|
BOX_00
CONTEXT HEADER DISPLAY INSTRUCTIONS:
DISPLAY PERS.FULLNAME, PRND.BEGREFMM,DD,YY AND
PRND.ENDREFMM,DD,YY.
MEDICINES ARE FLAGGED AS ‘CREATED’ ONLY ONCE
(I.E., THE ROUND IN WHICH THE MEDICINE IS
INITIALLY REPORTED). MEDICINES ARE FLAGGED AS
‘SELECTED’ WHEN CHOSEN IN SUBSEQUENT ROUNDS.
THUS, FOR ONE ROUND, A MEDICINE CAN ONLY BE
FLAGGED AS EITHER ‘CREATED’ OR ‘SELECTED’, BUT
NOT BOTH.
IF PERSON HAS NO MEDICINES CREATED OR SELECTED
ON PERSON’S-PRESCRIBED-MEDICINES-ROSTER DURING
THE CURRENT ROUND, GO TO PM04
OTHERWISE, CONTINUE WITH PM02
PM01
OMITTED.
PM02
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
While we were talking about {your/{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.)
{NAME OF PRESCRIPTION MEDICINE}
{NAME OF PRESCRIPTION MEDICINE}
{NAME OF PRESCRIPTION MEDICINE}
INFORMATION OKAY ....................... 1 {PM04}
AT LEAST ONE MEDICINE INCORRECT ........ 2
[Code One]
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
ROSTER DETAILS:
Title: PERSON’S_PRESCRIBED-MEDICINES_1
COL #1 HEADER: DRUG NAME
INSTRUCTIONS: DISPLAY NAME OF PRESCRIBED MEDICINE
(DRUG.DRUGNAME)
ROSTER DEFINITION:
THIS ITEM DISPLAYS THE PERSON’S-PRESCRIBED-
MEDICINES-ROSTER FOR DISPLAY.
ROSTER BEHAVIOR:
1. DISPLAY ONLY.
2. SELECT, ADD, DELETE, AND EDIT DISALLOWED.
ROSTER FILTER:
DISPLAY ONLY THOSE PRESCRIBED MEDICINES THAT ARE
FLAGGED AS EITHER ‘CREATED’ OR ‘SELECTED’ DURING
THE CURRENT ROUND.
PM03
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
SELECT MEDICINE(S) THAT WERE RECORDED INCORRECTLY.
[1. Prescribed Medicine]
[2. Prescribed Medicine]
[3. Prescribed Medicine]
FLAG SELECTED MEDICINES AS 'INCORRECT'. THESE
MEDICINES WILL NOT BE ELIGIBLE FOR LOOP_01 (I.E.,
NOT ‘CREATED’ OR ‘SELECTED’ THIS ROUND).
GO TO PM04
ROSTER DETAILS:
Title: PERSON’S_PRESCRIBED-MEDICINES_1
COL #1 HEADER: PRESCRIBED MEDICINE
INSTRUCTIONS: DISPLAY NAME OF PRESCRIBED MEDICINE
(DRUG.DRUGNAME)
ROSTER DEFINITION:
THIS ITEM DISPLAYS THE PERSON’S-PRESCRIBED-
MEDICINES-ROSTER FOR SELECTION.
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.
2. ADD, DELETE, AND EDIT DISALLOWED.
ROSTER FILTER:
DISPLAY ONLY THOSE PRESCRIBED MEDICINES THAT ARE
FLAGGED AS EITHER ‘CREATED’ OR ‘SELECTED’ DURING
THE CURRENT ROUND.
PM04
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
{Since {START DATE}/Between {START DATE} and {END
DATE}},
{have/has} {you/{PERSON}} obtained any medicines [we
have not yet
talked about]? For example, {have/has} {you/he/she}
had any new
prescriptions or a refill of a prescription?
Please include any on-line prescriptions.
[It would be very helpful if we could look at the
bottles,
containers, tubes, or bags for each of the medicines
we will
be talking about.]
YES .................................... 1 {PM05}
NO ..................................... 2 {PM06}
REF ................................... -7 {PM06}
DK .................................... -8 {PM06}
HELP AVAILABLE 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?
[1. Prescribed Medicine]
[2. Prescribed Medicine]
[3. Prescribed Medicine]
FLAG ANY MEDICINE ADDED TO THE ROSTER AS ‘CREATED’
IN THIS ROUND.
FLAG ANY MEDICINE SELECTED FROM THE ROSTER AS
‘SELECTED’ IN THIS ROUND, IF THIS IS THE FIRST TIME
THAT THE MEDICINE IS SELECTED IN CAPI IN THIS
ROUND. FOR ANY ONE ROUND, A MEDICINE CAN BE FLAGGED
ONLY AS ‘CREATED’ OR ‘SELECTED’, BUT NOT BOTH IN
THAT SAME ROUND.
