MEPS Closing Section - P18R5P19R3P20R1

IF:
AT LEAST ONE PERSON-PROVIDER-PAIR ELIGIBLE (SEE
SAMPLING BOXES BELOW) FOR AUTHORIZATION FORM
COLLECTION FOR THE CURRENT ROUND,
OR
AT LEAST ONE PERSON-PROVIDER-PAIR ELIGIBLE FOR
AUTHORIZATION FORM COLLECTION DURING THE PREVIOUS
ROUND AND CL04 WAS CODED '3' (LEFT WITH R), ‘4’
(MAILED TO R), ‘5’ (REFUSED), ‘91’ (OTHER) OR ‘-1’
(ADDED BY COMMENT REVIEW) FOR THIS PERSON-
PROVIDER-PAIR IN PREVIOUS ROUND, CONTINUE WITH
CL01

OTHERWISE, GO TO BOX_02

NOTE: RECEIPT CONTROL WILL UPDATE CAPI INTER-
ROUND, USING THE CODE STRUCTURE AT CL04. UPDATES
CAN BE EITHER POSITIVE OR NEGATIVE. THIS MEANS
THAT INTER-ROUND AN AUTHORIZATION FORM’S STATUS
CAN EITHER GET UPDATED TO A HIGHER STATUS CODE
(FROM UNSIGNED TO SIGNED) OR TO A LOWER STATUS
CODE (FROM SIGNED TO UNSIGNED -- I.E., IT WAS NOT
SIGNED BY THE RIGHT PERSON). SEE MAPPING
SPECIFICATIONS FOR EXACT UPDATES TO STATUS CODES.

NOTE: DUE TO LEGISLATION THAT WENT INTO
EFFECT IN APRIL 2003, MEPS CHANGED TO NEW HIPAA-
COMPLIANT AUTHORIZATION FORMS.

NOTEBOX
THERE ARE 6 PERSON TYPES (AND TWO SUB-TYPES) IN
THE MEPS RU

TYPE PRSLT
DECEASED/ELIGIBLE FOR PART OF REF PERIOD 41
INSTITUTIONALIZED/ELIGIBLE PT OF REF PERIOD 51
IN A HEALTHCARE FACILITY (INSTTTYPE 1 OR 2)
IN A NON-HEALTHCARE FACILITY (INSTTYPE 3)
MEPS STUDENT/ELIGIBLE ALL OF REF PERIOD 71
LIVING OUTSIDE US/ELIGIBLE PT OF REF PERIOD 75
LIVING-MILITARY BASE/ELIGIBLE PT REF PERIOD 76
ELIGIBLE FOR ALL OF REFERENCE PERIOD 99

THE FOLLOWING PERSON TYPES (AND SUB-TYPES)
ARE ELIGIBLE FOR AUTHORIZATION FORM COLLECTION:
- PRSLT 41 - DECEASED/ELIGIBLE FOR PART OF
REF PERIOD
- PRSLT 51 – SUB-TYPE INSTITUTIONALIZED/ELIGIBLE
PT OF REF PERIOD IN A
HEALTHCARE FACILITY (INSTTYPE 1 OR 2)
- PRSLT 71 - MEPS STUDENT/ELIGIBLE ALL OF REF
PERIOD
- PRSLT 99 - ELIGIBLE FOR ALL OF REFERENCE PERIOD

THERE ARE TWO TYPES OF OUT OF SCOPE RU MEMBERS
THAT ARE ELIGIBLE FOR AUTHORIZATION FORM
COLLECTION (NOTE: OUT OF SCOPE REFERS TO RU
MEMBERS WHO HAD PARTIAL ELIGIBILITY IN THE
PREVIOUS ROUND AND NO ELIGIBILITY IN THE CURRENT
ROUND):
- PRSLT 41 - DECEASED/ELIGIBLE FOR PART OF REF
PERIOD
- PRSLT 51 – SUB-TYPE INSTITUTIONALIZED/ELIGIBLE
PT OF REF PERIOD IN A HEALTHCARE FACILITY
(INSTTYPE 1 OR 2)

2 PERSON TYPES AND 1 SUB-TYPE ARE NOT ELIGIBLE FOR
AUTHORIZATION FORM COLLECTION:
- PRSLT 51 – SUB-TYPE INSTITUTIONALIZED/ELIGIBLE
PT OF REF PERIOD IN A NON-HEALTHCARE FACILITY
(INSTTYPE 3)
- PRSLT 75 - LIVING OUTSIDE US/ELIGIBLE PT OF REF
PERIOD
- PRSLT 76 - LIVING-MILITARY BASE/ELIGIBLE PT REF
PERIOD

PERSON-PROVIDER-PAIRS WHERE THE PROVIDER LOCATION
IS IN A FOREIGN COUNTRY I.E., ‘FC’ IS ENTERED IN
THE STATE FIELD OF PROVIDER’S ADDRESS ARE NOT
ELIGIBLE FOR MPC AUTHORIZATION FORM COLLECTION)

SAMPLING BOX
PERSON-PROVIDER-PAIRS ELIGIBLE FOR MPC
AUTHORIZATION FORM COLLECTION:
NOTE: PERSON IS A KEY, ELIGIBLE RU MEMBER (AT
TIME OF EVENT).

ROUND 1: PERSON-PROVIDER-PAIRS ELIGIBLE FOR
AUTHORIZATION FORM COLLECTION ARE:

- PERSON-PROVIDER PAIRS ASSOCIATED WITH HOSPITAL
EVENTS (HS) BOTH OPEN AND CLOSED.
- PERSON-PROVIDER PAIRS ASSOCIATED WITH EMERGENCY
ROOM EVENTS (ER).
- PERSON-PROVIDER PAIRS ASSOCIATED WITH
OUTPATIENT EVENTS (OP).

ROUND 2: PERSON-PROVIDER-PAIRS ELIGIBLE FOR
AUTHORIZATION FORM COLLECTION ARE:

- PERSON-PROVIDER PAIRS ASSOCIATED WITH HOSPITAL
TYPE EVENTS (HS, ER AND OP) AS IN ROUND 1.
- PERSON-PROVIDER PAIRS ASSOCIATED WITH MEDICAL
EVENTS (MV) WHERE THE PROVIDER EITHER IS A
MEDICAL FACILITY (MV03=1) OR WORKS AT A MEDICAL
FACILITY (MV06=1).
- PERSON-PROVIDER PAIRS ASSOCIATED WITH HOME
HEALTH EVENTS (HH) WHERE THE HHTYPE IS AN
AGENCY, BOTH OPEN AND CLOSED.
- PERSON-PROVIDER PAIRS ASSOCIATED WITH
INSTITUTIONAL CARE EVENTS (IC), BOTH OPEN AND
CLOSED.
- ANY OUTSTANDING PERSON-PROVIDER PAIRS FROM
ROUND 1 ARE ALSO REQUESTED FOR THE HOSPITAL
RELATED PROVIDERS (EVENT TYPES HS, ER, OP), IC,
HH (WHERE THE HHTYPE IS AN AGENCY) OR MV EVENTS
WHERE THE PROVIDER EITHER IS A MEDICAL FACILITY
OR WORKS AT A MEDICAL FACILITY).

ROUND 3: PERSON-PROVIDER-PAIRS ELIGIBLE FOR
AUTHORIZATION FORM COLLECTION ARE:

- PERSON-PROVIDER PAIRS ASSOCIATED WITH HOSPITAL
TYPE EVENTS (HS, ER AND OP) AS IN OTHER ROUNDS.
- PERSON-PROVIDER PAIRS ASSOCIATED WITH MEDICAL
EVENTS (MV) WHERE THE PROVIDER EITHER IS A
MEDICAL FACILITY (MV03=1) OR WORKS AT A
MEDICAL FACILITY (MV06=1).
- PERSON-PROVIDER PAIRS ASSOCIATED WITH HOME
HEALTH EVENTS (HH) WHERE THE HHTYPE IS AN
AGENCY, BOTH OPEN AND CLOSED.
- PERSON-PROVIDER PAIRS ASSOCIATED WITH
INSTITUTIONAL CARE EVENTS (IC), BOTH OPEN
AND CLOSED.
- ANY OUTSTANDING PERSON-PROVIDER PAIRS FROM
ROUND 1 AND ROUND 2 ARE REQUESTED.

ROUND 4: PERSON-PROVIDER-PAIRS ELIGIBLE FOR
AUTHORIZATION FORM COLLECTION ARE:
- PERSON-PROVIDER PAIRS ASSOCIATED WITH HOSPITAL
TYPE EVENTS (HS, ER AND OP) AS IN OTHER ROUNDS.
- PERSON-PROVIDER PAIRS ASSOCIATED WITH MEDICAL
EVENTS (MV) WHERE THE PROVIDER EITHER IS A
MEDICAL FACILITY (MV03=1) OR WORKS AT A
MEDICAL FACILITY (MV06=1).
- PERSON-PROVIDER PAIRS ASSOCIATED WITH HOME
HEALTH EVENTS (HH) WHERE THE HHTYPE IS AN
AGENCY, BOTH OPEN AND CLOSED.
- PERSON-PROVIDER PAIRS ASSOCIATED WITH
INSTITUTIONAL CARE EVENTS (IC), BOTH OPEN AND
CLOSED.
- ANY OUTSTANDING PERSON-PROVIDER PAIRS
ASSOCIATED WITH EVENTS OCCURRING (OR ENDING)
IN REFERENCE YEAR 2 ARE ALSO REQUESTED.

NOTE: FOR HS AND IC EVENTS THIS MEANS THE PERSON
LEFT THE INSTITUTION/HOSPITAL DURING REFERENCE
YEAR 2 (I.E., THE EVENT’S END DATE IS REFERENCE
YEAR 2).

FOR OTHER EVENT TYPES, ANY WITH DATE OF
SERVICE WITH A REFERENCE YEAR 1 ARE NO LONGER
REQUESTED

ROUND 5: PERSON-PROVIDER-PAIRS ELIGIBLE FOR
AUTHORIZATION FORM COLLECTION ARE:

- PERSON-PROVIDER PAIRS ASSOCIATED WITH HOSPITAL
TYPE EVENTS (HS, ER AND OP) AS IN OTHER ROUNDS.
- PERSON-PROVIDER PAIRS ASSOCIATED WITH MEDICAL
EVENTS (MV) WHERE THE PROVIDER
EITHER IS A MEDICAL FACILITY (MV03=1) OR WORKS
AT A MEDICAL FACILITY (MV06=1).
- PERSON-PROVIDER PAIRS ASSOCIATED WITH HOME
HEALTH EVENTS (HH) WHERE THE HHTYPE
IS AN AGENCY, BOTH OPEN AND CLOSED.
- PERSON-PROVIDER PAIRS ASSOCIATED WITH
INSTITUTIONAL CARE EVENTS (IC), BOTH OPEN AND
CLOSED.
- ANY OUTSTANDING PERSON-PROVIDER PAIRS
ASSOCIATED WITH EVENTS OCCURRING (OR ENDING)
IN REFERENCE YEAR 2 ARE ALSO REQUESTED.

NOTE: FOR HS AND IC EVENTS THIS MEANS THE PERSON
LEFT THE INSTITUTION/HOSPITAL DURING REFERENCE
YEAR 2 (I.E., THE EVENT’S END DATE IS REFERENCE
YEAR 2).

SAMPLING BOX (FOR ROUNDS 2-5) CONT’D:

WHEN DETERMINING IF THE MV EVENTS FOR AN RU
REQUIRE AUTHORIZATION FORMS, AN RU IS SELECTED
FOR THE MPC SAMPLE AT THE TIME OF THE ROUND 1
INTERVIEW USING THE FOLLOWING RATES:
- 100% OF RUs WITH AT LEAST ONE RU MEMBER
COVERED BY MEDICAID OR GOV’T HOSPITAL
(PHYSICIAN) INSURANCE AT ANY TIME DURING THE
REFERENCE PERIOD
- 100% OF THE REMAINING RUs (THAT IS, RUs WITH
NO RU MEMBER COVERED BY MEDICAID OR GOV’T-
HOSPITAL/PHYSICIAN INSURANCE AT ANY TIME
DURING THE REFERENCE PERIOD) WITH AT LEAST ONE
RU MEMBER WITH HMO COVERAGE AT ANY TIME DURING
THE REFERENCE PERIOD. HMO COVERAGE IS DEFINED
AS:
IF AT LEAST ONE PRIVATE INSURANCE PLAN IN RU
MEETS THE FOLLOWING CONDITIONS:
- FLAGGED AS ‘PROVIDING HOSPITAL/PHYSICIAN
BENEFITS’ (EXCLUDE INSURERS WHERE
HOSPITAL/PHYSICIAN BENEFITS ARE PROVIDED
SOLELY THROUGH MEDIGAP)
- ESTABLISHMENT OR INSURER IS FLAGGED AS
‘HMO’
OR
INSURER IS AN HMO (MC01 IS CODED ‘1’
(YES))
OR
INSURER REQUIRES PERSONS TO SIGN UP WITH
PRIMARY PHYSICIAN (MC02 IS CODED ‘1’ (YES)
- 100% OF THE REMAINING RUs (THAT IS, RUs WITH
NO RU MEMBER COVERED BY MEDICAID OR GOV’T-
HOSPITAL/PHYSICIAN INSURANCE AND HMO COVERAGE
AT ANY TIME DURING THE REFERENCE PERIOD).

NOTE: IF THE SAME PROVIDER IS ASSOCIATED MORE
THAN ONCE WITH A PARTICULAR PERSON, ONLY ONE
AUTHORIZATION FORM IS CREATED FOR THAT PAIR. IF
THE SAME PROVIDER IS ASSOCIATED WITH MORE THAN ONE
PERSON, AN AUTHORIZATION FORM IS CREATED FOR EACH
UNIQUE PERSON-PROVIDER-PAIR.

NOTE: IF THE PERSON-PROVIDER-PAIR IS OUTSTANDING
FROM A PREVIOUS ROUND AND THERE IS A NEW ELIGIBLE
EVENT FOR THIS PAIR IN THE CURRENT ROUND, THE PAIR
WILL NOT BE TREATED AS IF IT IS OUTSTANDING. THAT
IS, THE DISPLAYS FOR PREVIOUS ROUND STATUS WILL
NOT BE SHOWN, ETC.

{[As I mentioned during the last interview], we/We} request
written authorization to contact medical providers for more
information about the services they provide. I would like to
get authorization from the following people:

[HAND RESPONDENT THE AUTHORIZATION FORM BOOKLET.]

[These materials explain more about why we contact medical
providers and answer questions people sometimes ask about this
part of the study. Please take a minute to review this
information while I prepare the forms.]

[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]

DISPLAY ‘[As I mentioned during the last
interview], we’ IF NOT ROUND 1 AND AT LEAST ONE
PERSON-PROVIDER-PAIR WAS ELIGIBLE FOR MPC
AUTHORIZATION FORM COLLECTION DURING THE PREVIOUS
ROUND. OTHERWISE, DISPLAY ‘We’.

DISPLAY EACH UNIQUE ELIGIBLE PERSON NAME ONLY
ONCE.

CONTINUE WITH LOOP_01

ROSTER DETAILS:
TITLE: RU_ESTB_PERS_PAIRS_1

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

ROSTER DEFINITION:
DISPLAY THE RU_PERSON_ESTABLISHMENT_PAIRS_ROSTER
FOR DISPLAY OF RU MEMBERS ONLY.

ROSTER BEHAVIOR:
1. DISPLAY ONLY.

