Access to Care (AC) Section

BOX_00A

THE AC SECTION IS ASKED IN ROUNDS 2 AND 4 ONLY. IF
IT IS ROUND 1, 3, OR 5, CONTINUE TO THE NEXT
SECTION.

BOX_00

CONTEXT HEADER DISPLAY INSTRUCTIONS:
DISPLAY PERS.FULLNAME, PROV.LORPNAME

AC01

OMITTED.

AC02

OMITTED.

AC02A

OMITTED.

LOOP_01A

OMITTED.

NAV_AC01A

OMITTED.

AC03

OMITTED.

AC04

OMITTED.

END_LP01A

OMITTED.

LOOP_01

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER, ASK
NAV_AC01 - END_LP01

LOOP DEFINITION: LOOP_01 COLLECTS THE NAME OF
THE USUAL SOURCE OF CARE PROVIDER, IF ANY, FOR
EACH CURRENT RU MEMBER. THIS LOOP CYCLES ON
PERSONS WHO MEET THE FOLLOWING CONDITIONS:

- PERSON IS A CURRENT RU MEMBER
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED

NAVIGATOR DETAILS: LOOP_01 USES NAV_AC01 TO
CONTROL THE FLOW OF THE LOOP.

NAV_AC01

SERIES: Identifying USC Provider (e.g., provider’s name,
transportation mode, provider’s specialty and race)

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DETAILS:
COL # 1 HEADER: RU MEMBER
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH RU MEMBER EACH TIME THE NAVIGATOR
IS PRESENTED

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS ON THE RU-MEMBERS-ROSTER
EXCLUDING DECEASED AND INSTITUTIONALIZED RU MEMBERS.

CONTINUE WITH AC05 FOR SELECTED RU MEMBER

AC05

{PERSON’S FIRST MIDDLE AND LAST NAME}

Is there a particular doctor’s office, clinic, health center,
or other place that {you/{PERSON}} usually {go/goes} if {you/he/she}
{are/is} sick or {need/needs} advice about {your/his/her} health?

YES ..................................... 1 {AC09}
NO ...................................... 2 {AC07}
MORE THAN ONE PLACE ..................... 3 {AC06}
REF ..................................... -7 {END_LP01}
DK ...................................... -8 {END_LP01}

[Code One]

HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF
HEALTH CARE.

AC06

{PERSON’S FIRST MIDDLE AND LAST NAME}

Would {you/{PERSON}} go to one of these places first or most often
if {you/he/she} {are/is} sick?

YES ..................................... 1 {AC09}
NO ...................................... 2 {AC07}
REF ..................................... -7 {END_LP01}
DK ...................................... -8 {END_LP01}

AC07

{PERSON’S FIRST MIDDLE AND LAST NAME}

What is the main reason {you/{PERSON}} {do/does} not have a usual
source of health care?

SELDOM OR NEVER GETS SICK ............... 1 {AC08}
RECENTLY MOVED INTO AREA ................ 2 {AC08}
DON’T KNOW WHERE TO GO FOR CARE ......... 3 {AC08}
USUAL SOURCE OF MEDICAL CARE IN THIS
AREA IS NO LONGER AVAILABLE ........... 4 {AC08}
CAN’T FIND A PROVIDER WHO SPEAKS
{YOUR/HIS/HER} LANGUAGE ............... 5 {AC08}
LIKES TO GO TO DIFFERENT PLACES FOR
DIFFERENT HEALTH NEEDS ................ 6 {AC08}
JUST CHANGED INSURANCE PLANS ............ 7 {AC08}
DON’T USE DOCTORS/TREAT MYSELF .......... 8 {AC08}
COST OF MEDICAL CARE .................... 9 {AC08}
NO HEALTH INSURANCE ..................... 10 {AC08}
OTHER REASON ............................ 91 {AC07OV}
REF ..................................... -7 {END_LP01}
DK ...................................... -8 {END_LP01}

[Code One]

HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF
HEALTH CARE.

AC07OV

ENTER OTHER REASON:

[Enter Other Specify] .................. {AC08}
REF ................................... -7 {AC08}
DK .................................... -8 {AC08}

AC08

{PERSON’S FIRST MIDDLE AND LAST NAME}

What are the other reasons {you/{PERSON}} {do/does} not have a usual
source of health care?

CHECK ALL THAT APPLY.

NO OTHER REASONS ........................ 0 {END_LP01}
SELDOM OR NEVER GETS SICK ............... 1
RECENTLY MOVED INTO AREA ................ 2
DON’T KNOW WHERE TO GO FOR CARE ......... 3
USUAL SOURCE OF MEDICAL CARE IN THIS
AREA IS NO LONGER AVAILABLE ........... 4
CAN’T FIND A PROVIDER WHO SPEAKS
{YOUR/HIS/HER} LANGUAGE ............... 5
LIKES TO GO TO DIFFERENT PLACES FOR
DIFFERENT HEALTH NEEDS ................ 6
JUST CHANGED INSURANCE PLANS ............ 7
DON’T USE DOCTORS/TREAT MYSELF .......... 8
COST OF MEDICAL CARE .................... 9
NO HEALTH INSURANCE ..................... 10
OTHER REASON ............................ 91 {AC08OV}
REF ..................................... -7 {END_LP01}
DK ...................................... -8 {END_LP01}

[Code All That Apply]

HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF
HEALTH CARE.

IF ‘RF’ (REFUSED) OR ‘DK’ (DON’T KNOW) IS SELECTED, CAPI SHOULD CODE AS ‘0’ (NO OTHER REASONS).

FOR SPECIFICATION PURPOSES ONLY: CAPI DOES NOT
ALLOW CODES ‘0’ (NO OTHER REASONS), ‘RF’
(REFUSED), OR ‘DK’ (DON’T KNOW) IN COMBINATION
WITH ANY OTHER CODES.

IF CODED ‘91’ (OTHER REASON) ALONE OR IN
COMBINATION WITH OTHER CODES, CONTINUE WITH AC08OV
(NOTE THAT AC08OV IS AN OVERLAY ON AC08.)

OTHERWISE, GO TO END_LP01

AC08OV

ENTER OTHER REASON:

[Enter Other Specify] .................. {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

AC09

{PERSON’S FIRST MIDDLE AND LAST NAME}

Please give me the name of the medical person, doctor’s office,
clinic, health center, or other place that {you/{PERSON}} usually
{go/goes} if {you/he/she} {are/is} sick or {need/needs} advice
about {your/his/her} health.