AT THIS ITEM, THE ROSTER WILL DISPLAY ALL
MEDICINES IN PERSON’S-PRESCRIBED-MEDICINES-ROSTER.
THAT DISPLAY WILL INCLUDE ALL MEDICINES CREATED IN
PREVIOUS ROUNDS AND IN THE CURRENT ROUND. WHEN A
MEDICINE CREATED IN A PREVIOUS ROUND IS SELECTED,
CREATE A NEW EVENT FOR THAT MEDICINE. FOR SUCH
MEDICINES, (AND FOR ADDED MEDICINES), CAPI WILL
ASK THE CP SECTION AND THE PHARMACY OF THE
PURCHASE.
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.
WHEN A MEDICINE FROM A PREVIOUS ROUND IS SELECTED,
CREATE A NEW EVENT SINCE IT INVOLVES A NEW
PURCHASE. A NEW PURCHASE REQUIRES ASKING THE
CHARGE/PAYMENT (CP) SECTION AND PHARMACY OF THE
PURCHASE. 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).
GO TO PM06
ROSTER DETAILS:
TITLE: PERSON'S_PRESCRIBED-MEDICINES_1
COL # 1 HEADER: PRESCRIBED MEDICINE
INSTRUCTIONS: DISPLAY NAME OF PRESCRIBED MEDICINE
(DRUG.DRUGNAME)
ROSTER DEFINITION:
THIS ITEM DISPLAYS PERSON'S-PRESCRIBED-MEDICINES-
ROSTER FOR SELECTION/ADDITION.
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.
2. MULTIPLE ADD ALLOWED.
3. LIMITED DELETE ALLOWED. INTERVIEWER MAY DELETE
A PMED ADDED ON THIS SCREEN AS LONG AS CAPI HAS
NOT YET CREATED THE LINK BETWEEN THIS PMED AND
THE EVENT.
4. EDIT DISALLOWED.
ROSTER FILTER:
DISPLAY ALL; NO FILTER.
PM06
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
{Since {START DATE}/Between {START DATE} and {END
DATE}}, did
{you/{PERSON}} get any free samples of prescribed
medicines from a
medical or dental provider that we have not yet talked
about?
YES .................................... 1 {PM07}
NO ..................................... 2 {BOX_01}
REF ................................... -7 {BOX_01}
DK .................................... -8 {BOX_01}
HELP AVAILABLE 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 {you/{PERSON}} got
as free
samples?
PROBE: Any other free samples?
[1. Prescribed Medicine]
[2. Prescribed Medicine]
[3. Prescribed Medicine]
FLAG MEDICINES AS ‘FREE SAMPLE’ ON IF MEDICINE
WAS CREATED AT PM07 DURING THE CURRENT ROUND.
GO TO BOX_01
ROSTER DETAILS:
TITLE: PERSON'S_PRESCRIBED-MEDICINES_1
COL # 1 HEADER: PRESCRIBED MEDICINE
INSTRUCTIONS: DISPLAY NAME OF PRESCRIBED MEDICINE
(DRUG.DRUGNAME)
ROSTER DEFINITION:
THIS ITEM DISPLAYS PERSON'S-PRESCRIPTION-
MEDICINES-ROSTER FOR SELECTION/ADDITION.
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.
2. MULTIPLE ADD ALLOWED.
3. LIMITED DELETE ALLOWED. INTERVIEWER MAY DELETE
A PMED ADDED ON THIS SCREEN AS LONG AS CAPI HAS
NOT YET CREATED THE LINK BETWEEN THIS PMED AND
THE EVENT.
4. EDIT DISALLOWED.
5. 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.
6. 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 THE CHARGE/PAYMENT (CP) SECTION
AND THE PHARMACY OF THE PURCHASE. 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).
ROSTER FILTER:
DISPLAY ALL; NO FILTER.
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 NAV_PM01 - 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.
NAVIGATOR DETAILS: LOOP_01 USES NAV_PM01 TO
CONTROL THE FLOW OF THE LOOP.
NAV_PM01
SERIES: Medicine Detail (e.g., for what condition,
date first
taken, number of times obtained)
USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.
WHEN ALL LINKS ARE MARKED "DONE," USE [Continue
Interview] TO GO
PAST THIS SERIES.
IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS
BEFORE THIS
SERIES.
Prescribed Medicine
[1. Person’s Prescribed Medicine-30] [Status-25]
[2. Person’s Prescribed Medicine-30] [Status-25]
[3. Person’s Prescribed Medicine-30] [Status-25]
ROSTER DETAILS:
COL # 1 HEADER: PRESCRIBED MEDICINE
INSTRUCTIONS: DISPLAY PERSON’S PRESCRIBED MEDICINE
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH MEDICINE EACH TIME THE NAVIGATOR
IS PRESENTED
ROSTER DEFINITION:
THIS ITEM DISPLAYS PERSON’S-PRESCRIBED-MEDICINES-
ROSTER FOR SELECTION.
