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BOX_00A
THE PC SECTION IS ASKED IN ROUNDS 3 AND 5 ONLY. IF
IT IS ROUND 1, 2, OR 4, CONTINUE TO THE NEXT
SECTION.
BOX_00
CONTEXT HEADER DISPLAY INSTRUCTIONS:
DISPLAY PERS.FULLNAME
BOX_01
NOTE: CURRENTLY THE QUALITY SUPPLEMENT CONTAINS
QUESTIONS FOR PERSONS FOR WHOM DIABETES OR ASTHMA
WAS REPORTED IN THE PRIORITY CONDITION ENUMERATION
(PE) SECTION. OTHER QUALITY QUESTIONS ARE LOCATED
IN THE PREVENTIVE CARE (AP) SECTION. HOWEVER, THE
QUALITY SECTION COULD INCLUDE QUESTIONS FOR THE
OTHER PRIORITY CONDITIONS AS THEY ARE NEEDED IN
FUTURE PANELS.
PC01
OMITTED.
BOX_02
IF PERSON IS => 18 YEARS OF AGE OR IN AGE
CATEGORIES 4-9 AND IF PERSON IS A KEY RU MEMBER
AND IF ‘DIABETES’ ON PERSON’S- MEDICAL-CONDITIONS-
ROSTER AND FLAGGED AS CREATED IN THE PE SECTION
(IN ANY ROUND), CONTINUE WITH BOX_03
OTHERWISE, GO TO BOX_04
BOX_03
IF PERSON BEING ASKED ABOUT IS FLAGGED AS
‘DECEASED’ FOR THE CURRENT ROUND, GO TO BOX_04
OTHERWISE, CONTINUE WITH PC02A
PC01A
OMITTED.
PC01B
OMITTED.
PC01C
OMITTED.
PC01D
OMITTED.
PC01E
OMITTED.
PC01F
OMITTED.
PC01G
OMITTED.
PC01H
OMITTED.
PC02
OMITTED.
PC02A
{PERSON'S FIRST MIDDLE AND LAST NAME}
{During an earlier interview, it/It} was mentioned
that {you/{PERSON}}
{have/has} diabetes. To obtain more information on the
care of
adults with diabetes, we have a short
questionnaire for {you/him/her}.
SELECT ‘CONTINUE’ UNLESS RESPONDENT VOLUNTEERS
DIABETES REPORTED
IN ERROR.
CONTINUE ............................... 1 {PC03}
{PERSON} DOES NOT HAVE DIABETES ........ 2
{BOX_04}
[Code One]
DISPLAY ‘During an earlier interview, it’ IF
DIABETES WAS NOT CREATED DURING THE CURRENT ROUND.
DISPLAY ‘It’ IF DIABETES CREATED DURING THE
CURRENT ROUND.
DISPLAY ‘NOT’ IN BOLD IN THE ANSWER TEXT.
IF ‘PERSON DOES NOT HAVE DIABETES’ IS SELECTED,
THIS DOES NOT RE-SET THE DATA FROM THE PE SECTION
(PRND.PCDIABET). THE RESPONSE TO PC02A WILL
DETERMINE WHETHER PC03 IS ASKED AND WHETHER THERE
IS DCS FOLLOW-UP FOR THIS PERSON IN THE CL SECTION
PC03
{PERSON'S FIRST MIDDLE AND LAST NAME}
DOB: {MM/DD/YYYY} PID: {PID} RU ID: {RUID-7}
STATUS: {CURRENT/INSTITUTIONALIZED}
DETERMINE IF SELF OR PROXY DIABETES CARE SUPPLEMENT
(DCS)
SHOULD BE DISTRIBUTED:
SELF DCS: FOR ANY CURRENT RU MEMBER (18 YEARS OR
OLDER) WHO HAS
DIABETES.
PROXY DCS: FOR ANY CURRENT RU MEMBER (18 OR OLDER) WHO
IS
INSTITUTIONALIZED OR OTHERWISE INCAPACITATED.
CODE TYPE OF DCS DISTRIBUTED FOR {PERSON}.
SELF ................................... 1 {PC03A}
PROXY .................................. 2 {PC03OV1}
[Code One]
DISPLAY PID OF PERSON BEING ASKED ABOUT FOR ‘PID’.
DISPLAY DATE OF BIRTH FOR PERSON BEING ASKED ABOUT
FOR ‘MM/DD/YYYY’.