If possible, give me the name of the particular person that
{you/he/she} usually {see/sees}.

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF
HEALTH CARE.

BEGINNING IN PANEL 12, ROUND 4 AND PANEL 13,
ROUND 2, AC09 AND PV01 WERE REVISED TO PROMPT
RESPONDENTS TO NAME A PERSON-PROVIDER AS THE USC
PROVIDER IF POSSIBLE. THE DATA AT VARIABLE
PROVTY42 IS EXPECTED TO CHANGE SIGNIFICANTLY
BASED ON THIS NEW WORDING AND PROBING.

BOX_01

ASK THE PROVIDER ROSTER (PV) SECTION

AT THE COMPLETION OF THE PROVIDER ROSTER (PV)
SECTION, CONTINUE WITH BOX_02

BOX_02

FLAG THE PROVIDER ADDED OR SELECTED AS THE ‘USC
(USUAL SOURCE OF CARE) PROVIDER’ FOR THIS PERSON
FOR THIS PARTICULAR ROUND.

IF THIS USC PROVIDER IS FLAGGED AS ‘FACILITY-
TYPE-PROVIDER’ OR AS ‘PERSON-IN-FACILITY-PROVIDER’
AND AC11 WAS NOT ALREADY ASKED FOR THIS USC
PROVIDER IN AN EARLIER LOOP, GO TO AC11

OTHERWISE, (THAT IS, IF THIS USC PROVIDER IS
FLAGGED AS ‘PERSON-TYPE-PROVIDER’ OR IF THIS USC
PROVIDER IS FLAGGED AS ‘FACILITY-TYPE-PROVIDER’
OR AS ’PERSON-IN-FACILITY-PROVIDER’ AND AC11 HAS
ALREADY BEEN ASKED FOR THIS USC PROVIDER), GO TO
AC12

AC10

OMITTED.

AC11

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......}

ASK IF NOT OBVIOUS.

{Is {PROVIDER}/Does {PROVIDER} work at} a clinic in a hospital,
a hospital outpatient department, an emergency room at a
hospital, or some other kind of place?

HOSPITAL CLINIC OR OUTPATIENT
DEPARTMENT ............................ 1 {AC12}
HOSPITAL EMERGENCY ROOM ................. 2 {AC12}
OTHER KIND OF PLACE ..................... 3 {AC12}
REF ..................................... -7 {AC12}
DK ...................................... -8 {AC12}

[Code One]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

DISPLAY ‘Is {PROVIDER}’ IF USC PROVIDER IS FLAGGED
AS ‘FACILITY-TYPE-PROVIDER’. DISPLAY ‘Does
{PROVIDER} work at’ IF USC PROVIDER IS FLAGGED AS
‘PERSON-IN-FACILITY-PROVIDER’.

NOTE: FOR QUESTIONS AC11 – AC20, THE CONTEXT
HEADER WILL DISPLAY THE PERSON-PROVIDER NAME IF
THE USC PROVIDER BEING ASKED ABOUT IS FLAGGED AS
‘PERSON-TYPE-PROVIDER’ OR ‘PERSON-IN-FACILITY-
PROVIDER’. IF THE USC PROVIDER BEING ASKED ABOUT
IS FLAGGED AS ‘FACILITY-TYPE-PROVIDER’, THE
CONTEXT HEADER WILL DISPLAY THE FACILITY-PROVIDER
NAME.

AC12

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......}

How {do/does} {you/{PERSON}} usually get to {PROVIDER}?

DRIVE ................................. 1 {AC13}
IS DRIVEN ............................. 2 {AC13}
TAXI, BUS, TRAIN, OTHER
PUBLIC TRANSPORTATION ............... 3 {AC13}
WALKS ................................. 4 {AC13}
SOME OTHER WAY ........................ 5 {AC13}
REF .................................. -7 {AC13}
DK ................................... -8 {AC13}

[Code One]

AC13

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER.......}

How long does it take {you/{PERSON}} to get to {PROVIDER}?

LESS THAN 15 MINUTES ................... 1 {AC14}
15 TO 30 MINUTES ....................... 2 {AC14}
31 TO 60 MINUTES (1 HOUR) .............. 3 {AC14}
61 TO 90 MINUTES ....................... 4 {AC14}
91 TO 120 MINUTES (2 HOURS) ............ 5 {AC14}
MORE THAN 120 MINUTES (2 HOURS) ........ 6 {AC14}
REF ................................... -7 {AC14}
DK .................................... -8 {AC14}

[Code One]

AC14

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER.......}

SHOW CARD AC-1.

How difficult is it for {you/{PERSON}} to get to {PROVIDER}?

Would you say it is ...

very difficult, ........................ 1 {BOX_03}
somewhat difficult, .................... 2 {BOX_03}
not too difficult, or .................. 3 {BOX_03}
not at all difficult? .................. 4 {BOX_03}
REF ................................... -7 {BOX_03}
DK .................................... -8 {BOX_03}

[Code One]

BOX_03

IF THIS USC PROVIDER IS FLAGGED AS ‘PERSON-
TYPE-PROVIDER’ OR ‘PERSON-IN-FACILITY-PROVIDER’
AND AC15 WAS NOT ALREADY ASKED FOR THIS USC
PROVIDER IN AN EARLIER LOOP, CONTINUE WITH AC15

OTHERWISE, GO TO END_LP01

AC15

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......}

Is {PROVIDER} a medical doctor?

YES ..................................... 1 {AC17}
NO ...................................... 2 {AC16}
REF ..................................... -7 {AC18}
DK ...................................... -8 {AC18}

HELP AVAILABLE FOR DEFINITION OF MEDICAL DOCTOR.

AC16

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......}

Is {PROVIDER} a nurse, nurse practitioner, physician’s
assistant, midwife, or some other kind of person?

SELECT ‘CHIROPRACTOR’ IF CHIROPRACTOR VOLUNTEERED AS TYPE
OF MEDICAL PERSON.

NURSE ................................... 1 {AC18}
NURSE PRACTITIONER ...................... 2 {AC18}
PHYSICIAN’S ASSISTANT ................... 3 {AC18}
MIDWIFE ................................. 4 {AC18}
CHIROPRACTOR ............................ 5 {AC18}
OTHER ................................... 91 {AC16OV}
REF ..................................... -7 {AC18}
DK ...................................... -8 {AC18}

[Code One]

HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.