ROSTER BEHAVIOR:
1. SELECT ALLOWED.
2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.
ROSTER FILTER:
DISPLAY EACH MEDICINE IN PERSON’S-PRESCRIBED-
MEDICINES-ROSTER THAT MEETS THE FOLLOWING
CONDITIONS:
- PRESCRIBED MEDICINE IS FLAGGED AS ‘CREATED’
DURING THE CURRENT ROUND.
OR
- PRESCRIBED MEDICINE IS FLAGGED AS ‘SELECTED’
DURING THE CURRENT ROUND.
CONTINUE WITH BOX_01A FOR SELECTED MEDICINE.
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 {PM08}
NO ..................................... 2 {END_LP01}
REF ................................... -7 {PM08}
DK .................................... -8 {PM08}
IF CODED ‘2’ (NO), FLAG MEDICINE AS ‘INCORRECT’.
THIS MEDICINE SHOULD NOT BE FLAGGED AS ‘CREATED’
OR ‘SELECTED’ FOR ROUND 5 AND THE ROUND 5 RECORDS
SHOULD BE DELETED.
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 {PM09}
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, SELECT ENTRY ON
ROSTER.
[1. Medical Condition]
[2. Medical Condition]
[3. Medical Condition]
GO TO BOX_02A
DISPLAY ‘ADD CONDITION’ AS AN OPTION ON THIS
SCREEN.
ROSTER DETAILS:
Title: PERS_COND_1
COL #1 HEADER: MEDICAL CONDITION
INSTRUCTIONS: DISPLAY NAME OF MEDICAL CONDITION
(COND.CONDNAM)
ROSTER DEFINITION:
DISPLAY THE PERSON-MEDICAL-CONDITIONS-ROSTER FOR
THE SELECTION AND ADDITION OF ONE OR MANY MEDICAL
CONDITION(S) ASSOCIATED WITH THIS EVENT.
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED. SELECTION SHOULD NOT
IMPACT THE ROUND FLAG OF THE CONDITION.
2. MULTIPLE ADD ALLOWED. INTERVIEWER SHOULD RECORD
CONDITION NAME.
3. LIMITED DELETE ALLOWED. INTERVIEWER MAY DELETE
A CONDITION ADDED ON THIS SCREEN AS LONG AS
CAPI HAS NOT YET CREATED THE LINK BETWEEN THIS
CONDITION AND THE EVENT.
4. LIMITED EDIT ALLOWED. INTERVIEWER MAY EDIT A
CONDITION NAME NEWLY ADDED ON THIS SCREEN AS
LONG AS CAPI HAS NOT YET CREATED THE LINK
BETWEEN THIS CONDITION AND THE EVENT.
ROSTER FILTER:
DISPLAY ALL CONDITIONS ON PERSON’S ROSTER; NO
FILTER.
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 {you/{PERSON}} first use
{MEDICINE}?
XXXX HAS NOT YET TAKEN/USED
[Enter Year-4] ........................
REF ................................... -7 {PM10}
DK .................................... -8 {PM10}
IF XXXX (HAS NOT YET TAKEN/USED) ENTERED, GO TO
PM10
IF YEAR IS REFERENCE YEAR OR REFERENCE YEAR MINUS
1, CONTINUE WITH PM11OV1
OTHERWISE, GO TO PM10
PM11OV1
MONTH:
[Enter Month-2] .......................
REF ................................... -7
DK .................................... -8
FOR SPECIFICATIONS PURPOSES ONLY (CAPI HANDLES
AUTOMATICALLY): ALLOWABLE VALUES FOR MONTH ARE
1-12.
IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV2
OTHERWISE, GO TO PM10
PM11OV2
DAY:
[Enter Day-2] ......................... {PM10}
REF ................................... -7 {PM10}
DK .................................... -8 {PM10}
HARD CHECK:
ENTRIES FOR DAY MUST CORRESPOND TO CALENDAR
MONTHS AND DAYS. THAT IS,
- 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 2008 (LEAP YEAR);
- ALLOWABLE VALUES = 01 - 28 IF MONTH CODED
‘02’ AND YEAR IS NOT 2008 (I.E., NOT LEAP
YEAR).
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
{you/{PERSON}} {since {START DATE}/between {START
DATE} and {END
DATE}}?
[Enter Number of Times] ................ {BOX_02B}
REF ................................... -7 {BOX_02B}
DK .................................... -8 {BOX_02B}
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 IS NOT -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 {YEAR}?
[Enter Number of Times] ................ {BOX_02}
REF ................................... -7 {BOX_02}
DK .................................... -8 {BOX_02}
FOR ‘NUMBER OF TIMES,’ DISPLAY THE NUMBER ENTERED
AT PM10.
