, |
| END LOOP_01 AND CONTINUE WITH BOX_03 |
----------------------------------------------------
BOX_03 ======
----------------------------------------------------
| IF ALL PRESCRIBED MEDICINES FOR THIS PERSON ARE |
| FLAGGED AS ‘FREE SAMPLES’ (IN BOTH PM AND CP) |
| DURING THE CURRENT ROUND, GO TO BOX_06 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH LOOP_02 |
----------------------------------------------------
LOOP_02 =======
----------------------------------------------------
| FOR EACH OF THE FOLLOWING: |
| |
| PHARMACY 1 |
| PHARMACY 2 |
| PHARMACY 3 |
| PHARMACY 4 |
| |
| ASK BOX_04A-END_LP02 |
----------------------------------------------------
----------------------------------------------------
| LOOP DEFINITION: LOOP_02 ENUMERATES PHARMACIES |
| USED BY PERSON FOR PRESCRIBED MEDICINES THAT WERE |
| CREATED OR SELECTED DURING THE CURRENT ROUND. |
| THE RESPONSE TO PM17 DETERMINES IF THE LOOP CYCLES|
| AGAIN. IF PM17 IS CODED ‘1’ (YES), THE LOOP CYCLES|
| TO COLLECT THE NEXT PHARMACY USED BY PERSON. |
| IF PM17 IS CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’|
| (DON’T KNOW), THE LOOP ENDS. |
----------------------------------------------------
BOX_04A =======
----------------------------------------------------
| AS A PHARMACY IS ENTERED OR SELECTED, FLAG THE |
| PHARMACY 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 PERMISSION FORM COLLECTION |
| FOR THIS RU MEMBER. |
----------------------------------------------------
BOX_04 ======
----------------------------------------------------
| IF THERE ARE NO PHARMACIES ON THE RU-PHARMACIES- |
| ROSTER, GO TO PM14 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH PM12 |
----------------------------------------------------
PM12 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
What is the name of the (next) pharmacy that filled the
prescription(s) for (PERSON)?
TO TURN CHECK MARK ON/OFF, USE ARROW KEYS, PRESS ENTER.
TO LEAVE, PRESS ESC.
| ROSTER. PHARMACY | PM12_02. STREET | PM12_03. CITY |
|---|---|---|
| 1. Pharmacy | [Display Truncated Street Address] |
[Display Truncated City] |
| 2. Pharmacy | [Display Truncated Street Address] |
[Display Truncated City] |
| 3. Pharmacy | [Display Truncated Street Address] |
[Display Truncated City] |
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS THE RU- |
| PHARMACIES-ROSTER. |
----------------------------------------------------
----------------------------------------------------
| ROSTER BEHAVIOR SPECIFICATIONS: |
| |
| 1. INTERVIEWER MAY SELECT ANY PHARMACY ALREADY |
| LISTED OR SELECT ‘NONE OF THE ABOVE.’ |
| 2. ONLY ONE SELECTION MAY BE MADE. |
| 3. INTERVIEWER CAN NOT ADD AT THIS SCREEN. |
| PHARMACIES ARE ‘ADDED’ BY USING THE ‘NONE OF |
| THE ABOVE’ SELECTION. |
| 4. INTERVIEWER CAN NOT DELETE AT THIS SCREEN |
| (I.E., CTRL/D). |
----------------------------------------------------
----------------------------------------------------
| DISPLAY 'NONE OF THE ABOVE' AS THE LAST ENTRY. |
----------------------------------------------------
----------------------------------------------------
| IF 'NONE OF THE ABOVE' IS SELECTED, GO TO PM14 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH PM13 |
----------------------------------------------------
PM13 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
Is the address of (READ NAME AND ADDRESS OF PHARMACY BELOW)...
{PHARMACY NAME SELECTED AT PM12}
{PHARMACY STREET ADDRESS LINE1.}
{PHARMACY STREET ADDRESS LINE2.}
{PHARMACY CITY..,ST,ZIPCODE...}
{PHRM PHONE}
ADDRESS AND TELEPHONE CORRECT .......... 1 {BOX_05}
ADD NEW ADDRESS FOR PHARMACY ........... 2
ABOVE ADDRESS/TELEPHONE NEEDS
CORRECTION ............................. 3 {PM15}
SELECTED WRONG PHARMACY/ADDRESS ........ 4
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}
[Code One]
----------------------------------------------------
| IF CODED '4' (SELECTED WRONG PHARMACY/ADDRESS), |
| CAPI REDISPLAYS PM12 TO ALLOW INTERVIEWER TO |
| SELECT CORRECT PHARMACY. |
----------------------------------------------------
PM14 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
What is the name and address of the (next) pharmacy that filled
the prescription(s) for (PERSON)?