2. SELECT, ADD, DELETE DISALLOWED.

ROSTER FILTER:
DISPLAY ONLY THOSE PERSONS WHO MEET THE FOLLOWING
CONDITION(S):
- PERSON IS ELIGIBLE FOR MPC AUTHORIZATION FORM
COLLECTION FOR THE CURRENT ROUND (SEE BOX_01
SAMPLING SPECIFICATIONS)
OR
- PERSON WAS ASSOCIATED WITH A PERSON-PROVIDER-
PAIR ELIGIBLE FOR AUTHORIZATION FORM COLLECTION
IN PREVIOUS ROUND, AND
- CL04 WAS CODED '3' (LEFT WITH R), ‘4’ (MAILED
TO R), ‘5’ (REFUSED), ‘91’ (OTHER) OR ‘-1’
(ADDED BY COMMENT REVIEW) FOR THIS PERSON-
PROVIDER-PAIR IN PREVIOUS ROUND

FOR EACH ELEMENT ON THE RU-PERSON-PROVIDER-PAIRS-
ROSTER, ASK CL03 - END_LP01

LOOP DEFINITION: LOOP_01 PRESENTS EACH UNIQUE
PERSON-PROVIDER-PAIR ELIGIBLE FOR AUTHORIZATION
FORM COLLECTION (THIS INCLUDES NEW AND OUTSTANDING
FORMS) FOR THE INTERVIEWER TO COMPLETE THE
AUTHORIZATION FORM. THIS LOOP CYCLES ON RU-
PERSON-PROVIDER-PAIRS WITH AN EVENT-PROVIDER-
PAIR THAT MEET THE FOLLOWING CONDITION(S):
- PAIR IS ELIGIBLE FOR AUTHORIZATION FORM
COLLECTION FOR THE CURRENT ROUND (SEE BOX_01
SAMPLING SPECIFICATIONS)
OR
- PAIR WAS ELIGIBLE FOR AUTHORIZATION FORM
COLLECTION IN PREVIOUS ROUND, AND
- CL04 WAS CODED '3' (LEFT WITH R), ‘4’ (MAILED
TO R), ‘5’ (REFUSED), ‘91’ (OTHER) OR ‘-1’
(ADDED BY COMMENT REVIEW) FOR THIS PAIR IN THE
PREVIOUS ROUND

NOTE: LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON-
PROVIDER-PAIR.

INTERVIEWER: {COMPLETE A NEW MPC AF FOR THIS PAIR./CHECK FIRST FOR
PREPRINTED MPC AF FOR THIS PAIR. IF THERE IS NO PREPRINTED AF, FILL
OUT A BLANK MPC AF.}

PID: [PID-3] PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]

RU ID: [RUID-7] REGION: [Reg ID-1] PROVIDER ID: [ProvID-4]
PROVIDER NAME: [Provider Full Name-65]
PROVIDER ADDRESS: [Street Address from Provider Directory]
[City Name], [ST] [Zip Code] [Telephone]

{AF STATUS FROM PREVIOUS ROUND: {DISPLAY PREVIOUS ROUND STATUS - 40}}

SIGNATURE DATE ON MPC AF MUST BE ON OR AFTER: {MM/DD/YYYY}

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

HELP AVAILABLE FOR MORE INFORMATION ON MPC AUTHORIZATION FORMS.

DISPLAY ‘COMPLETE A NEW MPC AF FOR THIS PAIR.’ IF
ROUND 1. OTHERWISE, (I.E., ROUND 2-5) DISPLAY
‘CHECK...MPC AF.’

DISPLAY ‘AF STATUS ... -40}’ IF CURRENT PERSON-
PROVIDER-PAIR IS OUTSTANDING FROM THE PREVIOUS
ROUND AND NO ELIGIBLE EVENT WAS CREATED FOR THIS
PAIR IN THE CURRENT ROUND.

FOR ‘DISPLAY PREVIOUS...-40’, DISPLAY THE CATEGORY
ENTRY ASSOCIATED WITH THE PREVIOUS ROUND (OR
RECEIPT CONTROL UPDATED) CL04 OUTSTANDING STATUS.
THAT IS, IF CL04 WAS CODED ‘3’, DISPLAY ‘LEFT WITH
R’; IF CL04 WAS CODED ‘4’, DISPLAY ‘MAILED TO R’;
IF CL04 WAS CODED ‘5’, DISPLAY ‘REFUSED’; AND IF
CL04 WAS CODED ‘91’ OR ‘-1’, DISPLAY THE FIRST 40
CHARACTERS FROM THE OTHER SPECIFY ENTRY FIELD (OR
THE RECEIPT CONTROL UPDATE TEXT GENERATED FOR THE
‘91’ AND ‘-1’ CODES).

DISPLAY THE INTERVIEW DATE OF THE MOST RECENT
ROUND’S INTERVIEW FOR WHICH PAIR IS/WAS ELIGIBLE
FOR AUTHORIZATION FORM COLLECTION FOR
‘MM/DD/YYYY’.

CYCLE ON NEXT PAIR ON THE RU-PERSON-PROVIDER-
PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN
THE LOOP DEFINITION.

IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END
LOOP_01 AND CONTINUE WITH LOOP_02

FOR EACH ELEMENT ON THE RU-PERSON-PROVIDER-PAIRS-
ROSTER, ASK CL04 - END_LP02

LOOP DEFINITION: LOOP_02 COLLECTS THE STATUS OF
PERSON-PROVIDER AUTHORIZATION FORMS ELIGIBLE FOR
AUTHORIZATION FORM COLLECTION (THIS INCLUDES NEW
AND OUTSTANDING FORMS). THIS LOOP CYCLES ON
RU-PERSON-PROVIDER-PAIRS WITH AN EVENT-PROVIDER-
PAIR THAT MEET THE FOLLOWING CONDITION(S):
- PAIR IS ELIGIBLE FOR AUTHORIZATION FORM
COLLECTION FOR THE CURRENT ROUND (SEE BOX_01
SAMPLING SPECIFICATIONS)
OR
- PAIR WAS ELIGIBLE FOR AUTHORIZATION FORM
COLLECTION IN PREVIOUS ROUND, AND
- CL04 WAS CODED '3' (LEFT WITH R), ‘4’ (MAILED TO
R), ‘5’ (REFUSED), ‘91’ (OTHER) OR ‘-1’ (ADDED
BY COMMENT REVIEW) FOR THIS PAIR
IN THE PREVIOUS ROUND

NOTE: LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON-
PROVIDER-PAIR.

INTERVIEWER: ASK APPROPRIATE PERSON(S) TO SIGN AUTHORIZATION FORM.
IF NOT AVAILABLE TO SIGN, LEAVE AF AND BOOKLET WITH RESPONDENT.

PID: [PID-3] PERSON: [First, [Middle], Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]

RU ID: [RUID-7] REGION: [Reg ID-1] PROVIDER ID: [ProvID-4]
PROVIDER NAME: [Provider Full Name-65]
PROVIDER ADDRESS: [Street Address from Provider Directory]
[City Name], [ST] [Zip Code] [Telephone]

SIGNATURE DATE ON MPC AF MUST BE ON OR AFTER: {MM/DD/YYYY}

SELECT THE AUTHORIZATION FORM STATUS:

SIGNED, NO PROBLEM ..................... 1 {CL05}
SIGNED WITH PROBLEM .................... 2 {CL04OV1}
LEFT WITH RESPONDENT ................... 3 {END_LP02}
MAILED TO RESPONDENT ................... 4 {END_LP02}
REFUSED ................................ 5 {CL06}
OTHER ................................. 91 {CL04OV2}

HELP AVAILABLE FOR MORE INFORMATION ON MPC AUTHORIZATION FORMS.

[Code One]

FOR ‘MM/DD/YYYY’, DISPLAY THE RU END REFERENCE
DATE OF THE MOST RECENT ROUND’S INTERVIEW FOR
WHICH PAIR IS/WAS ELIGIBLE FOR AUTHORIZATION FORM
COLLECTION.

SOFT CHECK:
CODE ‘4’ (MAILED TO R) MUST BE VERIFIED (ENTERED
TWICE) IF RU IS NOT A STUDENT RU. IF CODE ‘4’
SELECTED AND RU IS NOT A STUDENT RU, DISPLAY THE
FOLLOWING MESSAGE: ‘UNLIKELY RESPONSE. VERIFY
AND RE-ENTER.’

PROBLEM:

[Enter Problem-45] ..................... {CL05}

HELP AVAILABLE FOR MORE INFORMATION ON MPC AUTHORIZATION FORMS.

SPECIFY:

[Enter Other Specify-45] ............... {END_LP02}

HELP AVAILABLE FOR MORE INFORMATION ON MPC AUTHORIZATION FORMS.

FOR ‘MM/DD/YYYY’, DISPLAY THE RU END REFERENCE
DATE OF THE MOST RECENT ROUND’S INTERVIEW FOR
WHICH PAIR IS/WAS ELIGIBLE FOR AUTHORIZATION FORM
COLLECTION.

NOTE: EACH AUTHORIZATION FORM HAS A PRE-ASSIGNED
AUTHORIZATION FORM NUMBER.

HARD CHECK – PANEL 18 MPC AUTHORIZATION FORMS:
AUTHORIZATION FORM NUMBERS ARE PANEL AND ROUND
SPECIFIC. NUMBER ENTERED MUST BE 8 CHARACTERS LONG
AND MUST BEGIN AND END WITH AN ALPHA CHARACTER.
PANEL 18 MPC AUTHORIZATION FORMS ARE PRINTED ON
GREEN PAPER.

HARD CHECK – PANEL 19 MPC AUTHORIZATION FORMS:
AUTHORIZATION FORM NUMBERS ARE PANEL AND ROUND
SPECIFIC. NUMBER ENTERED MUST BE 8 CHARACTERS LONG
AND MUST BEGIN WITH AN ALPHA CHARACTER AND END
WITH AN ALPHA CHARACTER. PANEL 19 MPC
AUTHORIZATION FORMS ARE PRINTED ON WHITE PAPER.

HARD CHECK – PANEL 20 MPC AUTHORIZATION FORMS:
AUTHORIZATION FORM NUMBERS ARE PANEL AND ROUND
SPECIFIC. NUMBER ENTERED MUST BE 8 CHARACTERS LONG
AND MUST BEGIN AND END WITH AN ALPHA CHARACTER.
PANEL 20 MPC AUTHORIZATION FORMS ARE PRINTED ON
BLUE PAPER.

SOME IMPORTANT POINTS TO REMEMBER ABOUT MPC
AUTHORIZATION FORMS:
- THE PREFIX LETTER CHANGES BASED ON THE TYPE OF
AUTHORIZATION FORM AND THE ORIGIN OF THE FORM.
THIS MEANS THAT A PRE-PRINTED OR FIELD
GENERATED MPC AUTHORIZATION FORM WILL DRAW FROM
THE SAME LETTER OR RANGE OF LETTERS IN EACH
PANEL.
- THE 5-NUMBER SEQUENCE REPEATS ITSELF FOR EACH
PANEL.
- THE CHECK-DIGIT ALWAYS REMAINS CONSTANT.
- THE ROUND IDENTIFIER IS DIFFERENT FOR EACH
PANEL. THE ROUND IDENTIFIER WILL REMAIN THE
SAME FOR ALL AUTHORIZATION FORMS COLLECTED
WITHIN A PANEL, BUT CHANGES BASED ON THE ROUND.
FOR EXAMPLE: AUTHORIZATION FORMS GENERATED FOR
PANEL 19, ROUND 1 WILL USE THE ROUND IDENTIFIER
"M"; "M" OR "N" FOR ROUND 2; "M", "N", OR "P"
FOR ROUND 3; "M", "N", "P" OR "Q" FOR ROUND 4;
AND "M", "N", "P", "Q" OR "R" FOR ROUND 5.

MPC AUTHORIZATION FORM SIGNATURE DATE:

[Enter Month, Day, Year-4] .................. {END_LP02}

NOTE: INTERVIEWERS WILL BE INSTRUCTED TO COLLECT
SIGNED MPC AUTHORIZATION FORMS WITH DATES EARLIER
THAN THE ONE DISPLAYED, BUT WILL NOT ENTER THE
NUMBER IN CAPI SINCE THE CURRENT STATUS FOR THE
AUTHORIZATION FORM WITH THE CORRECT DATE MAY BE
SOMETHING ELSE. THE CAPI STATUS OF THE MPC
AUTHORIZATION FORM SHOULD REFLECT THE FORM WITH
THE MOST RECENT DATE.

HARD CHECK:
DATE ENTERED MUST BE ON OR AFTER THE INTERVIEW
DATE OF THE MOST RECENT ROUND’S INTERVIEW FOR
WHICH THE PAIR IS/WAS ELIGIBLE FOR AUTHORIZATION
FORM COLLECTION, BUT CANNOT BE AFTER ‘TODAY’S’
DATE (THE CURRENT DATE SET ON THE LAPTOP. IF DATE
IS BEFORE CORRECT DATE, DISPLAY THE FOLLOWING
MESSAGE: ‘MPC AF MUST BE SIGNED ON OR AFTER ABOVE
DATE. VERIFY AND RE-ENTER DATE OR COMPLETE NEW
AF.’

PID: [PID-3] PERSON: [First, [Middle], Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]

RU ID: [RUID-7] REGION: [Reg ID-1] PROVIDER ID: [ProvID-4]
PROVIDER NAME: [Provider Full Name-65]
PROVIDER ADDRESS: [Street Address from Provider Directory]
[City Name], [ST] [Zip Code] [Telephone]

SELECT MAIN REASON FOR REFUSAL:

DOESN’T WANT TO BOTHER PROVIDER ........ 1 {END_LP02}
CONFIDENTIALITY/SENSITIVE INFO ......... 2 {END_LP02}
PAYMENT PROBLEM WITH PROVIDER .......... 3 {END_LP02}
HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP02}
WANTS MORE INFO BEFORE SIGNING ......... 5 {END_LP02}
NOT INTERESTED IN STUDY ................ 6 {END_LP02}
NO REASON GIVEN ........................ 7 {END_LP02}
OTHER SPECIFY ......................... 91 {CL06OV}

[Code One]

CYCLE ON NEXT PAIR ON THE RU-PERSON-PROVIDER-
PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN
THE LOOP DEFINITION.

IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END
LOOP_02 AND CONTINUE WITH BOX_02

IF NOT ROUND 1 AND ANY KEY RU MEMBER HAD A
STATUS OF INSTITUTIONALIZED (IN A HEALTH CARE
INSTITUTION) AT THE PREVIOUS ROUND’S INTERVIEW
DATE, BUT HAS A DIFFERENT STATUS AS OF THE
CURRENT ROUND’S INTERVIEW DATE, CONTINUE WITH
LOOP_02A

OTHERWISE, GO TO BOX_03

FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK
NAV_CL02A - END_LP02A

LOOP DEFINITION: LOOP_02A INSTRUCTS THE
INTERVIEWER TO COLLECT THE HEALTH CARE INSTITUTION
HISTORY AND THE APPROPRIATE NUMBER OF MEDICAL
PROVIDER AUTHORIZATION FORMS FOR ALL RU MEMBERS
WHO HAD A STATUS OF INSTITUTIONALIZED (IN A HEALTH
CARE INSTITUTION) IN ANY PREVIOUS ROUND
BUT WHO REJOINED THE COMMUNITY (OR CHANGED STATUS)
DURING THE CURRENT ROUND. THIS LOOP CYCLES ON RU
MEMBERS WHO MEET THE FOLLOWING CONDITIONS:
- PERSON IS AN RU MEMBER
- PERSON IS KEY
- PERSON DOES NOT HAVE A STATUS OF
INSTITUTIONALIZED AS OF THE CURRENT ROUND’S
INTERVIEW DATE (RE19A = 1, 3, -7, -8 IN THE
CURRENT ROUND)
- PERSON HAD A STATUS OF INSTITUTIONALIZED IN ANY
PREVIOUS ROUND

NAVIGATOR DETAILS: LOOP_02A USES NAV_CL02A TO
CONTROL THE FLOW OF THE LOOP.

SERIES: Complete the Institutionalized Health History Worksheet

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 RU MEMBERS WHO MEET THE CONDITIONS
STATED AT THE LOOP_02A DEFINITION.