AC16OV

OTHER:

[Enter Other Specify] .................. {AC18}
REF ................................... -7 {AC18}
DK .................................... -8 {AC18}

AC17

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......}

What is {PROVIDER}’s specialty?

GENERAL/FAMILY PRACTICE ................. 1 {AC18}
INTERNAL MEDICINE ....................... 2 {AC18}
PEDIATRICS .............................. 3 {AC18}
OB/GYN .................................. 4 {AC18}
SURGERY ................................. 5 {AC18}
CHIROPRACTOR ............................ 6 {AC18}
CARDIOLOGIST ............................ 7 {AC18}
DOCTOR OF OSTEOPATHY..................... 8 {AC18}
OTHER ................................... 91 {AC17OV}
REF ..................................... -7 {AC18}
DK ...................................... -8 {AC18}

[Code One]

AC17OV

OTHER:

[Enter Other Specify] .................. {AC18}
REF ................................... -7 {AC18}
DK .................................... -8 {AC18}

AC18

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER.......}

Is {PROVIDER} Hispanic or Latino?

YES .................................... 1 {AC19}
NO ..................................... 2 {AC19}
REF ................................... -7 {AC19}
DK .................................... -8 {AC19}

AC19

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER.......}

SHOW CARD AC-2.

What is {PROVIDER}’s race?

CHECK ALL THAT APPLY.

WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91 {AC19OV}
REF ................................... -7 {AC20}
DK .................................... -8 {AC20}

[Code All That Apply]

IF CODED ’91’ (SOME OTHER RACE) ALONE OR IN
COMBINATION WITH OTHER CODES, CONTINUE WITH
AC19OV

OTHERWISE, GO TO AC20

AC19OV

OTHER RACE:

[Enter Other Specify] .................. {AC20}
REF ................................... -7 {AC20}
DK .................................... -8 {AC20}

AC20

{PERSON’S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER.......}

Is {PROVIDER} male or female?

MALE ................................... 1 {END_LP01}
FEMALE ................................. 2 {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

[Code One]

END_LP01

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_01 AND CONTINUE WITH BOX_04

BOX_04

IF AT LEAST ONE PROVIDER FLAGGED AS ‘USC PROVIDER’
ON THE RU-MEDICAL-PROVIDERS-ROSTER, CONTINUE WITH
IntroUSCP

OTHERWISE, GO TO AC32A

IntroUSCP

THE NEXT QUESTIONS WILL ONLY BE ASKED ONCE ABOUT
EACH USUAL SOURCE OF CARE PROVIDER.

　
PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

CONTINUE WITH LOOP_02

LOOP_02

FOR EACH ELEMENT IN THE RU-MEDICAL-PROVIDERS-
ROSTER, ASK NAV_AC02 - END_LP02

LOOP DEFINITION: LOOP_02 COLLECTS DETAILED
INFORMATION ON EACH UNIQUE USUAL SOURCE OF CARE
PROVIDER IDENTIFIED FOR THIS RU. THIS LOOP CYCLES
ON PROVIDERS WHO MEET THE FOLLOWING CONDITION:

- PROVIDER FLAGGED AS ‘USC PROVIDER’ DURING THE
CURRENT ROUND FOR A CURRENT RU MEMBER.

NOTE: IF THE USC PROVIDER BEING LOOPED ON IS
FLAGGED AS ‘PERSON-TYPE-PROVIDER’ OR ‘PERSON-IN-
FACILITY-PROVIDER’ THE CONTEXT HEADER IN LOOP_02
WILL DISPLAY THE PERSON-PROVIDER NAME. IF THE USC
PROVIDER BEING LOOPED ON IS FLAGGED AS ‘FACILITY-
TYPE-PROVIDER’ THE CONTEXT HEADER IN LOOP_02 WILL
DISPLAY THE FACILITY-PROVIDER NAME.

NAVIGATOR DETAILS: LOOP_02 USES NAV_AC02 TO
CONTROL THE FLOW OF THE LOOP.

NAV_AC02

SERIES: USC Provider Detail (e.g., experience with provider,
provider hours, satisfaction with provider’s care)

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.

USC Provider

[1. Provider or Facility Name-30] [Status-25]
[2. Provider or Facility Name-30] [Status-25]
[3. Provider or Facility Name-30] [Status-25]

ROSTER DETAILS:
COL # 1 HEADER: USC PROVIDER
INSTRUCTIONS: DISPLAY PROVIDER FIRST INITIAL AND
LAST NAME IF PERSON-PROVIDER OR PERSON-IN-FACILITY
PROVIDER. DISPLAY FACILITY NAME IF FACILITY-
PROVIDER.
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH PROVIDER EACH TIME THE NAVIGATOR
IS PRESENTED

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEDICAL-PROVIDERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PROVIDERS WHO MEET THE FOLLOWING
CONDITIONS:
- PROVIDER FLAGGED AS ‘USC PROVIDER’ DURING THE
CURRENT ROUND FOR A CURRENT RU MEMBER.

CONTINUE WITH AC21 FOR SELECTED PROVIDER.

AC21

{NAME OF MEDICAL CARE PROVIDER......}

The next few questions ask about the experience (READ NAME(S)
BELOW) (have/has) had with {PROVIDER}. Please think about their
overall experiences when answering the following questions.

IF ONLY CHILDREN ARE DISPLAYED BELOW, USE THE PRONOUN ’YOU’ OR
THE PARENT’S NAME.

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

CONTINUE WITH AC22

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR DISPLAY.

ROSTER BEHAVIOR:
1. SELECT, ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS ON THE RU-MEMBERS-ROSTER
WHO IDENTIFIED PROVIDER BEING ASKED ABOUT AS
PERSON’S USC PROVIDER FOR THE CURRENT ROUND.

AC22

{NAME OF MEDICAL CARE PROVIDER......}

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

Is {PROVIDER} the {person/place} (READ NAME(S) ABOVE) would
go to for ...

YES = 1
NO = 2
RF = -7
DK = -8

AC22_01

a. New health problems? ( )

AC22_02

b. Preventive health care, such as general
checkups, examinations, and immunizations? ( )

AC22_03

c. Referrals to other health professionals when
needed? ( )

AC22_04

d. Ongoing health problems? ( )

HELP AVAILABLE FOR DEFINITION OF PREVENTIVE HEALTH CARE
AND REFERRAL.