DISPLAY THE RU ID FOR THE CURRENT CASE FOR
‘RUID-7’.
DISPLAY ‘CURRENT’ IF PERSON BEING ASKED ABOUT IS A
CURRENT RU MEMBER AND IS NOT DECEASED OR
INSTITUTIONALIZED. DISPLAY ‘INSTITUTIONALIZED’ IF
PERSON BEING ASKED ABOUT IS FLAGGED AS
‘INSTITUTIONALIZED’ FOR THE CURRENT ROUND.
FLAG ALL PERSONS WHO ARE ASKED PC03 FOR DCS
FOLLOW-UP IN THE CLOSING (CL) SECTION.
PC03OV1
{PERSON'S FIRST MIDDLE AND LAST NAME}
DOB: {MM/DD/YYYY} PID: {PID} RU ID: {RUID-7}
STATUS: {CURRENT/INSTITUTIONALIZED}
CODE REASON FOR PROXY DCS.
INSTITUTIONALIZED ...................... 2 {PC03A}
OTHER .................................. 3 {PC03OV2}
[Code One]
THIS ITEM IS A SEPARATE SCREEN RATHER THAN AN
OVERLAY AS IMPLIED BY THE ITEM NAME.
PC03OV2
SPECIFY OTHER REASON FOR PROXY DCS.
[Enter Other Specify] .................. {PC03A}
PC03A
{PERSON'S FIRST MIDDLE AND LAST NAME}
DOB: {MM/DD/YYYY} PID: {PID} RU ID: {RUID-7}
PREPARE {SELF/PROXY} DIABETES CARE SUPPLEMENT (DCS):
WRITE IN
PERSON NAME, PID, DATE OF BIRTH, AND RUID.
HAND PREPARED {SELF/PROXY} DCS TO RESPONDENT AND SAY:
We hope that {you/{PERSON}}/you or someone else in the
family} would
be able to fill out this short questionnaire on the
care {you/{PERSON}}
{get/gets} for diabetes. {You/He/She} can give it to
me before I leave
today, or I can pick it up later.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
DISPLAY ‘SELF’ AND ‘{you/{PERSON}}’ IF PC03 IS
CODED '1' (SELF). DISPLAY ‘PROXY’ AND ‘you or
someone else in the family’ IF PC03 IS CODED '2'
(PROXY)
DISPLAY PID OF PERSON BEING ASKED ABOUT FOR ‘PID’.
DISPLAY DATE OF BIRTH FOR PERSON BEING ASKED ABOUT
FOR ‘MM/DD/YYYY’.
DISPLAY THE RU ID FOR THE CURRENT CASE FOR
‘RUID-7’.
BOX_04
IF PANEL 16 ROUND 3 OR PANEL 15 ROUND 5, CONTINUE
WITH BOX_05
OTHERWISE, GO TO BOX_07
NOTE: THE DISTRIBUTION AND COLLECTION OF THE
CANCER SAQ OCCURS ONLY DURING PANEL 16 ROUND 3 AND
PANEL 15 ROUND 5. AT THIS TIME, THERE ARE NO
PLANS TO COLLECT THE CANCER SAQ IN FUTURE ROUNDS.
BOX_05
IF PERSON IS => 18 YEARS OF AGE OR IN AGE
CATEGORIES 4-9 AND IF PERSON IS A KEY RU MEMBER
AND ‘CANCER – {ANY TYPE}’ (CODED AT PE22 OR
PE22OV) ON PERSON’S-MEDICAL-CONDITIONS-ROSTER AND
FLAGGED AS CREATED IN THE PE SECTION (IN ANY
ROUND), CONTINUE WITH BOX_06
OTHERWISE, GO TO BOX_07
BOX_06
IF PERSON BEING ASKED ABOUT IS FLAGGED AS
‘DECEASED’ OR ‘INSTITUTIONALIZED’ FOR THE CURRENT
ROUND, GO TO BOX_07
OTHERWISE, CONTINUE WITH PC04
PC04
{PERSON'S FIRST MIDDLE AND LAST NAME}
{During an earlier interview, it/It} was mentioned
that (PERSON)
{(have/has)/had} cancer. To obtain more information
about
experiences with cancer, we have a short questionnaire
for (PERSON).