CONTINUE WITH CL06A FOR SELECTED RU MEMBER.

PID: [PID-3] PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]
DATE ORIGINALLY INSTITUTIONALIZED: [MM/DD/YYYY]
DATE REJOINED COMMUNITY/CHANGED STATUS: [MM/DD/YYYY]
RU ID: [RUID-7] REGION: [Reg ID-1]

SIGNATURE DATE ON MPC AF MUST BE ON OR AFTER: {MM/DD/YYYY}

{We request written authorization to contact medical facilities
for more information about the services they provide.
[HAND RESPONDENT THE AUTHORIZATION FORM BOOKLET.]
[These materials explain more about why we contact medical
facilities and answer questions people sometimes ask about
this part of the study. Please take a minute to review this
information while I prepare the forms.]}

INTERVIEWER: THE PERSON NAMED ABOVE WAS INSTITUTIONALIZED IN A
PREVIOUS ROUND AND HAS NOW REJOINED THE COMMUNITY OR CHANGED
STATUS. COMPLETE THE FOLLOWING STEPS:

1. FILL OUT HEALTH CARE INSTITUTION HISTORY.

2. COMPLETE A MPC AF FOR EACH DIFFERENT HEALTH CARE INSTITUTION
LISTED ON HEALTH CARE INSTITUTION HISTORY. WRITE ‘IC’ IN UPPER
LEFT CORNER OF MPC AF. REFER TO SECTION 3 OF HISTORY FOR
INSTRUCTIONS ON COMPLETING THESE AF(S).

3. REQUEST SIGNATURE(S) ON AF(S).

4. LEAVE UNSIGNED AF(S) AND THE AF BOOKLET WITH RESPONDENT.

5. PLACE EACH SIGNED MPC AF IN THE CASE FOLDER. MAKE FOLLOW-UP
ARRANGEMENTS FOR EACH UNSIGNED MPC AF. CAPI WILL
NOT COLLECT INFORMATION ON STATUS.

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

DISPLAY THE INTERVIEW DATE OF THE MOST RECENT
ROUND’S INTERVIEW FOR WHICH PAIR IS/WAS ELIGIBLE
FOR AUTHORIZATION FORM COLLECTION FOR
‘MM/DD/YYYY’.

DISPLAY ‘We request ... prepare the forms.]’ IF
CL01 WAS NOT ASKED FOR THE CURRENT ROUND.
OTHERWISE, USE A NULL DISPLAY.

CONTINUE WITH END_LP02A

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

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_02A AND CONTINUE WITH BOX_03

Subsection 2: HIPS AUTHORIZATION FORMS (BEGINNING
WITH THE SECOND YEAR OF PANEL 2 AND THE FIRST YEAR
OF PANEL 3 (1998), SAMPLING CONTINUES BUT
AUTHORIZATION FORMS ARE NOT COLLECTED).

SAMPLING BOX FOR ROUNDS 2 AND 3: (TO BASE ON
ROUND 1 CRITERIA FOR COLLECTION OF AFs IN ROUND 2
AND ROUND 3):
RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS
AUTHORIZATION FORM COLLECTION:

- ALL PAIRS WHERE THE PERSON IS THE POLICYHOLDER
OF THIS INSURANCE ON THE DATE OF THE ROUND 1
INTERVIEW AND THE ESTABLISHMENT IS A PRIVATE
SOURCE OF INSURANCE (DEFINED LATER) HELD ON THE
DATE OF THE ROUND 1 INTERVIEW (DEFINED LATER)
WITH FOUR EXCEPTIONS:
1. ESTABLISHMENT IS FLAGGED AS ‘EMPLOYER’ AND
EMPLOYER IS THE FEDERAL GOVERNMENT (EM96=2
OR HP13=1)
2. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-
EMPLOYED’ WITH ONE EMPLOYEE (EM91=1) AND ONE
LOCATION (EM93=2)
3. PERSON IS THE POLICYHOLDER OF THIS INSURANCE
AND IS FLAGGED AS ‘POLICYHOLDER NOT LISTED
IN RU’
4. ESTABLISHMENT ONLY PROVIDES LONG TERM CARE
IN A NURSING HOME, EXTRA CASH FOR HOSPITAL
STAYS, SERIOUS DISEASE OR DREAD DISEASE,
DISABILITY, WORKER’S COMPENSATION, OR
ACCIDENT INSURANCE (HX48 IS CODED ONLY
COMBINATIONS OF CODES ‘6’, ‘7’, ‘8’, ‘9’,
‘10’, AND ‘11’).

SAMPLING BOX FOR ROUNDS 2 AND 3: (TO BASE ON
ROUND 1 CRITERIA FOR COLLECTION OF AFs IN ROUND 2
AND ROUND 3):
RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS
AUTHORIZATION FORM COLLECTION:

- ALL PAIRS WHERE THE ESTABLISHMENT IS FLAGGED AS
‘EMPLOYER’ AND THE JOB SUBTYPE OF THAT EMPLOYER
IS FLAGGED AS ‘CURRENT MAIN’ AND THE JOB IS NOT
FLAGGED AS ‘PROVIDES HEALTH INSURANCE’ (PERSON
IS THE JOBHOLDER OF THIS CURRENT MAIN JOB ON THE
DATE OF THE ROUND 1 INTERVIEW) AS OF THE ROUND 1
INTERVIEW DATE WITH THREE EXCEPTIONS:
1. ESTABLISHMENT IS THE FEDERAL GOVERNMENT
(EM96 = 2)
2. ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’
WITH A FIRM-SIZE=1
3. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-
EMPLOYED’ WITH ONE EMPLOYEE (EM91=1) AND ONE
LOCATION (EM93=2)

SAMPLING BOX FOR ROUNDS 4 AND 5:
RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS
AUTHORIZATION FORM COLLECTION:

- ALL PAIRS WHERE THE ESTABLISHMENT IS FLAGGED AS
‘EMPLOYER’ AND THE JOB SUBTYPE OF THAT EMPLOYER
IS FLAGGED AS ‘CURRENT MAIN’ AND THE JOB IS NOT
FLAGGED AS ‘PROVIDES HEALTH INSURANCE’ (PERSON
IS THE JOBHOLDER OF THIS CURRENT MAIN JOB ON THE
DATE OF THE ROUND 1 INTERVIEW) AS OF THE ROUND 1
INTERVIEW DATE WITH THREE EXCEPTIONS:
1. ESTABLISHMENT IS THE FEDERAL GOVERNMENT
(EM96 = 2)
2. ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’
WITH A FIRM-SIZE=1
3. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-
EMPLOYED’ WITH ONE EMPLOYEE (EM91=1) AND ONE
LOCATION (EM93=2)

NOTE: PRIVATE INSURANCE IS DEFINED AS:
- ESTABLISHMENTS FLAGGED AS ‘EMPLOYER’ AND
FLAGGED AS ‘PROVIDES HEALTH INSURANCE’
(ESTABLISHMENTS FLAGGED AS ‘SELF-EMPLOYED’ WITH
A FIRM-SIZE-1 ARE TREATED AS DIRECT PURCHASED,
SEE NOTE BELOW)
- DIRECT PURCHASED INSURANCE, THAT IS,
ESTABLISHMENTS CREATED FROM THE HX23 SERIES

NOTE: HELD ON THE DATE OF THE ROUND 1 INTERVIEW:
- FOR PRIVATE SOURCES -- POLICYHOLDER HELD
INSURANCE AT THE TIME OF THE ROUND 1 INTERVIEW
DATE (HQ01 IS CODED ‘1’ (WHOLE TIME) OR HQ02 IS
CODED ‘1’ (YES, COVERED NOW) FOR THE
POLICYHOLDER)
- FOR PRIVATE SOURCES WHERE POLICYHOLDER IS
DECEASED -- AT LEAST ONE DEPENDENT (SELECTED AT
HP16) IS COVERED BY THE INSURANCE AT THE TIME OF
THE ROUND 1 INTERVIEW DATE (HQ01 IS CODED ‘1’
(WHOLE TIME) OR HQ02 IS CODED ‘1’ (YES, COVERED
NOW) FOR THE COVERED PERSON)

NOTE: ESTABLISHMENTS WHICH ARE EMPLOYERS AND
PROVIDE HEALTH INSURANCE AND ARE FLAGGED AS ‘SELF-
EMPLOYED’ WITH A FIRM-SIZE=1 ARE TREATED AS DIRECT
PURCHASED INSURANCE, THAT IS, HIPS WILL CONTACT
THE ESTABLISHMENT PROVIDING THE INSURANCE, (I.E.,
CREATED FROM THE HX03 SERIES) NOT THE EMPLOYER.

NOTE: FOR ESTABLISHMENTS WHICH ARE CURRENT MAIN
EMPLOYERS (ON THE ROUND 1 INTERVIEW DATE) AND
PROVIDE HEALTH INSURANCE, WHERE THE HEALTH
INSURANCE IS ONLY FROM A UNION (EM117=2), A HIPS
AUTHORIZATION FORM IS REQUIRED FOR BOTH THE
EMPLOYER AND THE UNION. IN THESE CASES, BOTH
ESTABLISHMENT-PERSON-PAIRS ARE ELIGIBLE FOR HIPS
AUTHORIZATION FORM COLLECTION.

NOTE: IF A CURRENT MAIN JOB IS FLAGGED AS
‘PREVIOUS HEALTH INSURANCE’ BUT THAT INSURANCE IS
ONLY LONG TERM CARE IN A NURSING HOME, EXTRA CASH
FOR HOSPITAL STAYS, SERIOUS DISEASE OR DREAD
DISEASE, DISABILITY, WORKER’S COMPENSATION, AND/OR
ACCIDENT INSURANCE, THE JOB IS PROCESSED AS IF IT
DOES NOT PROVIDE HEALTH INSURANCE BUT IS ELIGIBLE
FOR HEALTH INSURANCE PROVIDER AUTHORIZATION FORM
COLLECTION (AS LONG AS OTHER REQUIREMENTS ARE
MET).

NOTE: A ‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW)
RESPONSE AT ANY QUESTION LISTED ABOVE DOES NOT
MEET THE CRITERIA.

NOTE: IN ROUND 4, A NEW HIPS FLAG WILL BE SET AND
NEW HIPS AUTHORIZATION FORMS WILL BE COLLECTED FOR
ALL ESTABLISHMENT-PERSON-PAIRS BASED ON THE ABOVE
SAMPLING CRITERIA, BUT USING ROUND 3 DATA.

SAMPLING BOX (TO BASE ON ROUND 3 CRITERIA, FOR
COLLECTION OF AFs IN ROUNDS 4 AND 5):
RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS
AUTHORIZATION FORM COLLECTION:

- ALL PAIRS WHERE THE PERSON IS THE POLICYHOLDER
OF THIS INSURANCE ON THE DATE OF THE ROUND 3
INTERVIEW AND THE ESTABLISHMENT IS A PRIVATE
SOURCE OF INSURANCE (DEFINED LATER) HELD ON THE
DATE OF THE ROUND 3 INTERVIEW (DEFINED LATER)
WITH FOUR EXCEPTIONS:
1. ESTABLISHMENT IS FLAGGED AS ‘EMPLOYER’ AND
EMPLOYER IS THE FEDERAL GOVERNMENT (EM96=2
OR HP13=1)
2. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-
EMPLOYED’ WITH ONE EMPLOYEE (EM91=1) AND ONE
LOCATION (EM93=2)
3. PERSON IS THE POLICYHOLDER OF THIS INSURANCE
AND IS FLAGGED AS ‘POLICYHOLDER NOT LISTED
IN DU’
4. ESTABLISHMENT PROVIDES ONLY LONG TERM CARE
IN A NURSING HOME, EXTRA CASH FOR HOSPITAL
STAYS, SERIOUS DISEASE OR DREAD DISEASE,
DISABILITY, WORKER’S COMPENSATION, OR
ACCIDENT INSURANCE (HX48, OE10, OE24, OR
OE37 IS CODED ONLY COMBINATIONS OF CODES
‘6’, ‘7’, ‘8’, ‘9’, ‘10’, AND ‘11’).

SAMPLING BOX FOR ROUNDS 4 AND 5: (TO BASE ON ROUND
3 CRITERIA, FOR COLLECTION OF AFs IN ROUNDS 4 AND
5):
RU-ESTABLISHMENT-PERSON-PAIRS ELIGIBLE FOR HIPS
AUTHORIZATION FORM COLLECTION:

- ALL PAIRS WHERE THE ESTABLISHMENT IS FLAGGED AS
‘EMPLOYER’ AND THE JOB SUBTYPE OF THAT EMPLOYER
IS FLAGGED AS ‘CURRENT MAIN’ AND THE JOB IS NOT
FLAGGED AS ‘PROVIDES HEALTH INSURANCE’ (PERSON
IS THE JOBHOLDER OF THIS CURRENT MAIN JOB ON THE
DATE OF THE ROUND 3 INTERVIEW) AS OF THE ROUND 3
INTERVIEW DATE WITH THREE EXCEPTIONS:
1. ESTABLISHMENT IS THE FEDERAL GOVERNMENT
(EM96 = 2)
2. ESTABLISHMENT IS FLAGGED AS ‘SELF-EMPLOYED’
WITH A FIRM-SIZE=1
3. ESTABLISHMENT IS FLAGGED AS ‘NOT SELF-
EMPLOYED’ WITH ONE EMPLOYEE (EM91=1) AND ONE
LOCATION (EM93=2)

NOTE: HELD ON THE DATE OF THE ROUND 3 INTERVIEW:
- FOR PRIVATE SOURCES -- POLICYHOLDER HELD
INSURANCE AT THE TIME OF THE ROUND 3 INTERVIEW
DATE [(HQ01 IS CODED ‘1’ (WHOLE TIME) OR HQ02 IS
CODED ‘1’ (YES, COVERED NOW) FOR THE
POLICYHOLDER) OR (OE01, OE12, OE26 IS CODED ‘1’
(YES) FOR THE POLICYHOLDER)
- FOR PRIVATE SOURCES WHERE POLICYHOLDER IS
DECEASED -- AT LEAST ONE DEPENDENT [(SELECTED AT
HP16 OR OE45) OR (CONFIRMED AS STILL COVERED AT
OE29 OR OE30)] IS COVERED BY THE INSURANCE AT
THE TIME OF THE ROUND 3 INTERVIEW DATE [(HQ01
IS CODED ‘1’ (WHOLE TIME) OR HQ02 IS CODED ‘1’
(YES, COVERED NOW) FOR THE COVERED PERSON) OR
(OE26 IS CODED ‘1’ (YES) FOR THE COVERED
PERSON)]

NOTE: ESTABLISHMENTS WHICH ARE EMPLOYERS AND
PROVIDE HEALTH INSURANCE AND ARE FLAGGED AS
‘SELF-EMPLOYED’ WITH A FIRM-SIZE=1 ARE TREATED AS
DIRECT PURCHASED INSURANCE, THAT IS, HIPS WILL
CONTACT THE ESTABLISHMENT PROVIDING THE INSURANCE,
(I.E., CREATED FROM THE HX03 SERIES) NOT THE
EMPLOYER.

NOTE: FOR ESTABLISHMENTS WHICH ARE CURRENT MAIN
EMPLOYERS (ON THE ROUND 3 INTERVIEW DATE) AND
PROVIDE HEALTH INSURANCE, WHERE THE HEALTH
INSURANCE IS ONLY FROM A UNION (EM117=2), A HIPS
AUTHORIZATION FORM IS REQUIRED FOR BOTH THE
EMPLOYER AND THE UNION. IN THESE CASES, BOTH
ESTABLISHMENT-PERSON-PAIRS ARE ELIGIBLE FOR HIPS
AUTHORIZATION FORM COLLECTION.

NOTE: A ‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW)
RESPONSE AT ANY QUESTION LISTED ABOVE DOES NOT
MEET THE CRITERIA.