DISPLAY ‘person’ IF THE USC PROVIDER BEING LOOPED
ON IS FLAGGED AS ‘PERSON-TYPE-PROVIDER’ OR
‘PERSON-IN-FACILITY-PROVIDER’. DISPLAY ‘place’ IF
USC PROVIDER BEING LOOPED ON IS FLAGGED AS
‘FACILITY-TYPE-PROVIDER’.

ALLOW ‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW) ON ALL
FORM ITEMS.

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR DISPLAY.

ROSTER BEHAVIOR:
1. SELECT, ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS ON THE RU-MEMBERS-ROSTER
WHO IDENTIFIED PROVIDER BEING ASKED ABOUT AS
PERSON’S USC PROVIDER FOR THE CURRENT ROUND.

AC23

{NAME OF MEDICAL CARE PROVIDER......}

SHOW CARD AC-1.

How difficult is it to contact {a medical person at} {PROVIDER}
during regular business hours over the telephone about a health
problem?

Would you say it is ...

very difficult, ......................... 1
somewhat difficult, ..................... 2
not too difficult, or ................... 3
not at all difficult? ................... 4
REF ..................................... -7
DK ...................................... -8

[Code One]

DISPLAY ‘a medical person at’ IF USC PROVIDER
BEING LOOPED ON IS FLAGGED AS ‘FACILITY-TYPE-
PROVIDER’. OTHERWISE, USE A NULL DISPLAY.

IF AC11 WAS CODED ‘2’ (HOSPITAL EMERGENCY ROOM)
FOR THIS USC PROVIDER, GO TO AC25

OTHERWISE, CONTINUE WITH AC24

AC24

{NAME OF MEDICAL CARE PROVIDER......}

Does {PROVIDER} have office hours at night or on weekends?

YES ..................................... 1 {AC25}
NO ...................................... 2 {AC25}
REF ..................................... -7 {AC25}
DK ...................................... -8 {AC25}

AC25

{NAME OF MEDICAL CARE PROVIDER.......}

SHOW CARD AC-1.

How difficult is it to contact {a medical person at} {PROVIDER}
after their regular hours in case of urgent medical needs?

Would you say it is ...

very difficult, ........................ 1 {AC26}
somewhat difficult, .................... 2 {AC26}
not too difficult, or .................. 3 {AC26}
not at all difficult? .................. 4 {AC26}
REF ................................... -7 {AC26}
DK .................................... -8 {AC26}

[Code One]

DISPLAY ‘a medical person at’ IF USC PROVIDER
BEING LOOPED ON IS FLAGGED AS ‘FACILITY-TYPE-
PROVIDER’. OTHERWISE, USE A NULL DISPLAY.

AC26

{NAME OF MEDICAL CARE PROVIDER......}

Does {someone at} {PROVIDER} usually ask about prescription
medications and treatments other doctors may give them?

YES ..................................... 1 {AC27}
NO ...................................... 2 {AC27}
REF ..................................... -7 {AC27}
DK ...................................... -8 {AC27}

DISPLAY ‘someone at’ IF USC PROVIDER BEING LOOPED
ON IS FLAGGED AS ‘FACILITY-TYPE-PROVIDER’.
OTHERWISE, USE A NULL DISPLAY.

AC27

{NAME OF MEDICAL CARE PROVIDER.......}

SHOW CARD AC-3.

Thinking about the types of medical, traditional and alternative
treatments that (READ NAME(S) BELOW) (is/are) are happy with, how
often does {a medical person at} {PROVIDER} show respect for these
treatments?

Would you say...

IF ONLY CHILDREN ARE DISPLAYED BELOW, USE THE PRONOUN ‘YOU’ OR THE
PARENT’S NAME.

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

never, ................................. 1 {AC28}
sometimes, ............................. 2 {AC28}
usually, or ............................ 3 {AC28}
always? ................................ 4 {AC28}
REF ................................... -7 {AC28}
DK .................................... -8 {AC28}

[Code One]

DISPLAY ’a medical person at’ IF USC PROVIDER
BEING LOOPED ON IS FLAGGED AS ’FACILITY-TYPE-
PROVIDER.’ OTHERWISE, USE A NULL DISPLAY.

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR DISPLAY.

ROSTER BEHAVIOR:
1. SELECT, ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS ON THE RU-MEMBERS-ROSTER
WHO IDENTIFIED PROVIDER BEING ASKED ABOUT AS
PERSON’S USC PROVIDER FOR THE CURRENT ROUND.

AC28

{NAME OF MEDICAL CARE PROVIDER.......}

SHOW CARD AC-3.

If there were a choice between treatments, how often would
{a medical person at} {PROVIDER} ask (READ NAME(S) BELOW) to
help make the decision?

Would you say...

IF ONLY CHILDREN ARE DISPLAYED BELOW, USE THE PRONOUN ‘YOU’ OR
THE PARENT’S NAME.

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

never, ................................. 1 {AC30}
sometimes, ............................. 2 {AC30}
usually, or ............................ 3 {AC30}
always? ................................ 4 {AC30}
REF ................................... -7 {AC30}
DK .................................... -8 {AC30}

[Code One]

DISPLAY ‘a medical person at’ IF USC PROVIDER
BEING LOOPED ON IS FLAGGED AS ‘FACILITY-TYPE-
PROVIDER’. OTHERWISE, USE A NULL DISPLAY.

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR DISPLAY.

ROSTER BEHAVIOR:
1. SELECT, ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS ON THE RU-MEMBERS-ROSTER
WHO IDENTIFIED PROVIDER BEING ASKED ABOUT AS
PERSON’S USC PROVIDER FOR THE CURRENT ROUND.

AC29

OMITTED.

AC30

{NAME OF MEDICAL CARE PROVIDER.......}

Does {a medical person at} {PROVIDER} present and explain all
options to (READ NAME(S) BELOW)?

IF ONLY CHILDREN ARE DISPLAYED BELOW, USE THE PRONOUN ‘YOU’ OR
THE PARENT’S NAME.