SELECT ‘CONTINUE’ UNLESS RESPONDENT VOLUNTEERS CANCER
REPORTED
IN ERROR.
CONTINUE ............................... 1 {PC04A}
(PERSON) {DOES/DID} NOT HAVE CANCER .... 2
{BOX_07}
[Code One]
DISPLAY ‘During an earlier interview, it’ IF
CANCER WAS NOT CREATED DURING THE CURRENT ROUND.
DISPLAY ‘It’ IF CANCER WAS CREATED DURING THE
CURRENT ROUND.
DISPLAY ‘(have/has)’ AND ‘DOES’ IF PE25 IS CODED
‘2’ (NO) FOR THIS PERSON FOR AT LEAST ONE CANCER
TYPE. OTHERWISE, DISPLAY ‘had’ AND ‘DID’.
DISPLAY ‘PERSON’ IN PURPLE IN THE ANSWER TEXT.
DISPLAY ‘NOT’ IN BOLD IN THE ANSWER TEXT.
IF ‘PERSON DOES NOT HAVE CANCER’ IS SELECTED,
THIS DOES NOT RE-SET THE DATA FROM THE PE SECTION
(PRND.CANCERML). THE RESPONSE TO PC04 WILL
DETERMINE WHETHER PC04A IS ASKED AND WHETHER THERE
IS CANCER SAQ FOLLOW-UP FOR THIS PERSON IN THE CL
SECTION.
NOTE: THE DISTRIBUTION AND COLLECTION OF THE
CANCER SAQ OCCURS ONLY DURING PANEL 16 ROUND 3
AND PANEL 15 ROUND 5. AT THIS TIME, THERE ARE NO
PLANS TO COLLECT THE CANCER SAQ IN FUTURE ROUNDS.
PC04A
{PERSON'S FIRST MIDDLE AND LAST NAME}
DOB: {MM/DD/YYYY} PID: {PID} RU ID: {RUID-7}
PREPARE ‘YOUR EXPERIENCES WITH CANCER’ (CANCER SAQ):
WRITE IN PERSON NAME, DATE OF BIRTH, PID, AND RUID.
HAND PREPARED CANCER SAQ TO RESPONDENT AND SAY:
We hope that (PERSON) would be able to fill out this
short
questionnaire on (PERSON)’s experiences with cancer.
(PERSON)
can give it to me before I leave today, or I can pick
it up later.
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.
DISPLAY DATE OF BIRTH FOR PERSON BEING ASKED ABOUT
FOR ‘MM/DD/YYYY’.
DISPLAY PID OF PERSON BEING ASKED ABOUT FOR ‘PID’.
DISPLAY THE RU ID FOR THE CURRENT CASE FOR
‘RUID-7’.
FLAG ALL PERSONS WHO ARE ASKED PC04A FOR CANCER
SAQ FOLLOW-UP IN THE CLOSING (CL) SECTION.
CONTINUE WITH BOX_07
NOTE: THE DISTRIBUTION AND COLLECTION OF THE
CANCER SAQ OCCURS ONLY DURING PANEL 16 ROUND 3
AND PANEL 15 ROUND 5. AT THIS TIME, THERE ARE NO
PLANS TO COLLECT THE CANCER SAQ IN FUTURE ROUNDS.
BOX_07
IF ‘ASTHMA’ ON PERSON’S-MEDICAL-CONDITIONS-ROSTER,
AND FLAGGED AS CREATED IN THE PE SECTION (IN ANY
ROUND), CONTINUE WITH PC04B
OTHERWISE, GO TO BOX_08
PC04B
{PERSON'S FIRST MIDDLE AND LAST NAME}
{During an earlier interview, it was mentioned that
{you/{PERSON}}
{have/has} asthma.}
Now I would like to ask you a few questions about
{your/{PERSON}’s}
asthma and the course of treatment {you/he/she}
received.
SELECT ‘CONTINUE’ UNLESS RESPONDENT VOLUNTEERS ASTHMA
REPORTED IN ERROR.
CONTINUE ............................... 1 {PC05A}
{PERSON} DOES NOT HAVE ASTHMA .......... 2
{BOX_08}
[Code One]
DISPLAY ‘During an earlier interview....’ IF
ASTHMA WAS NOT CREATED DURING THE CURRENT ROUND.
IF ASTHMA WAS CREATED DURING THE CURRENT ROUND,
USE A NULL DISPLAY.