Subsection 4: Pharmacy Requests and Authorization
Forms (Rounds 2-5)

AS A PHARMACY WAS ENTERED OR SELECTED DURING THE
PRESCRIBED MEDICINES SECTION, THE PERSON-PHARMACY-
PAIR WAS FLAGGED 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 AUTHORIZATION
FORM COLLECTION FOR THIS RU MEMBER.

IF ROUND 1, GO TO BOX_14

OTHERWISE (I.E., IF ROUNDS 2-5), CONTINUE
WITH BOX_11

NOTE: PANELS 1 THROUGH 12 INCLUDED PHARMACY AF
COLLECTION ONLY IN ROUNDS 3 AND 5. PANEL 13
INCLUDES PHARMACY AF COLLECTION IN ROUNDS 3, 4,
AND 5. BEGINNING IN PANEL 14, AND ALL SUBSEQUENT
PANELS, PHARMACY AF COLLECTION OCCURS IN ROUNDS
2-5.

IF AT LEAST ONE PERSON-PHARMACY-PAIR ELIGIBLE
(SEE SAMPLING BOX BELOW) FOR PHARMACY
AUTHORIZATION FORM COLLECTION FOR THE CURRENT
ROUND,
OR
AT LEAST ONE PERSON-PHARMACY-PAIR ELIGIBLE FOR
AUTHORIZATION FORM COLLECTION DURING THE PREVIOUS
ROUND AND CL32 WAS CODED '3' (LEFT WITH R), ‘4’
(MAILED TO R), ‘5’ (REFUSED), ‘91’ (OTHER), OR
‘-1’ (ADDED BY COMMENT REVIEW) FOR THIS PERSON-
PHARMACY-PAIR IN PREVIOUS ROUND, CONTINUE WITH
CL30

OTHERWISE, GO TO BOX_14

NOTE: RECEIPT CONTROL WILL UPDATE CAPI INTER-
ROUND, USING THE CODE STRUCTURE AT CL32. UPDATES
CAN BE EITHER POSITIVE OR NEGATIVE. THIS MEANS
THAT INTER-ROUND AN AUTHORIZATION FORM’S STATUS
CAN EITHER GET UPDATED TO A HIGHER STATUS CODE
(FROM UNSIGNED TO SIGNED) OR TO A LOWER STATUS
CODE (FROM SIGNED TO UNSIGNED -- I.E., IT WAS NOT
SIGNED BY THE RIGHT PERSON). SEE MPC MAPPING
SPECIFICATIONS FOR EXACT UPDATES TO STATUS CODES.

NOTE BOX
THERE ARE 6 PERSON TYPES (AND TWO SUB-TYPES) IN
THE MEPS RU

TYPE PRSLT
DECEASED/ELIGIBLE FOR PART OF REF PERIOD 41
INSTITUTIONALIZED/ELIGIBLE PT OF REF PERIOD 51
IN A HEALTHCARE FACILITY (INSTTTYPE 1 OR 2)
IN A NON-HEALTHCARE FACILITY (INSTTYPE 3)
MEPS STUDENT/ELIGIBLE ALL OF REF PERIOD 71
LIVING OUTSIDE US/ELIGIBLE PT OF REF PERIOD 75
LIVING-MILITARY BASE/ELIGIBLE PT REF PERIOD 76
ELIGIBLE FOR ALL OF REFERENCE PERIOD 99

THE FOLLOWING PERSON TYPES (AND SUB-TYPES)
ARE ELIGIBLE FOR PHARMACY AUTHORIZATION FORM
COLLECTION:
- PRSLT 41 - DECEASED/ELIGIBLE FOR PART OF
REF PERIOD
- PRSLT 51 – SUB-TYPE INSTITUTIONALIZED/ELIGIBLE
PT OF REF PERIOD IN A
HEALTHCARE FACILITY (INSTTYPE 1 OR 2)
- PRSLT 71 - MEPS STUDENT/ELIGIBLE ALL OF REF
PERIOD
- PRSLT 99 - ELIGIBLE FOR ALL OF REFERENCE PERIOD

THERE ARE TWO TYPES OF OUT OF SCOPE RU MEMBERS
THAT ARE ELIGIBLE FOR PHARMACY AUTHORIZATION FORM
COLLECTION (NOTE: OUT OF SCOPE REFERS TO RU
MEMBERS WHO HAD PARTIAL ELIGIBILITY IN THE
PREVIOUS ROUND AND NO ELIGIBILITY IN THE CURRENT
ROUND):
- PRSLT 41 - DECEASED/ELIGIBLE FOR PART OF REF
PERIOD
- PRSLT 51 – SUB-TYPE INSTITUTIONALIZED/ELIGIBLE
PT OF REF PERIOD IN A HEALTHCARE FACILITY
(INSTTYPE 1 OR 2)

2 PERSON TYPES AND 1 SUB-TYPE ARE NOT ELIGIBLE FOR
PHARMACY AUTHORIZATION FORM COLLECTION:
- PRSLT 51 – SUB-TYPE INSTITUTIONALIZED/ELIGIBLE
PT OF REF PERIOD IN A NON-HEALTHCARE FACILITY
(INSTTYPE 3)
- PRSLT 75 - LIVING OUTSIDE US/ELIGIBLE PT OF REF
PERIOD
- PRSLT 76 - LIVING-MILITARY BASE/ELIGIBLE PT REF
PERIOD

PERSON-PHARMACY-PAIRS WHERE THE PHARMACY LOCATION
IS IN A FOREIGN COUNTRY (I.E., ‘FC’ IS ENTERED IN
THE STATE FIELD OF PHARMACY’S ADDRESS ARE NOT
ELIGIBLE FOR PHARMACY AUTHORIZATION FORM
COLLECTION)

NOTE: PHARMACY AUTHORIZATION FORMS ARE NOT EVENT
DEPENDENT, ARE NOT LINKED TO ANY SPECIFIC YEAR IN
ROUND 3 AND ARE ASKED AS TWO SEPARATE SAMPLES.
FOR THE FIRST SAMPLE, CAPI REQUESTS AUTHORIZATION
FORMS FROM ROUNDS 1, 2 AND 3. FOR THE SECOND
SAMPLE, CAPI REQUESTS AUTHORIZATION FORMS FROM
ROUNDS 3, 4 AND 5. REQUESTS FOR OUTSTANDING
AUTHORIZATION FORMS FROM ROUNDS 1 AND 2 SHOULD
NOT BE CONTINUED IN ROUND 4, INCLUDING
AUTHORIZATION FORMS FOR DECEASED AND
INSTITUTIONALIZED PERSONS.

SAMPLING BOX

PERSON-PHARMACY-PAIRS ELIGIBLE FOR PHARMACY
AUTHORIZATION FORM COLLECTION:
NOTE: PERSON IS A KEY, ELIGIBLE RU MEMBER (AT TIME
OF EVENT).

ROUND 1:
- AUTHORIZATION FORMS (AFS) ARE NOT REQUESTED
IN ROUND 1 BUT PHARMACY RECORDS ARE CREATED.

ROUND 2:
- PERSON-PHARMACY PAIRS CREATED IN THE CURRENT
ROUND.
- PERSON-PHARMACY PAIRS CREATED IN THE
PREVIOUS ROUND.

ROUND 3:
- PERSON-PHARMACY PAIRS CREATED IN THE CURRENT
ROUND.
- PERSON-PHARMACY PAIRS OUTSTANDING FROM THE
PREVIOUS ROUND.
- PERSON-PHARMACY PAIRS CREATED IN PREVIOUS
ROUNDS BUT SELECTED IN THE CURRENT ROUND.
ROUND.

ROUND 4:
- PERSON-PHARMACY PAIRS CREATED IN THE CURRENT
ROUND.
- PERSON-PHARMACY PAIRS OUTSTANDING FROM THE
PREVIOUS ROUND IF THEY WERE CREATED IN
ROUND 3.
- PERSON-PHARMACY PAIRS CREATED IN PREVIOUS
ROUNDS BUT SELECTED IN THE CURRENT ROUND.

ROUND 5:
- PERSON-PHARMACY PAIRS CREATED IN THE CURRENT
ROUND.
- PERSON-PHARMACY PAIRS OUTSTANDING FROM THE
PREVIOUS ROUND IF THEY WERE CREATED IN ROUND
3 OR 4.
- PERSON-PHARMACY PAIRS CREATED IN PREVIOUS
ROUNDS BUT SELECTED IN THE CURRENT ROUND.

NOTE: IF THE SAME PHARMACY IS ASSOCIATED MORE
THAN ONCE WITH A PARTICULAR PERSON, ONLY ONE
AUTHORIZATION FORM IS ASKED ABOUT FOR THAT PAIR.
IF THE SAME PHARMACY IS ASSOCIATED WITH MORE THAN
ONE PERSON, AN AUTHORIZATION FORM IS ASKED FOR
EACH UNIQUE PERSON-PHARMACY-PAIR.

NOTE: IF THE PERSON-PHARMACY-PAIR IS OUTSTANDING
FROM A PREVIOUS ROUND AND THE SAME PHARMACY
IS SELECTED FOR THAT PERSON IN THE CURRENT ROUND,
THE PAIR WILL NOT BE TREATED AS IF IT IS
OUTSTANDING. THAT IS, THE DISPLAYS FOR PREVIOUS
ROUND STATUS WILL NOT BE SHOWN, ETC.

To obtain complete and accurate information about health care use
and expenditures, we would like authorization to contact pharmacies
to obtain a printed summary for:

(READ PERSON BELOW)’s prescriptions filled at (READ PHARMACY BELOW).

[HAND RESPONDENT THE AUTHORIZATION FORM BOOKLET.]

[These materials explain more about why we contact pharmacies
and answer questions people sometimes ask about this part of
the study. Please take a minute to review this information
while I gather the forms.]

ROSTER DETAILS:
TITLE: RU_PERS_PHAR_PAIR_1

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

COL # 2 HEADER: PHARMACY
INSTRUCTIONS: DISPLAY PHARMACY NAME
(PHAR.PHARNAME)

ROSTER DEFINITION:
DISPLAY EACH UNIQUE PAIR ON THE RU-PERSON-
PHARMACY-PAIRS-ROSTER.

ROSTER BEHAVIOR:
1. DISPLAY ONLY.

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

ROSTER FILTER:
DISPLAY ONLY THOSE PAIRS THAT MEET THE FOLLOWING
CONDITION(S):
- PAIR IS ELIGIBLE FOR PHARMACY AUTHORIZATION FORM
COLLECTION FOR THE CURRENT ROUND (SEE BOX_11
SAMPLING SPECIFICATIONS)
OR
- PAIR ELIGIBLE FOR PHARMACY AUTHORIZATION FORM
COLLECTION IN PREVIOUS ROUND,
AND
- CL32 WAS CODED '3' (LEFT WITH R), ‘4’ (MAILED
TO R), ‘5’ (REFUSED), ‘91’ (OTHER) OR ‘-1’
(ADDED BY COMMENT REVIEW) FOR THIS PERSON-
PHARMACY-PAIR IN PREVIOUS ROUND

NOTE: DISPLAY EACH UNIQUE ELIGIBLE PERSON-
PHARMACY-PAIR ONLY ONCE.

FOR EACH ELEMENT ON THE RU-PERSON-PHARMACY-PAIRS-
ROSTER, ASK CL31 - END_LP07

LOOP DEFINITION: LOOP_07 PRESENTS EACH UNIQUE
PERSON-PHARMACY-PAIR ELIGIBLE FOR PHARMACY
AUTHORIZATION FORM COLLECTION FOR THE INTERVIEWER
TO COMPLETE THE AUTHORIZATION FORM. THIS LOOP
CYCLES ON THE RU-PERSON-PHARMACY-PAIRS THAT MEET
THE FOLLOWING CONDITIONS:

- PAIR IS ELIGIBLE FOR PHARMACY AUTHORIZATION FORM
COLLECTION FOR THE CURRENT ROUND (SEE BOX_11
SAMPLING SPECIFICATIONS)
OR
- PAIR ELIGIBLE FOR PHARMACY AUTHORIZATION FORM
COLLECTION IN PREVIOUS ROUND,
AND
- CL32 WAS CODED '3' (LEFT WITH R), ‘4’ (MAILED
TO R), ‘5’ (REFUSED), ‘91’ (OTHER) OR ‘-1’
(ADDED BY COMMENT REVIEW) FOR THIS PERSON-
PHARMACY-PAIR IN PREVIOUS ROUND

NOTE: LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON-
PHARMACY-PAIR.

INTERVIEWER: CHECK FIRST FOR PREPRINTED PHARMACY AF FOR THIS PAIR.
IF THERE IS NO PREPRINTED AF, FILL OUT A BLANK PHARMACY AF.

PID: [PID] PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]

RU ID: [RUID-7] REGION: [Reg ID-1] PHARMID: [PharmID-4]
PHARMACY NAME: [Pharmacy Name-35]
PHARMACY ADDRESS: [Street Address for Pharmacy]
[City Name], [ST] [Zip Code] [Telephone]

{PHARMACY AF STATUS FROM PREVIOUS ROUND: {DISPLAY PREVIOUS ROUND
STATUS – 40}}

SIGNATURE DATE ON PHARMACY AF MUST BE ON OR AFTER: {MM/DD/YYYY}

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

HELP AVAILABLE FOR MORE INFORMATION ON PHARMACY
AUTHORIZATION FORMS.

DISPLAY ‘PHARMACY AF STATUS ... -40}’ IF CURRENT
PERSON-PHARMACY-PAIR IS OUTSTANDING FROM THE
PREVIOUS ROUND.

FOR ‘DISPLAY PREVIOUS ROUND STATUS-40’, DISPLAY
THE CATEGORY ENTRY ASSOCIATED WITH THE PREVIOUS
ROUND (OR RECEIPT CONTROL UPDATED) CL32
OUTSTANDING STATUS. THAT IS, IF CL32 WAS CODED
‘3’, DISPLAY ‘LEFT WITH R’; IF CL32 WAS CODED ‘4’,
DISPLAY ‘MAILED TO R’; IF CL32 WAS CODED ‘5’,
DISPLAY ‘REFUSED’; AND IF CL32 WAS CODED ‘91’ OR
‘-1’, DISPLAY THE FIRST 40 CHARACTERS FROM THE
OTHER SPECIFY ENTRY FIELD (OR THE RECEIPT CONTROL
UPDATE TEXT GENERATED FOR THE ‘91’ OR ‘-1’ CODES)

DISPLAY THE INTERVIEW DATE OF THE MOST RECENT
ROUND’S INTERVIEW FOR WHICH PAIR IS/WAS ELIGIBLE
FOR AUTHORIZATION FORM COLLECTION FOR
‘MM/DD/YYYY’.

CYCLE ON NEXT PAIR ON THE RU-PERSON-PHARMACY-
PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN
THE LOOP DEFINITION.

IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END
LOOP_07 AND CONTINUE WITH LOOP_08

FOR EACH ELEMENT ON THE RU-PERSON-PHARMACY-PAIRS-
ROSTER, ASK CL32 - END_LP08

LOOP DEFINITION: LOOP_08 PRESENTS EACH UNIQUE
PERSON-PHARMACY-PAIR ELIGIBLE FOR PHARMACY
AUTHORIZATION FORM COLLECTION FOR THE INTERVIEWER
TO RECORD THE STATUS OF THE AUTHORIZATION FORM.
THIS LOOP CYCLES ON THE RU-PERSON-PHARMACY-PAIRS
THAT MEET THE FOLLOWING CONDITIONS:

- PAIR IS ELIGIBLE FOR PHARMACY AUTHORIZATION FORM
COLLECTION FOR THE CURRENT ROUND (SEE BOX_11
SAMPLING SPECIFICATIONS)
OR
- PAIR ELIGIBLE FOR PHARMACY AUTHORIZATION FORM
COLLECTION IN PREVIOUS ROUND,
AND
- CL32 WAS CODED '3' (LEFT WITH R), ‘4’ (MAILED
TO R), ‘5’ (REFUSED), ‘91’ (OTHER) OR ‘-1’
(ADDED BY COMMENT REVIEW) FOR THIS PERSON-
PHARMACY-PAIR IN PREVIOUS ROUND

NOTE: LOOP ONLY ONE TIME FOR EACH UNIQUE PERSON-
PHARMACY-PAIR.