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

YES .................................... 1 {BOX_05}
NO ..................................... 2 {BOX_05}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}

DISPLAY ‘a medical person at’ IF USC PROVIDER
BEING LOOPED ON IS FLAGGED AS ‘FACILITY-TYPE-
PROVIDER.’ OTHERWISE, USE A NULL DISPLAY.

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR DISPLAY.

ROSTER BEHAVIOR:
1. SELECT, ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS ON THE RU-MEMBERS-ROSTER
WHO IDENTIFIED PROVIDER BEING ASKED ABOUT AS
PERSON’S USC PROVIDER FOR THE CURRENT ROUND.

BOX_05

IF RE102B WAS CODED ‘3’ (NOT WELL) OR ‘4’ (NOT AT
ALL) FOR AT LEAST ONE RU MEMBER IN ANY ROUND AND
PERSON IDENTIFIED THIS USC PROVIDER AS THEIR USC
PROVIDER (AC05 IS SET TO ‘1’ OR AC06 IS SET TO
‘1’), CONTINUE WITH AC31

OTHERWISE, GO TO END_LP02

AC31

{NAME OF MEDICAL CARE PROVIDER.......}

Does {someone at} {PROVIDER} speak the language (READ NAME(S)
BELOW) prefer(s) or provide translator services for them?

IF ONLY CHILDREN ARE DISPLAYED BELOW, USE THE PRONOUN ‘YOU’ OR
THE PARENT’S NAME.

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

YES .................................... 1 {END_LP02}
NO ..................................... 2 {END_LP02}
REF ................................... -7 {END_LP02}
DK .................................... -8 {END_LP02}

DISPLAY ’someone at’ IF USC PROVIDER BEING LOOPED
ON IS FLAGGED AS ’FACILITY-TYPE-PROVIDER.’
OTHERWISE, USE A NULL DISPLAY.

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR DISPLAY.

ROSTER BEHAVIOR:
1. SELECT, ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS ON THE RU-MEMBERS-ROSTER
WHO
- IDENTIFIED PROVIDER BEING ASKED ABOUT AS
PERSON’S USC PROVIDER FOR THE CURRENT ROUND
AND
- RE102B WAS CODED ‘3’ (NOT WELL) OR ‘4’ (NOT AT
ALL) FOR THIS PERSON IN ANY ROUND.

END_LP02

CYCLE ON NEXT PROVIDER IN THE RU-MEDICAL-
PROVIDERS-ROSTER WHO MEETS THE CONDITIONS STATED
IN THE LOOP DEFINITION.

IF NO OTHER PROVIDERS MEET THE STATED CONDITIONS,
END LOOP_02 AND CONTINUE WITH AC32A

AC32A

When answering the next few questions, do not include dental care
and prescription medicines.

In the last 12 months, did anyone in the family or a doctor
believe they needed any medical care, tests, or treatment?

YES .................................... 1 {AC32}
NO ..................................... 2 {AC40A}
REF ................................... -7 {AC40A}
DK .................................... -8 {AC40A}

AC32

In the last 12 months, was anyone in the family unable to
obtain medical care, tests, or treatments they or a doctor
believed necessary?

　
YES .................................... 1
NO ..................................... 2 {AC36}
REF ................................... -7 {AC36}
DK .................................... -8 {AC36}

IF CODED ’1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AS ’UNMET NEED FOR
MEDICAL CARE’ AT AC33 BY CAPI.

IF CODED ’1’ (YES) AND A SINGLE-PERSON RU, GO TO
LOOP_03

IF CODED ’1’ (YES) AND A MULTI-PERSON RU, CONTINUE
WITH AC33

AC33

Who was that?

PROBE: Was anyone else in the family unable to get medical
care, tests, or treatments they or a doctor believed necessary?

[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]

IF THE ONLY PERSON SELECTED IS DECEASED OR
INSTITUTIONALIZED, GO TO AC36

OTHERWISE, CONTINUE WITH LOOP_03

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.
2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
NO FILTER; DISPLAY ALL.

LOOP_03

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER, ASK
NAV_AC03 – END_LP03

LOOP DEFINITION: LOOP_03 COLLECTS THE MAIN REASON
AND THE PROBLEM WITH THE UNMET NEED FOR MEDICAL
CARE. THIS LOOP CYCLES ON RU MEMBERS WHO MEET THE
FOLLOWING CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED
- PERSON HAD AN UNMET NEED FOR MEDICAL CARE (I.E.,
PERSON WAS SELECTED AT AC33)

NAVIGATOR DETAILS: LOOP_03 USES NAV_AC03 TO
CONTROL THE FLOW OF THE LOOP.

NAV_AC03

SERIES: Reason for Being Unable to Obtain Medical Care

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED
- PERSON HAD AN UNMET NEED FOR MEDICAL CARE (I.E.,
PERSON WAS SELECTED AT AC33)

CONTINUE WITH AC34 FOR SELECTED RU MEMBER

AC34

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD AC-4.

Which of these best describes the main reason {you/{PERSON}} {were/was}
unable to get medical care, tests, or treatments {you/he/she} or a
doctor believed necessary?

COULDN’T AFFORD CARE ..................... 1 {AC35}
INSURANCE COMPANY WOULDN’T APPROVE,
COVER, OR PAY FOR CARE ................. 2 {AC35}
DOCTOR REFUSED TO ACCEPT FAMILY’S
INSURANCE PLAN ......................... 3 {AC35}
PROBLEMS GETTING TO DOCTOR’S OFFICE ...... 4 {AC35}
DIFFERENT LANGUAGE ....................... 5 {AC35}
COULDN’T GET TIME OFF WORK ............... 6 {AC35}
DIDN’T KNOW WHERE TO GO TO GET CARE ...... 7 {AC35}
WAS REFUSED SERVICES ..................... 8 {AC35}
COULDN’T GET CHILD CARE .................. 9 {AC35}
DIDN’T HAVE TIME OR TOOK TOO LONG ....... 10 {AC35}
OTHER ................................... 91 {AC35}
REF ..................................... -7 {AC35}
DK ...................................... -8 {AC35}

[Code One]

AC35

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD AC-5.

How much of a problem was it that {you/{PERSON}} did not get medical
care, tests, or treatments {you/he/she} or a doctor believed necessary?