FOR SPECIFICATIONS PURPOSES ONLY (CAPI HANDLES
AUTOMATICALLY): FOR ‘YEAR’, DISPLAY THE YEAR THAT
IS THE FIRST YEAR OF THE GIVEN PANEL.
HARD CHECK:
NUMBER OF TIMES MUST BE <= NUMBER OF TIMES
OBTAINED/PURCHASED 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
PERSON-PHARMACY PAIR 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 {you/{PERSON}}?
[1. Pharmacy] [STREET ADDRESS] [CITY]
[2. Pharmacy] [STREET ADDRESS] [CITY]
[3. Pharmacy] [STREET ADDRESS] [CITY]
REF ................................... -7
DK .................................... -8
DISPLAY 'ADD PHARMACY' AND ‘DELETE PHARMACY’
BUTTONS AS OPTIONS ON THIS SCREEN.
IF ‘ADD PHARMACY’ IS SELECTED, GO TO PM14
(NOTE THAT PM14 IS ACTUALLY A POPUP ON PM12).
OTHERWISE, CONTINUE WITH PM13
ROSTER DETAILS:
Title: RU_PHAR_1
COL #1 HEADER: PHARMACY
INSTRUCTIONS: DISPLAY PHARMACY NAME
(PHAR.PHARNAME)
COL #2 HEADER: STREET ADDRESS
INSTRUCTIONS: DISPLAY TRUNCATED STREET ADDRESS
(PHAR.PHARADR1)
COL #3 HEADER: CITY
INSTRUCTIONS: DISPLAY TRUNCATED CITY
(PHAR.PHARCITY)
ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-PHARMACIES-ROSTER FOR
SELECTION/ADDITION.
ROSTER BEHAVIOR:
1. SELECT ONE ALLOWED. INTERVIEWER MUST SELECT
ONE ONLY FROM THE LIST OF PROVIDERS OR MAY
SELECT ‘ADD PHARMACY’
2. ADD ALLOWED.
3. EDITS ARE NOT ALLOWED.
4. LIMITED DELETE ALLOWED.
ROSTER FILTER:
DISPLAY ALL; NO FILTER.
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 {PM14}
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 {you/{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: [_____________]
PHARMACY_STR1: [_____________]
PHARMACY_STR2: [_____________]
PHARMACY_CITY: [_____________]
PHARMACY_STATE: [_____________]
PHARMACY_ZIPCDE: [_____________]
PHARMACY_PHONE: [_____________]
REF .................................. -7 {BOX_05}
DK ................................... -8 {BOX_05}
USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.
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.
CODES '-7' (REFUSED) AND '-8' (DON’T KNOW) ARE
ALLOWED ON EACH FORM ITEM EXCEPT FOR PHARMACY
NAME (PM14_01).
HARD CHECK: CHECK THAT STATE ABBREVIATION IS
VALID.
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 PRESS ENTER. TO CORRECT
OR ENTER
INFORMATION, TYPE ENTIRE FIELD.
PHARMACY_STR1: [_____________] {BOX_05}
PHARMACY_STR2: [_____________]
PHARMACY_CITY: [_____________]
PHARMACY_STATE: [_____________]
PHARMACY_ZIPCDE: [_____________]
PHARMACY_PHONE: [_____________]
RF ................................... -7 {BOX_05}
DK ................................... -8 {BOX_05}
USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.
ADDRESS FIELDS CONTAIN PREVIOUSLY COLLECTED
INFORMATION WHICH CAN BE UPDATED.
HARD CHECK:
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}{PHARMACY 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 {PM17}
IN ANOTHER STORE ....................... 2 {PM17}
IN HMO/CLINIC/HOSPITAL ................. 3 {PM17}
DRUG STORE ............................. 4 {PM17}
ON-LINE ................................ 5 {PM17}
REF ................................... -7 {PM17}
DK .................................... -8 {PM17}
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code One]
PM17
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
Did {you/{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 {END_LP02}
NO ..................................... 2 {END_LP02}
REF ................................... -7 {END_LP02}
DK .................................... -8 {END_LP02}
DISPLAY ‘since {START DATE}’ IF NOT ROUND 5.
DISPLAY ‘between {START DATE} and {END DATE}’ IF
ROUND 5.
END_LP02
IF PM17 IS CODED '1' (YES), CYCLE TO COLLECT
INFORMATION ABOUT THE NEXT PHARMACY USED BY
PERSON.
IF PM17 IS CODED '2' (NO), '-7 (REFUSED), OR '-8'
(DON'T KNOW), END LOOP_02 AND CONTINUE WITH BOX_06
BOX_06
GO TO NEXT QUESTIONNAIRE SECTION
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