ENTER COMPLETE (NAME AND) ADDRESS AND VERIFY SPELLING.
IF PHARMACY HAS MORE THAN ONE LOCATION, RECORD LOCATION
WHERE PERSON HAD PRESCRIPTION FILLED.
ENTER WEB ADDRESS ON STREET ADDRESS LINE(S).
PHARMACY_NAME (PM14_01): [_____________]
PHARMACY_STR1 (PM14_02): [_____________]
PHARMACY_STR2 (PM14_03): [_____________]
PHARMACY_CITY (PM14_04): [_____________]
PHARMACY_STATE (PM14_05): [_____________]
PHARMACY_ZIPCDE (PM14_06): [_____________]
PHARMACY_PHONE (PM14_07): [_____________]
PRESS F1 FOR LIST OF STATE ABBREVIATIONS.
----------------------------------------------------
| CODES '-7' (REF) AND '-8' (DK) ARE ALLOWED ON EACH|
| FORM ITEM EXCEPT FOR PHARMACY NAME (PM14_01). |
----------------------------------------------------
----------------------------------------------------
| EDIT: CHECK THAT STATE ABBREVIATION IS VALID. |
----------------------------------------------------
----------------------------------------------------
| IF PM13 IS CODED '2' (ADD NEW ADDRESS FOR |
| PHARMACY), PM14 WILL NOT COLLECT THE PHARMACY |
| NAME, PM14_01 WILL DISPLAY THE PHARMACY NAME AND |
| CANNOT BE EDITED. |
----------------------------------------------------
----------------------------------------------------
| GO TO BOX_05 |
----------------------------------------------------
PM15 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
CORRECT ADDRESS OR TELEPHONE FOR: {PHARMACY NAME W/WRONG
ADDRESS.}
TO VERIFY CURRENT INFORMATION OR TO LEAVE A FIELD BLANK, PRESS
ENTER. TO CORRECT OR ENTER INFORMATION, TYPE ENTIRE FIELD.
Current Info: [PHARMACY_STR1]
[PHARMACY_STR2]
[PHARMACY_CITY]
[PHARMACY_STATE]
[PHARMACY_ZIPCDE]
[PHARMACY_PHONE]
PHARMACY_STR1 (PM15_01): [_____________]
PHARMACY_STR2 (PM15_02): [_____________]
PHARMACY_CITY (PM15_03): [_____________]
PHARMACY_STATE (PM15_04): [_____________]
PHARMACY_ZIPCDE (PM15_05): [_____________]
PHARMACY_PHONE (PM15_06): [_____________]
PRESS F1 FOR LIST OF STATE ABBREVIATIONS.
----------------------------------------------------
| EDIT: CHECK THAT STATE ABBREVIATION IS VALID. |
----------------------------------------------------
BOX_05 ======
----------------------------------------------------
| IF THE NAME OR ADDRESS FIELDS WERE COMPLETED IN |
| PM14 FOR THE PHARMACY BEING ASKED ABOUT (THAT IS, |
| THE PHARMACY WAS ADDED TO THE RU-PHARMACIES- |
| ROSTER OR A NEW ADDRESS WAS ENTERED FOR AN |
| EXISTING PHARMACY), CONTINUE WITH PM16 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO PM17 |
----------------------------------------------------
PM16 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
What type of pharmacy is that? Is it a mail-order pharmacy;
a pharmacy located in another store such as a grocery or
department store; a pharmacy located in an HMO, clinic, or
hospital; a drug store that is not located within another
facility; or is it an on-line pharmacy?
MAIL-ORDER ............................. 1
IN ANOTHER STORE ....................... 2
IN HMO/CLINIC/HOSPITAL ................. 3
DRUG STORE ............................. 4
ON-LINE ................................ 5
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code One]
PM17 ====
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
Did (PERSON) use another pharmacy {since (START DATE)/between
(START DATE) and (END DATE)}?
FOR CHAIN ESTABLISHMENTS, PLEASE RECORD ALL PHARMACY LOCATIONS
USED (I.E., THOSE WITH THE SAME NAME BUT DIFFERENT ADDRESS).
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
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| DISPLAY ‘since (START DATE)’ IF NOT ROUND 5. |
| DISPLAY ‘between (START DATE) and (END DATE)’ IF |
| ROUND 5. |
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END_LP02 ========
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| IF PM17 IS CODED '1' (YES), CYCLE TO COLLECT |
| INFORMATION ABOUT THE NEXT PHARMACY USED BY |
| PERSON. |
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| IF PM17 IS CODED '2' (NO), '-7 (REFUSED), OR '-8' |
| (DON'T KNOW), END LOOP_02 AND CONTINUE WITH BOX_06|
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BOX_06 ======
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| GO TO NEXT QUESTIONNAIRE SECTION |
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