Would you say ...

a big problem, ......................... 1 {END_LP03}
a small problem, or .................... 2 {END_LP03}
not a problem? ......................... 3 {END_LP03}
REF ................................... -7 {END_LP03}
DK .................................... -8 {END_LP03}

[Code One]

END_LP03

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_03 AND CONTINUE WITH AC36

AC36

In the last 12 months, was anyone in the family delayed in
getting medical care, tests, or treatments they or a doctor
believed necessary?

YES .................................... 1
NO ..................................... 2 {AC40A}
REF ................................... -7 {AC40A}
DK .................................... -8 {AC40A}

IF CODED ’1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AS ’DELAY IN RECEIVING
MEDICAL CARE’ AT AC37 BY CAPI.

IF CODED ’1’ (YES) AND A SINGLE-PERSON RU, GO TO
LOOP_04

IF CODED ’1’ (YES) AND A MULTI-PERSON RU, CONTINUE
WITH AC37

AC37

Who was that?

PROBE: Was anyone else in the family delayed in getting
medical care, tests, or treatments they or a doctor believed
necessary?

[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]

IF THE ONLY PERSON SELECTED IS DECEASED OR
INSTITUTIONALIZED, GO TO AC40A

OTHERWISE, CONTINUE WITH LOOP_04

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.
2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
NO FILTER; DISPLAY ALL.

LOOP_04

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER, ASK
NAV_AC04 – END_LP04

LOOP DEFINITION: LOOP_04 COLLECTS THE MAIN REASON
AND THE PROBLEM WITH THE DELAY IN RECEIVING
MEDICAL CARE. THIS LOOP CYCLES ON RU MEMBERS WHO
MEET THE FOLLOWING CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED
- PERSON HAD A DELAY IN RECEIVING MEDICAL CARE
(I.E., PERSON WAS SELECTED AT AC37)

NAVIGATOR DETAILS: LOOP_04 USES NAV_AC04 TO
CONTROL THE FLOW OF THE LOOP.

NAV_AC04

SERIES: Reason for Delay In Obtaining Medical Care

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED
- PERSON HAD A DELAY IN RECEIVING MEDICAL CARE
(I.E., PERSON WAS SELECTED AT AC37)

CONTINUE WITH AC38 FOR SELECTED RU MEMBER

AC38

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD AC-4.

Which of these best describes the main reason {you/{PERSON}} {were/was}
delayed in getting medical care, tests, or treatments {you/he/she} or
a doctor believed necessary?

COULDN’T AFFORD CARE ..................... 1 {AC39}
INSURANCE COMPANY WOULDN’T APPROVE,
COVER, OR PAY FOR CARE ................. 2 {AC39}
DOCTOR REFUSED TO ACCEPT FAMILY’S
INSURANCE PLAN ......................... 3 {AC39}
PROBLEMS GETTING TO DOCTOR’S OFFICE ...... 4 {AC39}
DIFFERENT LANGUAGE ....................... 5 {AC39}
COULDN’T GET TIME OFF WORK ............... 6 {AC39}
DIDN’T KNOW WHERE TO GO TO GET CARE ...... 7 {AC39}
WAS REFUSED SERVICES ..................... 8 {AC39}
COULDN’T GET CHILD CARE .................. 9 {AC39}
DIDN’T HAVE TIME OR TOOK TOO LONG ....... 10 {AC39}
OTHER ................................... 91 {AC39}
REF ..................................... -7 {AC39}
DK ...................................... -8 {AC39}

[Code One]

AC39

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD AC-5.

How much of a problem was it that {you/{PERSON}} {were/was} delayed
in getting medical care, tests, or treatments {you/he/she} or a
doctor believed necessary?

Would you say ...

a big problem, ......................... 1 {END_LP04}
a small problem, or .................... 2 {END_LP04}
not a problem? ......................... 3 {END_LP04}
REF ................................... -7 {END_LP04}
DK .................................... -8 {END_LP04}

[Code One]

END_LP04

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_04 AND CONTINUE WITH AC40A

AC40A

In the last 12 months, did anyone in the family or a dentist
believe they needed any dental care, tests, or treatment?

YES .................................... 1 {AC40}
NO ..................................... 2 {AC48A}
REF ................................... -7 {AC48A}
DK .................................... -8 {AC48A}

AC40

In the last 12 months, was anyone in the family unable to
obtain dental care, tests, or treatments they or a dentist
believed necessary?

YES .................................... 1
NO ..................................... 2 {AC44}
REF ................................... -7 {AC44}
DK .................................... -8 {AC44}

IF CODED ’1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AS ’UNMET NEED FOR
DENTAL CARE’ AT AC41 BY CAPI.

IF CODED ’1’ (YES) AND A SINGLE-PERSON RU, GO TO
LOOP_05

IF CODED ’1’ (YES) AND A MULTI-PERSON RU, CONTINUE
WITH AC41

AC41

Who was that?

PROBE: Was anyone else in the family unable to get dental
care, tests, or treatments they or a dentist believed necessary?

[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]

IF THE ONLY PERSON SELECTED IS DECEASED OR
INSTITUTIONALIZED, GO TO AC44

OTHERWISE, CONTINUE WITH LOOP_05

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
NO FILTER; DISPLAY ALL.

LOOP_05

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER, ASK
NAV_AC05 – END_LP05

LOOP DEFINITION: LOOP_05 COLLECTS THE MAIN REASON
AND THE PROBLEM WITH THE UNMET NEED FOR DENTAL
CARE. THIS LOOP CYCLES ON RU MEMBERS WHO MEET THE
FOLLOWING CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED
- PERSON HAD AN UNMET NEED FOR DENTAL CARE (I.E.,
PERSON WAS SELECTED AT AC41)

NAVIGATOR DETAILS: LOOP_05 USES NAV_AC05 TO
CONTROL THE FLOW OF THE LOOP.

NAV_AC05

SERIES: Reason for Being Unable to Obtain Dental Care

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED
- PERSON HAD AN UNMET NEED FOR DENTAL CARE (I.E.,
PERSON WAS SELECTED AT AC41)

CONTINUE WITH AC42 FOR SELECTED RU MEMBER

AC42

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD AC-4.

Which of these best describes the main reason {you/{PERSON}} {were/was}
unable to get dental care, tests, or treatments {you/he/she} or a
dentist believed necessary?