INTERVIEWER: ASK APPROPRIATE PERSON(S) TO SIGN AUTHORIZATION FORM.
IF NOT AVAILABLE TO SIGN, LEAVE AUTHORIZATION FORM AND BOOKLET WITH
RESPONDENT.

PID: [PID] PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]

RU ID: [RUID-7] REGION: [Reg ID-1] PHARMID: [PharmID-4]
PHARMACY NAME: [Pharmacy Name-35]
PHARMACY ADDRESS: [Street Address for Pharmacy]
[City Name], [ST] [Zip Code] [Telephone]

SIGNATURE DATE ON PHARMACY AF MUST BE ON OR AFTER: {MM/DD/YYYY}

SELECT THE PHARMACY AUTHORIZATION FORM STATUS:

SIGNED, NO PROBLEM ..................... 1 {CL33}
SIGNED WITH PROBLEM .................... 2 {CL32OV1}
LEFT WITH R ............................ 3 {END_LP08}
MAILED TO R ............................ 4 {END_LP08}
REFUSED ................................ 5 {CL34}
OTHER ................................. 91 {CL32OV2}

[Code One]

HELP AVAILABLE FOR MORE INFORMATION ON PHARMACY
AUTHORIZATION FORMS.

FOR ‘MM/DD/YYY’, DISPLAY THE RU END REFERENCE DATE
OF THE MOST RECENT ROUND’S INTERVIEW FOR WHICH PAIR
IS/WAS ELIGIBLE FOR AUTHORIZATION FORM COLLECTION

PROBLEM:

[Enter Problem-45] ..................... {CL33}

HELP AVAILABLE FOR MORE INFORMATION ON PHARMACY
AUTHORIZATION FORMS.

SPECIFY:

[Enter Other Specify-45] ............... {END_LP08}

HELP AVAILABLE FOR MORE INFORMATION ON PHARMACY
AUTHORIZATION FORMS.

FOR ‘MM/DD/YYYY’, DISPLAY THE RU END REFERENCE
DATE OF THE MOST RECENT ROUND’S INTERVIEW FOR
WHICH PAIR IS/WAS ELIGIBLE FOR AUTHORIZATION FORM
COLLECTION.

NOTE: EACH PHARMACY AUTHORIZATION FORM HAS A
PRE-ASSIGNED PHARMACY AUTHORIZATION FORM NUMBER.

HARD CHECK–PANEL 18 PHARMACY AUTHORIZATION FORMS:
AUTHORIZATION FORM NUMBERS ARE PANEL AND ROUND
SPECIFIC. NUMBER ENTERED MUST BE 8 CHARACTERS LONG
AND MUST BEGIN AND END WITH AN ALPHA CHARACTER.
PANEL 18 PHARMACY AUTHORIZATION FORMS ARE PRINTED
ON GRAY PAPER.

HARD CHECK–PANEL 19 PHARMACY AUTHORIZATION FORMS:
AUTHORIZATION FORM NUMBERS ARE PANEL AND ROUND
SPECIFIC. NUMBER ENTERED MUST BE 8 CHARACTERS LONG
AND MUST BEGIN WITH AN ALPHA CHARACTER AND END
WITH AN ALPHA CHARACTER. PANEL 19 PHARMACY
AUTHORIZATION FORMS ARE PRINTED ON ORCHID PAPER.

HARD CHECK–PANEL 20 PHARMACY AUTHORIZATION FORMS:
AUTHORIZATION FORM NUMBERS ARE PANEL AND ROUND
SPECIFIC. NUMBER ENTERED MUST BE 8 CHARACTERS LONG
AND MUST BEGIN AND END WITH AN ALPHA CHARACTER.
PANEL 20 PHARMACY AUTHORIZATION FORMS ARE PRINTED
ON PINK PAPER.

SOME IMPORTANT POINTS TO REMEMBER ABOUT PHARMACY
AUTHORIZATION FORMS:
- THE PREFIX LETTER CHANGES BASED ON THE TYPE OF
AUTHORIZATION FORM AND THE ORIGIN OF THE FORM.
THIS MEANS THAT A PRE-PRINTED OR FIELD
GENERATED AUTHORIZATION FORM WILL DRAW FROM
THE SAME LETTER OR RANGE OF LETTERS IN EACH
PANEL. THE EXCEPTION IS PANEL 14 PHARMACY
AUTHORIZATION FORMS WHICH WILL DRAW FROM AN
EXPANDED LIST OF PREFIX LETTERS TO ACCOMMODATE
A CHANGE IN COLLECTION PROCEDURES.
- THE 5-NUMBER SEQUENCE REPEATS ITSELF FOR EACH
PANEL.
- THE CHECK-DIGIT ALWAYS REMAINS CONSTANT.
- THE ROUND IDENTIFIER IS DIFFERENT FOR EACH
PANEL. THE ROUND IDENTIFIER WILL REMAIN THE
SAME FOR ALL AUTHORIZATION FORMS COLLECTED
WITHIN A PANEL, BUT CHANGES BASED ON THE ROUND.
FOR EXAMPLE: AUTHORIZATION FORMS GENERATED FOR
PANEL 19, ROUND 1 WILL USE THE ROUND IDENTIFIER
"M"; "M" OR "N" FOR ROUND 2; "M", "N", OR "P"
FOR ROUND 3; "M", "N", "P" OR "Q" FOR ROUND 4;
AND "M", "N", "P", "Q" OR "R" FOR ROUND 5.

PHARMACY AUTHORIZATION FORM SIGNATURE DATE:

[Enter Month, Day, Year-4] .................. {END_LP08}

NOTE: INTERVIEWERS WILL BE INSTRUCTED TO COLLECT
SIGNED PHARMACY AUTHORIZATION FORMS WITH DATES
EARLIER THAN THE ONE DISPLAYED, BUT WILL NOT ENTER
THE NUMBER IN CAPI SINCE THE CURRENT STATUS FOR
THE AUTHORIZATION FORM WITH THE CORRECT DATE MAY
BE SOMETHING ELSE. THE CAPI STATUS OF THE PHARMACY
AUTHORIZATION FORM SHOULD REFLECT THE FORM WITH
THE MOST RECENT DATE.

HARD CHECK:
DATE ENTERED MUST BE ON OR AFTER THE INTERVIEW
DATE OF THE MOST RECENT ROUND’S INTERVIEW FOR
WHICH THE PAIR IS/WAS ELIGIBLE FOR AUTHORIZATION
FORM COLLECTION BUT CANNOT BE AFTER ‘TODAY’S DATE’
(THE CURRENT DATE SET ON THE LAPTOP). IF DATE IS
BEFORE CORRECT DATE, DISPLAY THE FOLLOWING
MESSAGE: ‘PHARMACY AF MUST BE SIGNED ON OR AFTER
ABOVE DATE. VERIFY AND RE-ENTER DATE OR COMPLETE
NEW AF.’

PID: [PID] PERSON: [First,[Middle],Last Name-35]
DOB: [MM/DD/YYYY] AGE: [XXX] STATUS: [Status Code Description]

RU ID: [RUID-7] REGION: [Reg ID-1] PHARMID: [PharmID-4]
PHARMACY NAME: [Pharmacy Name-35]
PHARMACY ADDRESS: [Street Address for Pharmacy]
[City Name], [ST] [Zip Code] [Telephone]

SELECT MAIN REASON FOR REFUSAL:

DOESN’T WANT TO BOTHER PHARMACY ........ 1 {END_LP08}
CONFIDENTIALITY/SENSITIVE ISSUE ........ 2 {END_LP08}
PAYMENT PROBLEM WITH PHARMACY .......... 3 {END_LP08}
HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP08}
WANTS MORE INFORMATION BEFORE SIGNING .. 5 {END_LP08}
NOT INTERESTED ......................... 6 {END_LP08}
NO REASON GIVEN ........................ 7 {END_LP08}
OTHER ................................. 91 {CL34OV}

[Code One]

OTHER REASON FOR REFUSAL:

[Enter Other Specify-45] ................. {END_LP08}

CYCLE ON NEXT PAIR ON THE RU-PERSON-PHARMACY-
PAIRS-ROSTER THAT MEETS THE CONDITIONS STATED IN
THE LOOP DEFINITION.

IF NO OTHER PAIRS MEET THE STATED CONDITIONS, END
LOOP_08 AND CONTINUE WITH BOX_14

SUBSECTION 5: SELF-ADMINISTERED QUESTIONNAIRE
(ROUNDS 2 THROUGH 5)

IF ROUND 2 OR 4, CONTINUE WITH BOX_15

IF ROUND 3 OR 5, GO TO BOX_16

OTHERWISE, GO TO BOX_16A

IF ROUND 2 OR 4 AND AT LEAST ONE KEY RU MEMBER
ELIGIBLE FOR SAQ (I.E., AT LEAST ONE CURRENT RU
MEMBER WHO IS KEY AND WHO IS NOT DECEASED OR
INSTITUTIONALIZED AND IS IN THE RU AT THE ROUND 2
OR 4 INTERVIEW DATE AND IS 18 YEARS OF AGE OR
OLDER (OR IN AGE CATEGORIES 4-9) ON JULY 1,
{YEAR}, WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF
THE PANEL, IF ROUND 2 OR ON JULY 1, {YEAR}, WHERE
‘YEAR’ IS THE SECOND CALENDAR YEAR OF THE PANEL,
IF ROUND 4, OR HAS TURNED 18 BETWEEN JULY 1,
{YEAR}, WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR
OF THE PANEL, AND THE DATE OF THE INTERVIEW IF
ROUND 2, OR JULY 1, {YEAR}, WHERE ‘YEAR’ IS THE
SECOND CALENDAR YEAR OF THE PANEL, AND THE DATE
OF THE INTERVIEW IF ROUND 4, CONTINUE WITH CL35

OTHERWISE, GO TO BOX_16E

NOTE: DETERMINING WHICH ADULTS IN THE RU RECEIVE
AN SAQ AND WHICH ADULTS ARE FOLLOWED-UP IN ROUND
3 OR 5 WILL BE BASED ONLY ON ROUND 2 OR 4
INFORMATION. THAT IS, NO RU MEMBERS ADDED IN
ROUND 3 OR 5 WILL BE ASKED TO COMPLETE AN SAQ.

Now I would like to ask (READ PERSON NAMES BELOW) to complete
a brief survey about health and health opinions.

AS APPROPRIATE, PREPARE AN SAQ FOR EACH PERSON LISTED ABOVE.

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

HELP AVAILABLE FOR MORE INFORMATION ON SAQ COLLECTION.

ROSTER DETAILS:
TITLE: RU-MEMBERS_7

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

COL # 2 HEADER: PID
INSTRUCTIONS: DISPLAY RU MEMBERS’ 3-DIGIT ID
(PERS.PID)

ROSTER DEFINITION:
DISPLAY PERSONS ON THE RU-MEMBERS-ROSTER FOR
DISPLAY ONLY.

ROSTER BEHAVIOR:
1. DISPLAY ONLY.
2. SELECT, EDIT, ADD, DELETE DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS KEY
- PERSON DOES NOT HAVE A STATUS OF DECEASED OR
INSTITUTIONALIZED ON ROUND 2 OR 4 INTERVIEW DATE
- PERSON CURRENTLY IN RU ON ROUND 2 OR 4 INTERVIEW
DATE
- PERSON IS 18 YEARS OF AGE OR OLDER (OR IN AGE
CATEGORIES 4-9) ON JULY 1, {YEAR}, WHERE ‘YEAR’
IS THE FIRST CALENDAR YEAR OF THE PANEL, IF
ROUND 2, OR ON JULY 1, {YEAR}, WHERE ‘YEAR’ IS
THE SECOND CALENDAR YEAR OF THE PANEL, IF ROUND
4, OR HAS TURNED 18 BETWEEN JULY 1, {YEAR},
WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE
PANEL, AND THE DATE OF THE INTERVIEW IF ROUND 2
OR JULY 1, {YEAR}, WHERE ‘YEAR’ IS THE SECOND
CALENDAR YEAR OF THE PANEL AND THE DATE OF THE
INTERVIEW IF ROUND 4.

FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK
NAV_CL09 – END_LP09

LOOP DEFINITION: LOOP_09 COLLECTS THE SAQ STATUS
FOR EACH PERSON ELIGIBLE TO COMPLETE THE SAQ.
THIS LOOP CYCLES ON EACH PERSON ON THE RU-MEMBERS-
ROSTER WHO MEETS THE FOLLOWING CONDITIONS:
- PERSON IS KEY
- PERSON DOES NOT HAVE A STATUS OF DECEASED OR
INSTITUTIONALIZED ON ROUND 2 OR 4 INTERVIEW DATE
- PERSON CURRENTLY IN RU ON ROUND 2 OR 4 INTERVIEW
DATE
- PERSON IS 18 YEARS OF AGE OR OLDER (OR IN AGE
CATEGORIES 4-9) ON JULY 1, {YEAR}, WHERE ‘YEAR’
IS THE FIRST CALENDAR YEAR OF THE PANEL, IF
ROUND 2, OR ON JULY 1, {YEAR}, WHERE ‘YEAR’ IS
THE SECOND CALENDAR YEAR OF THE PANEL, IF ROUND
4, OR HAS TURNED 18 BETWEEN JULY 1, {YEAR},
WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE
PANEL, AND THE DATE OF THE INTERVIEW IF ROUND 2
OR JULY 1, {YEAR}, WHERE ‘YEAR’ IS THE SECOND
CALENDAR YEAR OF THE PANEL AND THE DATE OF THE
INTERVIEW IF ROUND 4.

NAVIGATOR DETAILS: LOOP_09 USES NAV_CL09 TO
CONTROL THE FLOW OF THE LOOP.

SERIES: Collect and Record the Status of Each SAQ.

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 CONDITIONS
STATED AT THE LOOP_09 DEFINITION.

CONTINUE WITH CL36 FOR SELECTED RU MEMBER.

{PERSON’S FIRST MIDDLE AND LAST NAME}

PID: {PID}

COLLECT {PERSON}’S COMPLETED SAQ {AND EXPLAIN THAT THEY WILL
RECEIVE $5.00 FOR EACH COMPLETED SAQ}.

IF {PERSON} NOT AVAILABLE OR NOT ABLE TO COMPLETE SAQ AT
THIS TIME, LEAVE SAQ WITH {HIM/HER} OR RESPONDENT AND EXPLAIN
INSTRUCTIONS.

SELECT THE STATUS OF THE SAQ:

COMPLETED AND GIVEN TO INTERVIEWER ..... 1 {END_LP09}
NOT COMPLETED, WILL PICK UP AT
LATER DATE ........................... 2 {END_LP09}
NOT COMPLETED, WILL MAIL TO HOME OFFICE. 3 {END_LP09}
MAILED TO SAQ RESPONDENT ............... 4 {END_LP09}
REFUSED TO COMPLETE .................... 5 {CL37}
OTHER ................................. 91 {CL36OV}

[Code One]

DISPLAY THE PERSON’S 3-DIGIT PID FOR ‘PID’.

DISPLAY ‘AND EXPLAIN...SAQ’ IF PANEL 17, ROUND 4.
OTHERWISE, USE A NULL DISPLAY.

NOTE: STARTING IN PANEL 18, PAYMENT WILL NO
LONGER BE MADE FOR COMPLETED SAQ. FORMS.