DISPLAY ‘NOT’ IN BOLD IN THE ANSWER TEXT.
IF ‘PERSON DOES NOT HAVE ASTHMA’ IS SELECTED, THIS
DOES NOT RE-SET THE DATA AS RECORDED IN THE PE
SECTION (PRND.PCASTHMA). THE RESPONSE TO PC04B
WILL DETERMINE WHETHER SUBSEQUENT DETAILED ASTHMA
QUESTIONS ARE ASKED IN THIS PC SECTION.
PC05A
{PERSON’S FIRST MIDDLE AND LAST NAME}
I am going to ask you about two different kinds of asthma
medicine. One is for quick relief. The other does
not give
quick relief but protects your lungs and prevents symptoms over
the long term.
During the past 3 months, {have/has}
{you/{PERSON}} used the kind of
prescription inhaler that you breathe in
through your mouth that
gives quick relief from asthma symptoms?
YES .................................... 1 {PC05B}
NO ..................................... 2 {PC06A}
REF ................................... -7 {PC06A}
DK .................................... -8 {PC06A}
PC05B
{PERSON’S FIRST MIDDLE AND LAST NAME}
During the past 3 months, did {you/{PERSON}}
use more than three
canisters of this type of inhaler?
YES .................................... 1 {PC06A}
NO ..................................... 2 {PC06A}
REF ................................... -7 {PC06A}
DK .................................... -8 {PC06A}
PC06A
{PERSON’S FIRST MIDDLE AND LAST NAME}
{Have/Has} {you/{PERSON}} ever taken the preventive
kind of asthma
medicine used every day to protect your lungs and keep
you from
having attacks? Include both oral medicine and
inhalers. This is
different from inhalers used for quick relief.
YES .................................... 1 {PC06B}
NO ..................................... 2 {PC08}
REF ................................... -7 {PC08}
DK .................................... -8 {PC08}
PC06B
{PERSON’S FIRST MIDDLE AND LAST NAME}
{Are/Is} {you/{PERSON}} now taking this
medication (that protects
the lungs) daily or almost daily?
YES .................................... 1 {PC08}
NO ..................................... 2 {PC08}
REF ................................... -7 {PC08}
DK .................................... -8 {PC08}
PC06
OMITTED.
PC07
OMITTED.
PC08
{PERSON’S FIRST MIDDLE AND LAST NAME}
A peak flow meter measures how hard you can blow air
out of your
lungs. {Do/Does} {you/{PERSON}} currently have a peak
flow meter
at home?
YES .................................... 1 {PC08A}
NO ..................................... 2 {BOX_08}
REF ................................... -7 {BOX_08}
DK .................................... -8 {BOX_08}
PC08A
{PERSON’S FIRST MIDDLE AND LAST NAME}
Did {you/{PERSON}} ever use the peak flow meter?
YES .................................... 1 {PC08B}
NO ..................................... 2 {BOX_08}
REF ................................... -7 {BOX_08}
DK .................................... -8 {BOX_08}
PC08B
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD PC-1.
When did {you/{PERSON}} last use the peak flow meter?
Was it
within the last seven days, more than seven days ago
but within
the last thirty days, or more than thirty days ago?
WITHIN LAST 7 DAYS ..................... 1 {BOX_08}
MORE THAN 7, BUT WITHIN LAST 30 DAYS ... 2 {BOX_08}
MORE THAN 30 DAYS AGO .................. 3 {BOX_08}
REF ................................... -7 {BOX_08}
DK .................................... -8 {BOX_08}
[Code One]
BOX_02
OMITTED.
PC09
OMITTED.
PC10
OMITTED.
PC11
OMITTED.
PC11OV
OMITTED.
PC12
OMITTED.
PC12_01
OMITTED.
PC12_02
OMITTED.
PC12_03
OMITTED.
PC12_04
OMITTED.
PC12_04OV
OMITTED.
PC12_05
OMITTED.
PC12_06
OMITTED.
PC13
OMITTED.
PC13_01
OMITTED.
PC13_02
OMITTED.
PC14
OMITTED.
PC15
OMITTED.
PC16
OMITTED.
PC17
OMITTED.
PC18
OMITTED.
PC19
OMITTED.
PC20
OMITTED.
BOX_08
GO TO NEXT QUESTIONNAIRE SECTION
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