This survey is authorized under 42 U.S.C. 299a. This information collection is voluntary and the confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The data you provide will help AHRQ’s mission to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (OMB control number 0935-0118) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857, or by email to the AHRQ MEPS Project Director at MEPSPROJECTDIRECTOR@ahrq.hhs.gov.
DCS: READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.
PRESS NEXT TO CONTINUE IN THIS EVENT FORM
PRESS BREAKOFF TO DISCONTINUE
Q1. Date Filled
Month: Day: Year:
DK/REF – CONTINUE TO Q2
Q2. Prescription information will be identified using:
NOTE: TRY TO OBTAIN NDC. USE DRUG NAME
ONLY IF NDC NOT AVAILABLE.
[IF Prescription Information = 1 (NDC), GO TO Q2a;
IF Prescription Information = 2 (Drug Name, Strength/Unit, & Dosage Form), GO TO Q2b]
Q2a. NDC
ENTER 11-DIGIT NDC WITHOUT DASHES OR SPACES.
NDC IS UNKNOWN OR REFUSED, RETURN TO PREVIOUS SCREEN AND SELECT DRUG NAME OPTION
________________
When Q2a is COMPLETE, GO TO Q3a/QTY
Q2b. Drug Name:
Q2b_1:
Compound drug?
Durable Medical Equipment: DME_1
IF DURABLE MEDICAL EQUIPMENT GO TO Q3A***
MJ? MJ_1
IF MJ GO TO Q3a***
When Drug Name is complete, send user to Q2c/STRENGTH
Q2c. Strength
________________
Q2d. Unit:
________________
Q2c2. Strength 2:
________________
Q2d2. Unit 2:
________________
Q2e. Dosage Form:
________________
After Q2e, CONTINUE TO Q3a/b.
Q2b - DK/REF – CONTINUE TO Q2c/d
Q2c/d - DK/REF – CONTINUE TO Q2e
Q2e - DK/REF – CONTINUE TO Q3a/b
Q3a. Quantity:
________________
Q3b. Unit:
________________
Q3b – DK/REF – CONTINUE TO Q4
Q4. How many days were supplied?
IF PRESCRIPTION WAS TO BE USED “AS NEEDED” ENTER 999
________________
Q4 – DK/REF – CONTINUE TO Q5
Q5. Patient Payment:
$________.____
Q5a. Were there any 3rd party payers?
Q6. Type of 3rd Party Payer
________________
Q7. 3rd Party Payment
$________.____
NOTE: IF PATIENT PAYMENT WAS $1 OR LESS, EXPECT THE 3rd PARTY PAYER TO BE A PUBLIC PROGRAM, E.G., MEDICAID OR OTHER STATE/LOCAL GOVT, ETC.
Any more 3rd Party Payers?
Q6/Q7 - ALLOW A MAXIMUM OF TWO 3rd PARTY PAYERS. IF USER SAYS “YES, MORE” THREE TIMES THEN THE
PROGRAM WILL GO TO FINISH SCREEN.
Q5 - DK/REF – CONTINUE TO Q5a.
Q5a - DK/REF – CONTINUE TO EXIT SCREEN.
Q6 - DK/REF – CONTINUE TO Q7.
Q7 - DK/REF – CONTINUE TO EXIT SCREEN.
FINISH SCREEN
PRESS VALIDATE TO COMPLETE THIS EVENT FORM.