SOFT CHECK:
CODE ‘4’ (MAILED TO SAQ RESPONDENT) MUST BE
VERIFIED (ENTERED TWICE) IF RU IS NOT A STUDENT
RU. IF CODE ‘4’ SELECTED AND RU IS NOT A STUDENT
RU, DISPLAY THE FOLLOWING MESSAGE: ‘UNLIKELY
RESPONSE. VERIFY AND RE-ENTER.’

{PERSON’S FIRST MIDDLE AND LAST NAME}

SELECT MAIN REASON FOR REFUSAL:

TOO BUSY/NOT INTERESTED ................ 1 {END_LP09}
TOO PERSONAL/SENSITIVE INFORMATION ..... 2 {END_LP09}
TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP . 3 {END_LP09}
HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP09}
WANTS MORE INFORMATION ................. 5 {END_LP09}
NOT INTERESTED ......................... 6 {END_LP09}
NO REASON GIVEN ........................ 7 {END_LP09}
OTHER ................................. 91 {CL37OV}

[Code One]

OTHER REASON FOR REFUSAL:

[Enter Other Specify-45] ................. {END_LP09}

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

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_09 AND GO TO BOX_16A

IF AT LEAST ONE PERSON WITH AN SAQ DISPOSITION IN
THE PREVIOUS ROUND (SAQSTAT) OF ‘5’ (REFUSED TO
COMPLETE SAQ) OR [‘91’ (OTHER) AND UPDATED BY
RECEPIT CONTROL (RCFLG) to 0, 1, or 3] DURING
ROUND 2 OR 4 AND NOT UPDATED BY RECEIPT, CONTINUE
WITH CL38

OTHERWISE, GO TO BOX_16A

During the last interview a short booklet about health and
health opinions was left with (READ PERSON NAMES BELOW) to
complete.

I would like to check to see if I could pick these booklets
up or if they were already mailed back to the home office.}

1. COLLECT SAQs, IF AVAILABLE.

2. IF ANY REPORTED AS LOST, RE-DISTRIBUTE APPROPRIATE
NUMBER AND TYPE OF SAQs TO THE RESPONDENT.

HELP AVAILABLE FOR MORE INFORMATION ON SAQ COLLECTION.

ROSTER DEFINITION:
DISPLAY PERSONS ON THE RU-MEMBERS-ROSTER FOR
DISPLAY ONLY.

ROSTER BEHAVIOR:
1. DISPLAY ONLY.
2. SELECT, EDIT, ADD, DELETE DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO
MEET THE FOLLOWING CONDITIONS:
- PERSON IS KEY
- PERSON DID NOT HAVE A STATUS OF DECEASED OR
INSTITUTIONALIZED ON ROUND 2 OR 4 INTERVIEW DATE
- PERSON WAS CURRENTLY IN RU ON ROUND 2 OR 4
INTERVIEW DATE
- PERSON IS 18 YEARS OF AGE OR OLDER (OR IN AGE
CATEGORIES 4-9) ON JULY 1, {YEAR}, WHERE ‘YEAR’
IS THE FIRST CALENDAR YEAR OF THE PANEL, IF
ROUND 2, OR ON JULY 1, {YEAR}, WHERE ‘YEAR’ IS
THE SECOND CALENDAR YEAR OF THE PANEL, IF ROUND
4, OR HAS TURNED 18 BETWEEN JULY 1, {YEAR},
WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE
PANEL, AND THE DATE OF THE INTERVIEW IF ROUND 2
OR JULY 1, {YEAR}, WHERE ‘YEAR’ IS THE SECOND
CALENDAR YEAR OF THE PANEL AND THE DATE OF THE
INTERVIEW IF ROUND 4.
- CL36 WAS CODED ‘1’ (COMPLETED AND GIVEN TO
INTERVIEWER), ‘2’ (NOT COMPLETED, WILL PICK UP
AT LATER DATE), ‘3’ (NOT COMPLETED, WILL MAIL
TO OFFICE),‘4’ (MAILED TO SAQ RESPONDENT), ‘5’
(REFUSED TO COMPLETE SAQ), OR ‘91’ (OTHER)
DURING ROUND 2 OR 4 FOR PERSON AND NOT UPDATED
BY RECEIPT CONTROL TO ‘1’ (COMPLETE), ‘2’
(PARTIAL COMPLETE), ‘4’ (PROBLEM), OR ‘6’ (WRONG
SAQ TYPE) ((I.E., RECEIPT CONTROL IS EQUAL TO
‘3’ (REFUSED) OR ‘5’ (NOT HERE/BLANK))

FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK
NAV_CL10 - END_LP10

LOOP DEFINITION: LOOP_10 COLLECTS THE SAQ STATUS
FOR EACH PERSON ELIGIBLE TO COMPLETE THE SAQ.
THIS LOOP CYCLES ON EACH PERSON ON THE RU-MEMBERS-
ROSTER WHO MEETS THE FOLLOWING CONDITIONS:
- PERSON IS KEY
- PERSON DID NOT HAVE A STATUS OF DECEASED OR
INSTITUTIONALIZED ON ROUND 2 OR 4 INTERVIEW DATE
- PERSON WAS CURRENTLY IN RU ON ROUND 2 OR 4
INTERVIEW DATE
- PERSON IS 18 YEARS OF AGE OR OLDER (OR IN AGE
CATEGORIES 4-9) ON JULY 1, {YEAR}, WHERE ‘YEAR’
IS THE FIRST CALENDAR YEAR OF THE PANEL, IF
ROUND 2, OR ON JULY 1, {YEAR}, WHERE ‘YEAR’ IS
THE SECOND CALENDAR YEAR OF THE PANEL, IF ROUND
4, OR HAS TURNED 18 BETWEEN JULY 1, {YEAR},
WHERE ‘YEAR’ IS THE FIRST CALENDAR YEAR OF THE
PANEL, AND THE DATE OF THE INTERVIEW IF ROUND 2
OR JULY 1, {YEAR}, WHERE ‘YEAR’ IS THE SECOND
CALENDAR YEAR OF THE PANEL AND THE DATE OF THE
INTERVIEW IF ROUND 4.
- CL36 WAS CODED ‘1’ (COMPLETED AND GIVEN TO
INTERVIEWER), ‘2’ (NOT COMPLETED, WILL PICK UP
AT LATER DATE), ‘3’ (NOT COMPLETED, WILL MAIL
TO OFFICE),‘4’ (MAILED TO SAQ RESPONDENT), ‘5’
(REFUSED TO COMPLETE SAQ), OR ‘91’ (OTHER)
DURING ROUND 2 OR 4 FOR PERSON AND NOT UPDATED
BY RECEIPT CONTROL TO ‘1’ (COMPLETE), ‘2’
(PARTIAL COMPLETE), ‘4’ (PROBLEM), OR ‘6’
(WRONG SAQ TYPE) ((I.E., RECEIPT CONTROL IS
EQUAL TO ‘3’ (REFUSED) OR ‘5’ (NOT HERE/BLANK))

NAVIGATOR DETAILS: LOOP_10 USES NAV_CL10 TO
CONTROL THE FLOW OF THE LOOP.

SERIES: SAQ Forms.

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.

SAQ Forms
[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: SAQ FORMS
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 RU MEMBERS WHO MEET THE CONDITIONS
STATED AT THE LOOP_10 DEFINITION.

CONTINUE WITH CL39 FOR SELECTED RU MEMBER.

{PERSON’S FIRST MIDDLE AND LAST NAME}

PID: {PID}

{SAQ STATUS FROM PREVIOUS ROUND: {PREVIOUS ROUND STATUS -40}}

COLLECT {PERSON}'s COMPLETED SAQ {AND EXPLAIN THAT THEY WILL RECEIVE
$5.00 FOR EACH COMPLETED SAQ}.

SELECT THE STATUS OF THE SAQ:

COMPLETED AND GIVEN TO INTERVIEWER ..... 1 {END_LP10}
NOT COMPLETED, WILL PICK UP AT
LATER DATE ........................... 2 {END_LP10}
NOT COMPLETED, WILL MAIL TO HOME OFFICE. 3 {END_LP10}
MAILED TO SAQ RESPONDENT ............... 4 {END_LP10}
REFUSED TO COMPLETE .................... 5 {CL40}
OTHER ................................. 91 {CL39OV}

[Code One]

DISPLAY THE PERSON’S 3-DIGIT PID FOR ‘PID’.

DISPLAY ‘SAQ STATUS FROM PREVIOUS ROUND’ {PREVIOUS
ROUND STATUS -40}’. OTHERWISE, USE A NULL
DISPLAY.

FOR ‘PREVIOUS ROUND STATUS-40’, DISPLAY THE TEXT
ASSOCIATED WITH THE ROUND 2 OR 4 (OR RECEIPT
CONTROL UPDATED STATUS) STATUS ENTERED AT CL36.
OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘AND EXPLAIN...SAQ’ IF PANEL 17, ROUND 5.
OTHERWISE, USE A NULL DISPLAY.

NOTE: STARTING IN PANEL 18, PAYMENT WILL NO
LONGER BE MADE FOR COMPLETED SAQ FORMS.

{PERSON’S FIRST MIDDLE AND LAST NAME}

SELECT MAIN REASON FOR REFUSAL:

TOO BUSY/NOT INTERESTED ................ 1 {END_LP10}
TOO PERSONAL/SENSITIVE INFORMATION ..... 2 {END_LP10}
TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP . 3 {END_LP10}
HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP10}
WANTS MORE INFORMATION ................. 5 {END_LP10}
NOT INTERESTED ......................... 6 {END_LP10}
NO REASON GIVEN ........................ 7 {END_LP10}
OTHER ................................. 91 {CL40OV}

[Code One]

OTHER REASON FOR REFUSAL:

[Enter Other Specify-45] ................. {END_LP10}

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

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_10 AND CONTINUE WITH BOX_16A

SUBSECTION 5A: DIABETES CARE SUPPLEMENT (DCS)
QUESTIONNAIRE (ROUNDS 3 AND 5 ONLY)

IF ROUND 3 OR 5, CONTINUE WITH BOX_16B

OTHERWISE, GO TO CL41

IF ROUND 3 OR 5 AND AT LEAST ONE RU MEMBER
ELIGIBLE FOR DIABETES CARE SUPPLEMENT (I.E., AT
LEAST ONE RU MEMBER WHO IS CONFIRMED AS HAVING
DIABETES AT PC02A), CONTINUE WITH CL40A

OTHERWISE, GO TO BOX_16C

SELF DIABETES CARE SUPPLEMENT (DCS):

Earlier we asked (READ SELF NAMES BELOW) to complete
a few questions about the care received for diabetes.

PROXY DCS:

Earlier we asked that someone knowledgeable about
(READ PROXY NAMES BELOW) diabetes complete a few
questions about the care received.

AS APPROPRIATE, COLLECT A DCS FOR EACH PERSON LISTED ABOVE.

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

DISPLAY THE ROW PERSON’S PID FOR ‘PID’.

DISPLAY THE TYPE OF DCS FOR THE PERSON FOR
‘SELF/PROXY’. IF PC03 FOR THE ROW PERSON IS CODED
‘1’ (SELF), DISPLAY ‘SELF.’ IF PC03 FOR THE ROW
PERSON IS CODED ‘2’ (PROXY), DISPLAY ‘PROXY.’

ROSTER DETAILS:
TITLE: RU-MEMBERS_9

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

COL # 2 HEADER: PID
INSTRUCTIONS: DISPLAY RU MEMBERS’ 3-DIGIT ID
(PERS.PID)

ROSTER DEFINITION:
DISPLAY ALL PERSONS ON THE RU-MEMBERS-ROSTER FOR
DISPLAY ONLY.

ROSTER BEHAVIOR:
1. DISPLAY ONLY.
2. SELECT, ADD, EDIT, DELETE DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS WHO MEET THE FOLLOWING
CONDITION:

- PC02A IS CODED ‘1’ (CONTINUE) FOR THE PERSON

FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK
NAV-CL10A – END_LP10A

LOOP DEFINITION: LOOP_10A COLLECTS THE DCS STATUS
FOR EACH PERSON ELIGIBLE TO COMPLETE THE DCS.
THIS LOOP CYCLES ON EACH PERSON ON THE RU-
MEMBERS-ROSTER WHO MEETS THE FOLLOWING CONDITION:

- PC02A IS CODED ‘1’ (CONTINUE) FOR THE PERSON

NAVIGATOR DETAILS: LOOP_10A USES NAV_CL10A TO
CONTROL THE FLOW OF THE LOOP.

SERIES: DCS Forms.

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.

DCS Forms

[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: DCS FORMS
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 RU MEMBERS WHO MEET THE CONDITIONS
STATED AT THE LOOP_10A DEFINITION.

CONTINUE WITH CL40B FOR SELECTED RU MEMBER.

{PERSON’S FIRST MIDDLE AND LAST NAME}

PID: {PID} TYPE OF DCS: {SELF/PROXY}

COLLECT {PERSON}’S COMPLETED DIABETES CARE SUPPLEMENT

IF {PERSON} NOT AVAILABLE OR NOT ABLE TO COMPLETE DCS AT
THIS TIME, LEAVE DCS WITH {HIM/HER} OR RESPONDENT AND EXPLAIN
INSTRUCTIONS.

SELECT THE STATUS OF THE DCS:

COMPLETED AND GIVEN TO INTERVIEWER ..... 1 {END_LP10A}
NOT COMPLETED, WILL PICK UP AT
LATER DATE ........................... 2 {END_LP10A}
NOT COMPLETED, WILL MAIL TO OFFICE ..... 3 {END_LP10A}
MAILED TO DCS RESPONDENT ............... 4 {END_LP10A}
REFUSED TO COMPLETE .................... 5 {CL40C}
OTHER ................................. 91 {CL40BOV}

[Code One]

DISPLAY THE PERSON’S 3-DIGIT PID FOR ‘PID’.

FOR ‘SELF/PROXY’, DISPLAY ‘SELF’ IF THE PERSON
BEING LOOPED ON IS CODED ‘1’ (SELF) AT PC03.
DISPLAY ‘PROXY’ IF THE PERSON BEING LOOPED ON
IS CODED ‘2’ (PROXY) AT PC03.

SOFT CHECK:
CODE ‘4’ (MAILED TO DCS RESPONDENT) MUST BE
VERIFIED (ENTERED TWICE) IF RU IS NOT A STUDENT
RU. IF CODE ‘4’ SELECTED AND RU IS NOT A STUDENT
RU, DISPLAY THE FOLLOWING MESSAGE: ‘UNLIKELY
RESPONSE. VERIFY AND RE-ENTER.’

{PERSON’S FIRST MIDDLE AND LAST NAME}

SELECT MAIN REASON FOR REFUSAL:

TOO BUSY/NOT INTERESTED ................ 1 {END_LP10A}
TOO PERSONAL/SENSITIVE INFORMATION ..... 2 {END_LP10A}
TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP . 3 {END_LP10A}
HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP10A}
WANTS MORE INFORMATION ................. 5 {END_LP10A}
NOT INTERESTED ......................... 6 {END_LP10A}
NO REASON GIVEN ........................ 7 {END_LP10A}
OTHER ................................. 91 {CL40COV}

[Code One]

OTHER REASON FOR REFUSAL:

[Enter Other Specify-45] ................. {END_LP10A}

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

IF NO OTHER PERSONS MEET THE STATED CONDITION,
END LOOP_10A AND CONTINUE WITH BOX_16C

SUBSECTION 5B: CANCER SAQ QUESTIONNAIRE (ROUNDS 3
AND 5 ONLY)

IF PANEL 16 ROUND 3 OR PANEL 15 ROUND 5, CONTINUE
WITH BOX_16D

OTHERWISE, GO TO BOX_16E

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.