COULDN’T AFFORD CARE ..................... 1 {AC43}
INSURANCE COMPANY WOULDN’T APPROVE,
COVER, OR PAY FOR CARE ................. 2 {AC43}
DOCTOR REFUSED TO ACCEPT FAMILY’S
INSURANCE PLAN ......................... 3 {AC43}
PROBLEMS GETTING TO DOCTOR’S OFFICE ...... 4 {AC43}
DIFFERENT LANGUAGE ....................... 5 {AC43}
COULDN’T GET TIME OFF WORK ............... 6 {AC43}
DIDN’T KNOW WHERE TO GO TO GET CARE ...... 7 {AC43}
WAS REFUSED SERVICES ..................... 8 {AC43}
COULDN’T GET CHILD CARE .................. 9 {AC43}
DIDN’T HAVE TIME OR TOOK TOO LONG ....... 10 {AC43}
OTHER ................................... 91 {AC43}
REF ..................................... -7 {AC43}
DK ...................................... -8 {AC43}

[Code One]

AC43

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD AC-5.

How much of a problem was it that {you/{PERSON}} did not get dental
care, tests, or treatments {you/he/she} or a dentist believed necessary?

Would you say ...

a big problem, ......................... 1 {END_LP05}
a small problem, or .................... 2 {END_LP05}
not a problem? ......................... 3 {END_LP05}
REF ................................... -7 {END_LP05}
DK .................................... -8 {END_LP05}

[Code One]

END_LP05

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_05 AND CONTINUE WITH AC44

AC44

In the last 12 months, was anyone in the family delayed in
getting dental care, tests, or treatments they or a dentist
believed necessary?

YES .................................... 1
NO ..................................... 2 {AC48A}
REF ................................... -7 {AC48A}
DK .................................... -8 {AC48A}

IF CODED ’1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AS ’DELAY IN RECEIVING
DENTAL CARE’ AT AC45 BY CAPI.

IF CODED ’1’ (YES) AND A SINGLE-PERSON RU, GO TO
LOOP_06

IF CODED ’1’ (YES) AND A MULTI-PERSON RU, CONTINUE
WITH AC45

AC45

Who was that?

PROBE: Was anyone else in the family delayed in getting
dental care, tests, or treatments they or a dentist believed
necessary?

[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]

IF THE ONLY PERSON SELECTED IS DECEASED OR
INSTITUTIONALIZED, GO TO AC48A

OTHERWISE, CONTINUE WITH LOOP_06

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.
2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
NO FILTER; DISPLAY ALL.

LOOP_06

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER, ASK
NAV_AC06 – END_LP06

LOOP DEFINITION: LOOP_06 COLLECTS THE MAIN REASON
AND THE PROBLEM WITH THE DELAY IN RECEIVING
DENTAL CARE. THIS LOOP CYCLES ON RU MEMBERS WHO
MEET THE FOLLOWING CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED
- PERSON HAD A DELAY IN RECEIVING DENTAL CARE
(I.E., PERSON WAS SELECTED AT AC45)

NAVIGATOR DETAILS: LOOP_06 USES NAV_AC06 TO
CONTROL THE FLOW OF THE LOOP.

NAV_AC06

SERIES: Reason for Delay In Obtaining Dental Care

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED
- PERSON HAD A DELAY IN RECEIVING DENTAL CARE
(I.E., PERSON WAS SELECTED AT AC45)

CONTINUE WITH AC46 FOR SELECTED RU MEMBER

AC46

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD AC-4.

Which of these best describes the main reason {you/{PERSON}} {were/was}
delayed in getting dental care, tests, or treatments {you/he/she} or
a dentist believed necessary?

COULDN’T AFFORD CARE ..................... 1 {AC47}
INSURANCE COMPANY WOULDN’T APPROVE,
COVER, OR PAY FOR CARE ................. 2 {AC47}
DOCTOR REFUSED TO ACCEPT FAMILY’S
INSURANCE PLAN ......................... 3 {AC47}
PROBLEMS GETTING TO DOCTOR’S OFFICE ...... 4 {AC47}
DIFFERENT LANGUAGE ....................... 5 {AC47}
COULDN’T GET TIME OFF WORK ............... 6 {AC47}
DIDN’T KNOW WHERE TO GO TO GET CARE ...... 7 {AC47}
WAS REFUSED SERVICES ..................... 8 {AC47}
COULDN’T GET CHILD CARE .................. 9 {AC47}
DIDN’T HAVE TIME OR TOOK TOO LONG ....... 10 {AC47}
OTHER ................................... 91 {AC47}
REF ..................................... -7 {AC47}
DK ...................................... -8 {AC47}

[Code One]

AC47

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD AC-5.

How much of a problem was it that {you/{PERSON}} {were/was} delayed in
getting dental care, tests, or treatments {you/he/she} or a dentist
believed necessary?

Would you say ...

a big problem, ......................... 1 {END_LP06}
a small problem, or .................... 2 {END_LP06}
not a problem? ......................... 3 {END_LP06}
REF ................................... -7 {END_LP06}
DK .................................... -8 {END_LP06}

[Code One]

END_LP06

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_06 AND CONTINUE WITH AC48A

AC48A

In the last 12 months, did anyone in the family or a doctor
believe they needed prescription medicines?

YES .................................... 1 {AC48}
NO ..................................... 2 {BOX_06}
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}

AC48

In the last 12 months, was anyone in the family unable to
obtain prescription medicines they or a doctor believed
necessary?

YES .................................... 1
NO ..................................... 2 {AC52}
REF ................................... -7 {AC52}
DK .................................... -8 {AC52}

IF CODED ’1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AS ’UNMET NEED FOR
PRESCRIPTION MEDICINES’ AT AC49 BY CAPI AND GO TO
LOOP_07

IF CODED ’1’ (YES) AND A MULTI-PERSON RU, CONTINUE
WITH AC49

AC49

Who was that?

PROBE: Was anyone else in the family unable to get
prescription medicines they or a doctor believed necessary?

[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]

IF THE ONLY PERSON SELECTED IS DECEASED OR
INSTITUTIONALIZED, GO TO AC52

OTHERWISE, CONTINUE WITH LOOP_07

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.
2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
NO FILTER; DISPLAY ALL.