IF PANEL 16 ROUND 3 OR PANEL 15 ROUND 5 AND AT
LEAST ONE RU MEMBER ELIGIBLE FOR CANCER SAQ
(I.E., AT LEAST ONE RU MEMBER WHO IS CONFIRMED AS
HAVING CANCER AT PC04), CONTINUE WITH CL40D

OTHERWISE, GO TO BOX_16E

CANCER SAQ FOLLOW-UP:

Earlier we asked (READ NAMES BELOW) to complete a short
survey about their experience with cancer.

AS APPROPRIATE, COLLECT A CANCER SAQ FOR EACH PERSON LISTED ABOVE.

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

ROSTER DEFINITION:
DISPLAY ALL PERSONS ON THE RU-MEMBERS-ROSTER FOR
DISPLAY ONLY.

ROSTER BEHAVIOR:
1. DISPLAY ONLY.
2. SELECT, ADD, EDIT, DELETE DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS WHO MEET THE FOLLOWING
CONDITION:

- PC04 IS CODED ‘1’ (CONTINUE) FOR THE PERSON

FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK
NAV-CL10B – END_LP10B

LOOP DEFINITION: LOOP_10B COLLECTS THE CANCER
SAQ STATUS FOR EACH PERSON ELIGIBLE TO COMPLETE
THE CANCER SAQ. THIS LOOP CYCLES ON EACH PERSON
ON THE RU-MEMBERS-ROSTER WHO MEETS THE FOLLOWING
CONDITION:

- PC04 IS CODED ‘1’ (CONTINUE) FOR THE PERSON

NAVIGATOR DETAILS: LOOP_10B USES NAV_CL10B TO
CONTROL THE FLOW OF THE LOOP.

SERIES: Cancer SAQ Forms.

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.

Cancer SAQ Forms

[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: CANCER SAQ FORMS
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 RU MEMBERS WHO MEET THE CONDITIONS
STATED AT THE LOOP_10B DEFINITION.

CONTINUE WITH CL40E FOR SELECTED RU MEMBER.

{PERSON’S FIRST MIDDLE AND LAST NAME}

PID: {PID}

COLLECT {PERSON}’S COMPLETED CANCER SAQ.

IF {PERSON} NOT AVAILABLE OR NOT ABLE TO COMPLETE CANCER SAQ AT
THIS TIME, LEAVE CANCER SAQ WITH {HIM/HER} OR RESPONDENT AND EXPLAIN
INSTRUCTIONS.

SELECT THE STATUS OF THE CANCER SAQ:

COMPLETED AND GIVEN TO INTERVIEWER ..... 1 {END_LP10B}
NOT COMPLETED, WILL PICK UP AT
LATER DATE ........................... 2 {END_LP10B}
NOT COMPLETED, WILL MAIL TO HOME
OFFICE ............................... 3 {END_LP10B}
MAILED TO CANCER SAQ RESPONDENT ........ 4 {END_LP10B}
REFUSED TO COMPLETE .................... 5 {CL40F}
OTHER ................................. 91 {CL40EOV}

[Code One]

DISPLAY THE PERSON’S 3-DIGIT PID FOR ‘PID’.

SOFT CHECK:
CODE ‘4’ (MAILED TO CANCER SAQ RESPONDENT) MUST BE
VERIFIED (ENTERED TWICE) IF RU IS NOT A STUDENT
RU. IF CODE ‘4’ SELECTED AND RU IS NOT A STUDENT
RU, DISPLAY THE FOLLOWING MESSAGE: ‘UNLIKELY
RESPONSE. VERIFY AND RE-ENTER.’

{PERSON’S FIRST MIDDLE AND LAST NAME}

SELECT MAIN REASON FOR REFUSAL:

TOO BUSY/NOT INTERESTED ................ 1 {END_LP10B}
TOO PERSONAL/SENSITIVE INFORMATION ..... 2 {END_LP10B}
TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP . 3 {END_LP10B}
HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP10B}
WANTS MORE INFORMATION ................. 5 {END_LP10B}
NOT INTERESTED ......................... 6 {END_LP10B}
NO REASON GIVEN ........................ 7 {END_LP10B}
OTHER ................................. 91 {CL40FOV}

[Code One]

OTHER REASON FOR REFUSAL:

[Enter Other Specify-45] ................. {END_LP10B}

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

IF NO OTHER PERSONS MEET THE STATED CONDITION,
END LOOP_10B AND GO TO BOX_16E

BOX_16E BEGINS SUBSECTION 5B: COLLECTING/UPDATING
PREVENTIVE CARE SAQ STATUS (ROUND 5)

SUBSECTION 5B: PREVENTIVE CARE SELF-
ADMINISTERED QUESTIONNAIRE (ROUND 5)

IF ROUND 5 AND AT LEAST ONE RU MEMBER ELIGIBLE
FOR PREVENTIVE CARE SAQ (I.E., AT LEAST ONE
CURRENT RU MEMBER WHO DOES NOT HAVE ROUND 5 STATUS
OF DECEASED OR INSTITUTIONALIZED WAS SAMPLED),
CONTINUE WITH CL40AA

OTHERWISE, GO TO CL41

NOTE: THERE WILL BE NO FOLLOW-UP ON THE
PREVENTIVE CARE SAQS. COLLECTION INFORMATION IN
ROUND 5 WILL BE BASED ONLY ON PRELOADED SAMPLE
INFORMATION. THAT IS, NO RU MEMBERS ADDED IN ROUND
5 WILL BE ASKED TO COMPLETE A PREVENTIVE CARE
SAQ.

(Not long ago), we mailed a short {blue/purple} questionnaire about
health choices to (READ PERSON NAMES BELOW).

I want to check if (READ NAMES BELOW) completed that questionnaire
already or needs a replacement.

1. COLLECT BLUE PREVENTIVE CARE SAQ FROM MALES.
COLLECT PURPLE PREVENTIVE CARE SAQ FROM FEMALES.

2. IF INCORRECT COLOR PREVENTIVE CARE SAQ COMPLETED, GIVE CORRECT
COLOR.

3. IF ANY REPORTED AS LOST, RE-DISTRIBUTE APPROPRIATE
NUMBER AND TYPE OF SAQs TO THE RESPONDENT.

HELP AVAILABLE FOR MORE INFORMATION ON PREVENTIVE CARE SAQ COLLECTION.

DISPLAY ‘blue’ IF PERSON BEING ASKED ABOUT IS
MALE. DISPLAY ‘purple’ IF PERSON BEING ASKED
ABOUT IS FEMALE. IF MULTIPLE PERSONS OF DIFFERENT
SEXES ARE BEING ASKED ABOUT, USE A NULL DISPLAY.

ROSTER DEFINITION:
DISPLAY PERSONS ON THE RU-MEMBERS-ROSTER FOR
DISPLAY ONLY.

ROSTER BEHAVIOR:
1. DISPLAY ONLY.
2. SELECT, EDIT, ADD, DELETE DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS ON THE RU-MEMBERS-ROSTER WHO
MEET THE FOLLOWING CONDITIONS:
- PERSON MARKED WITH THE IN-SAMPLE INDICATOR
- PERSON CURRENTLY IN RU ON ROUND 5 INTERVIEW DATE
- PERSON DOES NOT HAVE A STATUS OF DECEASED OR
INSTITUTIONALIZED ON ROUND 5 INTERVIEW DATE

FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK
NAV_CL10C - END_LP10C

LOOP DEFINITION: LOOP_10C COLLECTS THE
YOUR CHOICES ABOUT YOUR HEALTH SAQ STATUS FOR EACH
PERSON ELIGIBLE TO COMPLETE THIS SAQ. THIS LOOP
CYCLES ON EACH PERSON ON THE RU-MEMBERS-ROSTER WHO
MEETS THE FOLLOWING CONDITIONS:
- RU MEMBER MARKED WITH THE IN-SAMPLE INDICATOR
- PERSON CURRENTLY IN RU ON ROUND 5 INTERVIEW DATE
- PERSON DOES NOT HAVE A STATUS OF DECEASED OR
INSTITUTIONALIZED ON ROUND 5 INTERVIEW DATE

NAVIGATOR DETAILS: LOOP_10C USES NAV_CL10C TO
CONTROL THE FLOW OF THE LOOP.

SERIES: Your Choices About Your Health SAQ.

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.

"Your Choices About Your Health" SAQ

[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: YOUR CHOICES ABOUT YOUR HEALTH
SAQ FORMS
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 RU MEMBERS WHO MEET THE CONDITIONS
STATED AT THE LOOP_10C DEFINITION.

CONTINUE WITH CL40AAA FOR SELECTED RU MEMBER.

{PERSON’S FIRST MIDDLE AND LAST NAME}

DOB: [MM/DD/YYYY] PID: [PID-3] RU ID: [RUID-7]

COLLECT {PERSON}’S COMPLETED "YOUR CHOICES ABOUT YOUR HEALTH" SAQ.
IF {PERSON} NOT AVAILABLE OR NOT ABLE TO COMPLETE THIS SAQ AT THIS
TIME, LEAVE {MALE=BLUE/FEMALE=PURPLE} "YOUR CHOICES ABOUT YOUR
HEALTH" SAQ WITH {HIM/HER} OR RESPONDENT AND EXPLAIN SAQ INSTRUCTIONS.

SELECT THE STATUS OF THE SAQ:

COMPLETED AND GIVEN TO INTERVIEWER ..... 1 {END_LP10C}
NOT COMPLETED, WILL PICK UP AT
LATER DATE ........................... 2 {END_LP10C}
NOT COMPLETED, WILL MAIL TO HOME OFFICE. 3 {END_LP10C}
MAILED TO SAQ RESPONDENT ............... 4 {END_LP10C}
REFUSED TO COMPLETE .................... 5 {CL40AAAA}
OTHER ................................. 91 {CL40AAAOV}

[Code One]

DISPLAY THE PERSON’S 3-DIGIT PID FOR ‘PID’.

DISPLAY ‘MALE=BLUE’ AND ‘HIM’ IF PERSON BEING
ASKED ABOUT IS MALE. DISPLAY ‘FEMALE=PURPLE’
AND ‘HER’ IF PERSON BEING ASKED ABOUT IS FEMALE.

{PERSON’S FIRST MIDDLE AND LAST NAME}

SELECT MAIN REASON FOR REFUSAL:

TOO BUSY/NOT INTERESTED ................ 1 {END_LP10C}
TOO PERSONAL/SENSITIVE INFORMATION ..... 2 {END_LP10C}
TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP . 3 {END_LP10C}
HAS ALREADY GIVEN ENOUGH INFORMATION ... 4 {END_LP10C}
WANTS MORE INFORMATION ................. 5 {END_LP10C}
NOT INTERESTED ......................... 6 {END_LP10C}
NO REASON GIVEN ........................ 7 {END_LP10C}
OTHER ................................. 91 {CL40_4OV}

[Code One]

OTHER REASON FOR REFUSAL:

[Enter Other Specify-45] ................. {END_LP10C}

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

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_10C AND GO TO CL41

CL41 BEGINS SUBSECTION 6: COLLECTING/UPDATING
LOCATING INFORMATION (ROUND 1 THROUGH ROUND 5)

{In the coming months, we will be contacting you again to collect
information on health care use and expenses./We are nearing the end
of this study. I’d like to verify a few pieces of information in case
my supervisor needs to reach you to confirm that I was here and
collected this information correctly.}

{Just to make sure I can reach you for the next interview, I’d
like to ask a few questions to help locate you in case you move./
Let me quickly review and update the information we have for
locating you that was collected during the last
interview.}

PRESS ENTER OR SELECT NEXT PAGE TO CONTINUE.

DISPLAY ‘In the coming months, ... use and
expenses.’ IF ROUNDS 1, 2, 3, OR 4. OTHERWISE,
DISPLAY ‘We are nearing ... correctly.’

DISPLAY ‘Just ... move.’ IF ROUND 1. OTHERWISE,
DISPLAY ‘Let ... interview.’

IF NOT ROUND 5, CONTINUE WITH CL42

OTHERWISE (I.E., IF ROUND 5), GO TO BOX_17

What is the best time of day and day of the week to get in
touch with you?

ENTER BEST TIME TO CONTACT RESPONDENT/PROXY.
RECORD VERBATIM. TO LEAVE BOX, PRESS TAB.

[Enter Text] ............................. {CL42OV1}

SELECT WHO BEST TIME RECORDED FOR:

CURRENT RESPONDENT ..................... 1 {BOX_17}
CURRENT PROXY .......................... 2 {BOX_17}
ENTIRE RU .............................. 3 {BOX_17}
OTHER ................................. 91 {CL42OV2}

[Code One]

NOTE: CL42OV1 IS ALWAYS DISPLAYED ON THE SCREEN
WITH CL42. IT IS NOT A TRUE ‘OVERLAY’.

IF NO CURRENT RU MEMBER PART OF THE RU ON THE
CURRENT INTERVIEW DATE (I.E., ALL RU MEMBERS
DECEASED, INSTITUTIONALIZED, OR OUT OF THE COUNTRY
ON CURRENT INTERVIEW DATE), GO TO BOX_18

OTHERWISE, CONTINUE WITH BOX_17AA

IF ROUND 1, GO TO CL42B

IF ROUNDS 2-5, AND THERE IS AN EMAIL ADDRESS
LINKED TO THE PID OF THE CURRENT RESPONDENT OR THE
CURRENT PROXY, CONTINUE WITH CL42A

OTHERWISE (I.E., IF ROUNDS 2-5 AND THE CURRENT
RESPONDENT OR THE CURRENT PROXY DOES NOT HAVE AN
EMAIL LINKED TO THEIR PID), GO TO CL42B

Is this still the best email address to contact you to
schedule appointments and send MEPS interview reminders?

Current Info: [EMAIL_ADDRESS]

YES .................................... 1 {CL42E}
NO, UPDATE EMAIL ADDRESS ............... 2 {CL42C}
NO, NO EMAIL ADDRESS ................... 3 {CL43}
REF ................................... -7 {CL43}
DK .................................... -8 {CL43}

[Code One]

FOR ‘EMAIL_ADDRESS’ DISPLAY THE EMAIL ADDRESS
ASSOCIATED WITH THE PID OF THE CURRENT RESPONDENT.

IF CODED ‘3’ (NO, NO EMAIL ADDRESS), ‘-7’ (REF)
OR ‘-8’ (DK), DELETE THE EMAIL ADDRESS ASSOCIATED
WITH THE PID OF THE CURRENT RESPONDENT.

Do you send or receive emails?

YES .................................... 1 {CL42C}
NO ..................................... 2 {CL43}
REF ................................... -7 {CL43}
DK .................................... -8 {CL43}

{What is your new email address?/We’d like to contact you
by email to help schedule the next interview and send an
interview reminder. May I have your email address?}

ENTER COMPLETE EMAIL ADDRESS. CONFIRM SPELLING.

EMAIL ADDRESS: [_____________] {CL42D}
REF ................................... -7 {CL43}
DK .................................... -8 {CL43}

DISPLAY ‘What is your new email address?’ IF CL42A
IS CODED ‘2’ (NO, UPDATE EMAIL ADDRESS). DISPLAY
‘We’d like to ... your email address?’ IF CL42B
IS CODED ‘1’ (YES).

ALLOW A 50 CHARACTER ENTRY INCLUDING ALPHA AND
NUMERIC CHARACTERS AS WELL AS SYMBOLS.

HARD CHECK:
EDITS: EMAIL ADDRESS MUST CONTAIN AN ‘@’ SYMBOL.
IF ENTRY DOES NOT INCLUDE THIS SYMBOL, DISPLAY THE
FOLLOWING MESSAGE: "EMAIL ADDRESS MUST CONTAIN
AN ‘@’ SYMBOL. VERIFY AND RE-ENTER."

EMAIL ADDRESS MUST NOT CONTAIN ANY SPACES.
IF ENTRY INCLUDES A SPACE, DISPLAY THE FOLLOWING
MESSAGE: "EMAIL ADDRESS CANNOT CONTAIN BLANK
SPACES. VERIFY AND RE-ENTER."