LOOP_07

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER, ASK
NAV_AC07 – END_LP07

LOOP DEFINITION: LOOP_07 COLLECTS THE MAIN REASON
AND THE PROBLEM WITH THE UNMET NEED FOR
PRESCRIPTION MEDICINES. THIS LOOP CYCLES ON RU
MEMBERS WHO MEET THE FOLLOWING CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED
- PERSON HAD AN UNMET NEED FOR PRESCRIPTION
MEDICINES (I.E., PERSON WAS SELECTED AT AC49)

NAVIGATOR DETAILS: LOOP_07 USES NAV_AC07 TO
CONTROL THE FLOW OF THE LOOP.

NAV_AC07

SERIES: Reason for Being Unable to Obtain Prescription Medicines

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED
- PERSON HAD AN UNMET NEED FOR PRESCRIPTION
MEDICINES (I.E., PERSON WAS SELECTED AT AC49)

CONTINUE WITH AC50 FOR SELECTED RU MEMBER

AC50

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD AC-4.

Which of these best describes the main reason {you/{PERSON}} {were/was}
unable to get prescription medicines {you/he/she} or a doctor believed
necessary?

COULDN’T AFFORD CARE ..................... 1 {AC51}
INSURANCE COMPANY WOULDN’T APPROVE,
COVER, OR PAY FOR CARE ................. 2 {AC51}
DOCTOR REFUSED TO ACCEPT FAMILY’S
INSURANCE PLAN ......................... 3 {AC51}
PROBLEMS GETTING TO DOCTOR’S OFFICE ...... 4 {AC51}
DIFFERENT LANGUAGE ....................... 5 {AC51}
COULDN’T GET TIME OFF WORK ............... 6 {AC51}
DIDN’T KNOW WHERE TO GO TO GET CARE ...... 7 {AC51}
WAS REFUSED SERVICES ..................... 8 {AC51}
COULDN’T GET CHILD CARE .................. 9 {AC51}
DIDN’T HAVE TIME OR TOOK TOO LONG ....... 10 {AC51}
OTHER ................................... 91 {AC51}
REF ..................................... -7 {AC51}
DK ...................................... -8 {AC51}

[Code One]

AC51

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD AC-5.

How much of a problem was it that {you/{PERSON}} did not get
prescription medicines {you/he/she} or a doctor believed
necessary?

Would you say ...

a big problem, ......................... 1 {END_LP07}
a small problem, or .................... 2 {END_LP07}
not a problem? ......................... 3 {END_LP07}
REF ................................... -7 {END_LP07}
DK .................................... -8 {END_LP07}

[Code One]

END_LP07

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_07 AND CONTINUE WITH AC52

AC52

In the last 12 months, was anyone in the family delayed in
getting prescription medicines they or a doctor believed
necessary?

YES .................................... 1
NO ..................................... 2 {BOX_06}
REF ................................... -7 {BOX_06}
DK .................................... -8 {BOX_06}

IF CODED ’1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AS ’DELAY IN RECEIVING
PRESCRIPTION MEDICINES’ AT AC53 BY CAPI AND GO TO
LOOP_08

IF CODED ’1’ (YES) AND A MULTI-PERSON RU, CONTINUE
WITH AC53

AC53

Who was that?

PROBE: Was anyone else in the family delayed in getting
prescription medicines they or a doctor believed necessary?

[1. First Name, [Middle Name], Last Name-65]
[2. First Name, [Middle Name], Last Name-65]
[3. First Name, [Middle Name], Last Name-65]

IF THE ONLY PERSON SELECTED IS DECEASED OR
INSTITUTIONALIZED, GO TO BOX_06

OTHERWISE, CONTINUE WITH LOOP_08

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.
2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
NO FILTER; DISPLAY ALL.

LOOP_08

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER, ASK
NAV_AC08 – END_LP08

LOOP DEFINITION: LOOP_08 COLLECTS THE MAIN REASON
AND THE PROBLEM WITH THE DELAY IN RECEIVING
PRESCRIPTION MEDICINES. THIS LOOP CYCLES ON RU
MEMBERS WHO MEET THE FOLLOWING CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED
- PERSON HAD A DELAY IN RECEIVING PRESCRIPTION
MEDICINES (I.E., PERSON WAS SELECTED AT AC53)

NAVIGATOR DETAILS: LOOP_08 USES NAV_AC08 TO
CONTROL THE FLOW OF THE LOOP.

NAV_AC08

SERIES: Reason for Delay In Obtaining Prescription Medicines

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS NOT INSTITUTIONALIZED
- PERSON HAD A DELAY IN RECEIVING PRESCRIPTION
MEDICINES (I.E., PERSON WAS SELECTED AT AC53)

CONTINUE WITH AC54 FOR SELECTED RU MEMBER

AC54

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD AC-4.

Which of these best describes the main reason {you/{PERSON}} {were/was}
delayed in getting prescription medicines {you/he/she} or a doctor
believed necessary?

COULDN’T AFFORD CARE ..................... 1 {AC55}
INSURANCE COMPANY WOULDN’T APPROVE,
COVER, OR PAY FOR CARE ................. 2 {AC55}
DOCTOR REFUSED TO ACCEPT FAMILY’S
INSURANCE PLAN ......................... 3 {AC55}
PROBLEMS GETTING TO DOCTOR’S OFFICE ...... 4 {AC55}
DIFFERENT LANGUAGE ....................... 5 {AC55}
COULDN’T GET TIME OFF WORK ............... 6 {AC55}
DIDN’T KNOW WHERE TO GO TO GET CARE ...... 7 {AC55}
WAS REFUSED SERVICES ..................... 8 {AC55}
COULDN’T GET CHILD CARE .................. 9 {AC55}
DIDN’T HAVE TIME OR TOOK TOO LONG ....... 10 {AC55}
OTHER ................................... 91 {AC55}
REF ..................................... -7 {AC55}
DK ...................................... -8 {AC55}

[Code One]

AC55

{PERSON’S FIRST MIDDLE AND LAST NAME}

SHOW CARD AC-5.

How much of a problem was it that {you/{PERSON}} {were/was} delayed
in getting prescription medicines {you/he/she} or a doctor believed
necessary?

Would you say ...

a big problem, ......................... 1 {END_LP08}
a small problem, or .................... 2 {END_LP08}
not a problem? ......................... 3 {END_LP08}
REF ................................... -7 {END_LP08}
DK .................................... -8 {END_LP08}

[Code One]

END_LP08

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_08 AND CONTINUE WITH BOX_06

BOX_06

GO TO NEXT QUESTIONNAIRE SECTION

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