LINK EMAIL ADDRESS COLLECTED TO PID OF RESPONDENT
SELECTED AT RE06/RE08 OR PROXY SELECTED AT
RE07/RE08 FOR THE CURRENT ROUND.

Is that your personal e-mail, work e-mail, a family or shared
e-mail address, or some other type of email account?

PERSONAL ............................... 1 {CL42E}
WORK ................................... 2 {CL42E}
FAMILY/SHARED .......................... 3 {CL42E}
OTHER TYPE ............................ 91 {CL42DOV}
REF ................................... -7 {CL42E}
DK .................................... -8 {CL42E}

[Code One]

SPECIFY TYPE OF EMAIL ACCOUNT:

[Enter Other Specify] .................. {CL42E}
REF ................................... -7 {CL42E}
DK .................................... -8 {CL42E}

How often do you check this email account?

PROBE: How many times per day, per week, per month, per
year do you check this email account?

NUMBER:

[Enter Number of Times-3] .............. {CL42EOV1}
REF ................................... -7 {CL43}
DK .................................... -8 {CL43}

PER PERIOD:

PER DAY ................................ 1 {CL43}
PER WEEK ............................... 2 {CL43}
PER MONTH .............................. 3 {CL43}
PER YEAR ............................... 4 {CL43}
REF ................................... -7 {CL43}
DK .................................... -8 {CL43}

[Code One]

Do you have a second phone number where you can be reached
such as a cell phone, a work number, or the number of a
friend or relative?

IF AVAILABLE, VERIFY CURRENT SECOND PHONE SHOWN BELOW.

Current Info: [2ND_TELEPHONE]

YES, ENTER NEW SECOND PHONE ............ 1 {CL44}
YES, SECOND PHONE ABOVE CORRECT ........ 2 {CL46}
YES, SECOND PHONE ABOVE NEEDS
CORRECTION ........................... 3 {CL44_2}
NO ..................................... 4 {CL46}
REF ................................... -7 {CL46}
DK .................................... -8 {CL46}

ASSUMPTION: THE QUESTIONS IN CLOSING IN WHICH
CONTACT AND LOCATING INFORMATION IS PRE-RECORDED
IN CAPI (CL43-CL64) ARE SPECIFIED WITH THE
FOLLOWING BASIC ASSUMPTIONS:
1. LOCATING AND CONTACTING INFORMATION WILL NOT BE
WRITTEN OVER FROM ROUND TO ROUND.
2. ONLY THE MOST CURRENT INFORMATION WILL APPEAR
IN THE TEXT OF THESE QUESTIONS AND NO HISTORY
OF CONTACT AND LOCATING INFORMATION WILL APPEAR
ON THE CAPI SCREEN FOR THE INTERVIEWER.
3. IF INFORMATION STAYS THE SAME, IT WILL BE
CARRIED FORWARD.
4. WHETHER OR NOT PREVIOUS ROUND’S INFORMATION OR
ANY CONTACT HISTORY WILL BE PRINTED ON THE FACE
SHEET FOR ANY OF THE CONTACTING AND LOCATING
QUESTIONS IS STILL NOT KNOWN.

HARD CHECK:
CODES ‘2’ (YES, SECOND PHONE ABOVE CORRECT) AND
‘3’ (YES, SECOND PHONE ABOVE NEEDS CORRECTION)
CANNOT BE SELECTED IF NO CURRENT SECOND PHONE
INFORMATION AVAILABLE. IF CODES ‘2’ OR ‘3’
SELECTED WHEN NO CURRENT SECOND PHONE, DISPLAY
THE FOLLOWING MESSAGE: ‘CODE NOT AVAILABLE. NO
CURRENT SECOND PHONE. VERIFY AND RE-ENTER.’

[What is that telephone number?]

ENTER COMPLETE SECOND TELEPHONE NUMBER.

Current Info: [2ND_TELEPHONE]

[Enter Area Code,Exchange,Local] ...... {CL45}
REF ................................... -7 {CL45}
DK .................................... -8 {CL45}

FLAG SECOND PHONE INFORMATION FOR THE RU WITH THE
NUMBER ENTERED OR CORRECTED AT CL44 FOR THE
CURRENT ROUND.

HARD CHECK:
DISALLOW LEADING ZEROES AS AN ENTRY.

AN ENTRY MUST BE MADE FOR EVERY FIELD (REF AND DK
ARE ALLOWED).

[What is that telephone number?]

UPDATE CURRENT SECOND PHONE.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

Current Info: [2ND_TELEPHONE]

[Enter Area Code,Exchange,Local] ...... {CL45}
REF ................................... -7 {CL45}
DK .................................... -8 {CL45}

FLAG SECOND PHONE INFORMATION FOR THE RU WITH THE
NUMBER ENTERED OR CORRECTED AT CL44 FOR THE
CURRENT ROUND.

HARD CHECK:
DISALLOW LEADING ZEROS AS AN ENTRY.

Where is that telephone located?

OFFICE/PLACE OF BUSINESS ............... 1 {CL45OV2}
RELATIVE ............................... 2 {CL45OV2}
NEIGHBOR ............................... 3 {CL45OV2}
FRIEND ................................. 4 {CL45OV2}
CELL PHONE ............................. 5 {CL45OV2}
OTHER ..................................91 {CL45OV1}
REF ................................... -7 {CL45OV2}
DK .................................... -8 {CL45OV2}

[Code One]

SPECIFY:

[Enter Other Specify-45] .............. {CL45OV2}
REF ................................... -7 {CL45OV2}
DK .................................... -8 {CL45OV2}

ENTER NAME AND/OR DESCRIPTION OF SECOND PHONE. ALSO, INCLUDE
ANY SPECIAL INSTRUCTIONS FOR CALLING AT THE ALTERNATE TELEPHONE
NUMBER (FOR EXAMPLE, CALL ONLY IN EMERGENCY).

[Enter Description] ................... {CL46}
REF ................................... -7 {CL46}
DK .................................... -8 {CL46}

ALLOW 2 LINES OF 45 CHARACTERS FOR DESCRIPTION.

Do you receive your mail at an address different from your home
address, such as a P.O. Box?

IF AVAILABLE, VERIFY CURRENT MAILING ADDRESS SHOWN BELOW.

Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY]
[STATE]
[ZIP CODE]

YES, ENTER NEW MAILING ADDRESS
(DIFFERENT FROM HOME ADDRESS) ........ 1 {CL47}
YES, MAILING ADDRESS ABOVE CORRECT ..... 2 {BOX_17A}
YES, MAILING ADDRESS ABOVE NEEDS
CORRECTION ........................... 3 {CL47_2}
NO (RECEIVE MAIL AT HOME ADDRESS) ...... 4 {BOX_17A}
REF ................................... -7 {BOX_17A}
DK .................................... -8 {BOX_17A}

HARD CHECK:
CODES ‘2’ (YES, MAILING ADDRESS ABOVE CORRECT)
AND ‘3’ (YES, MAILING ADDRESS ABOVE NEEDS
CORRECTION) CANNOT BE SELECTED IF NO CURRENT
MAILING ADDRESS INFORMATION AVAILABLE. IF CODES
‘2’ OR ‘3’ SELECTED WHEN NO CURRENT MAILING
ADDRESS, DISPLAY THE FOLLOWING MESSAGE: ‘CODE
NOT AVAILABLE. NO CURRENT MAILING ADDRESS.
VERIFY AND RE-ENTER.’

[What is that address?]

ENTER COMPLETE MAILING ADDRESS.

Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY],[STATE] [ZIP CODE]

1ST_STR_ADDRESS: [_____________]
2ND_STR_ADDRESS: [_____________]
CITY: [_____________]
STATE: [_____________]
ZIP CODE: [_____________] {BOX_17A}

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

CONTINUE WITH BOX_17A

HARD CHECK:
AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT
SECOND STREET ADDRESS (REF AND DK ARE ALLOWED).

[What is that address?]

USE TAB TO MOVE THROUGH FIELDS REQUIRING NO CORRECTION.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

TYPE THREE Xs (XXX) TO DELETE 2ND STREET ADDRESS.

Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY],[STATE] [ZIP CODE]

1ST_STR_ADDRESS: [_____________]
2ND_STR_ADDRESS: [_____________]
CITY: [_____________]
STATE: [_____________]
ZIP CODE: [_____________] {BOX_17A}

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

IF NOT ROUND 5, CONTINUE WITH CL48

OTHERWISE (I.E., IF ROUND 5), GO TO BOX_18

Do you have a second home, such as a vacation home, where we
could contact you if you’re not available at your usual
address?

IF AVAILABLE, VERIFY CURRENT SECOND HOME INFORMATION SHOWN BELOW.

Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]

YES, ENTER NEW SECOND HOME ADDRESS AND
TELEPHONE ............................ 1 {CL49}
YES, SECOND HOME ADDRESS AND TELEPHONE
ABOVE CORRECT ........................ 2 {CL50}
YES, SECOND HOME ADDRESS OR TELEPHONE
ABOVE NEEDS CORRECTION ............... 3 {CL49_2}
NO ..................................... 4 {CL50}
REF ................................... -7 {CL50}
DK .................................... -8 {CL50}

HARD CHECK:
CODES ‘2’ (YES, SECOND HOME ADDRESS AND TELEPHONE
ABOVE CORRECT) AND ‘3’ (YES, SECOND HOME ADDRESS
OR TELEPHONE ABOVE NEEDS CORRECTION) CANNOT BE
SELECTED IF NO CURRENT SECOND HOME ADDRESS
INFORMATION AVAILABLE. IF CODES ‘2’ OR ‘3’
SELECTED WHEN NO CURRENT SECOND HOME ADDRESS,
DISPLAY THE FOLLOWING MESSAGE: ‘CODE NOT
AVAILABLE. NO CURRENT SECOND HOME ADDRESS.
VERIFY AND RE-ENTER.’

[What is the address and phone number of that home?]

ENTER COMPLETE SECOND HOME ADDRESS.

Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]

1ST_STR_ADDRESS: [_____________]
2ND_STR_ADDRESS: [_____________]
CITY: [_____________]
STATE: [_____________]
ZIP CODE: [_____________]
TELEPHONE: [_____________]{CL50}

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

HARD CHECK:
AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT
SECOND STREET ADDRESS (REF AND DK ARE ALLOWED).

[What is the address and phone number of that home?]

USE TAB TO MOVE THROUGH FIELDS REQUIRING NO CORRECTION.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

TYPE THREE Xs (XXX) TO DELETE 2ND STREET ADDRESS.

Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]

1ST_STR_ADDRESS: [_____________]
2ND_STR_ADDRESS: [_____________]
CITY: [_____________]
STATE: [_____________]
ZIP CODE: [_____________]
TELEPHONE: [_____________]{CL50}

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

Do you have a friend or relative who does not live here who will
always know how to get in touch with the family?

IF AVAILABLE, VERIFY CURRENT CONTACT INFORMATION SHOWN BELOW.

Current Info: [CONTACT_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
[RELATIONSHIP]

YES, ENTER NEW CONTACT PERSON/INFORMATION .. 1 {CL51}
YES, CONTACT PERSON/ADDRESS ABOVE CORRECT .. 2 {CL52}
YES, CONTACT PERSON/ADDRESS ABOVE NEEDS
CORRECTION ............................... 3 {CL51_2}
NO CONTACT PERSON AVAILABLE ................ 4 {CL53}
REF ....................................... -7 {CL53}
DK ........................................ -8 {CL53}

HARD CHECK:
CODES ‘2’ (YES, CONTACT PERSON/ADDRESS ABOVE
CORRECT) AND ‘3’ (YES, CONTACT PERSON/ADDRESS
ABOVE NEEDS CORRECTION) CANNOT BE SELECTED IF NO
CURRENT CONTACT PERSON INFORMATION AVAILABLE. IF
CODES ‘2’ OR ‘3’ SELECTED WHEN NO CURRENT CONTACT
INFORMATION, DISPLAY THE FOLLOWING MESSAGE: ‘CODE
NOT AVAILABLE. NO CURRENT CONTACT INFORMATION.
VERIFY AND RE-ENTER.’

NOTE: BEGINNING IN PANEL 17 ROUND 1, PANEL 16
ROUND 3, AND PANEL 14 ROUND 5 AND FOR ALL FUTURE
ROUNDS MEPS NO LONGER COLLECTS OR DISPLAYS THE
CONTACT PERSON’S MIDDLE NAME (HOME.CONTMNAM) IN
CAPI OR IN THE IMS.

[What is the name, address, and phone number of that person?]

[PROBE: What is (his/her) relationship to {NAME OF REFERENCE PERSON}?]

ENTER COMPLETE CONTACT INFORMATION.

Current Info: [NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
[RELATIONSHIP]

NAME [FIRST, LAST] [_____________]
1ST_STR_ADDRESS [_____________]
2ND_STR_ADDRESS [_____________]
CITY [_____________]
STATE [_____________]
ZIP CODE [_____________]
TELEPHONE [_____________]
RELATIONSHIP [_____________]

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

DISPLAY THE NAME OF THE REFERENCE PERSON FOR THE
RU FOR ‘NAME OF REFERENCE PERSON’.

HARD CHECK:
AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT
SECOND STREET ADDRESS (REF AND DK ARE ALLOWED).

[What is the name, address, and phone number of that person?]

[PROBE: What is (his/her) relationship to {NAME OF REFERENCE PERSON}?]

USE TAB TO MOVE THROUGH FIELDS REQUIRING NO CORRECTION.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

TYPE THREE Xs (XXX) TO DELETE 2ND STREET ADDRESS.

Current Info: [CONTACT_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]
[RELATIONSHIP]

CONTACT_NAME: [_____________]
1ST_STR_ADDRESS: [_____________]
2ND_STR_ADDRESS: [_____________]
CITY: [_____________]
STATE: [_____________]
ZIP CODE: [_____________]
TELEPHONE: [_____________]
RELATIONSHIP: [_____________]

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

DISPLAY THE NAME OF THE REFERENCE PERSON FOR THE
RU FOR ‘NAME OF REFERENCE PERSON’.

If you are not available for the next interview, who would be the best
person to provide information about the family for the next interview?

IF AVAILABLE, VERIFY CURRENT ALTERNATE RESPONDENT INFORMATION SHOWN
BELOW.

Current Info: [ALTERNATE_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]

ENTER NEW ALTERNATE RESPONDENT
INFORMATION .......................... 1 {CL54}
ALTERNATE RESPONDENT INFORMATION ABOVE
CORRECT .............................. 2 {CL56}
ALTERNATE RESPONDENT INFORMATION ABOVE
NEEDS CORRECTION ..................... 3 {CL54}
NO ALTERNATE RESPONDENT AVAILABLE ...... 4 {CL57}
REF ................................... -7 {CL57}
DK .................................... -8 {CL57}

IF CURRENT ALTERNATE RESPONDENT IS A DU MEMBER,
DO NOT DISPLAY CURRENT ADDRESS AND PHONE
INFORMATION. ONLY DISPLAY CURRENT ADDRESS AND
PHONE INFORMATION IF CURRENT ALTERNATE RESPONDENT
IS OUTSIDE OF THE DU.

HARD CHECK:
CODES ‘2’ (ALTERNATE RESPONDENT INFORMATION
CORRECT) AND ‘3’ (ALTERNATE RESPONDENT INFORMATION
NEEDS CORRECTION) CANNOT BE SELECTED IF NO CURRENT
ALTERNATE RESPONDENT INFORMATION AVAILABLE. IF
CODES ‘2’ OR ‘3’ SELECTED WHEN NO CURRENT
ALTERNATE RESPONDENT INFORMATION, DISPLAY THE
FOLLOWING MESSAGE: ‘RESPONSE NOT AVAILABLE. NO
NO CURRENT ALTERNATE INFORMATION. VERIFY AND
RE-ENTER.’

INTERVIEWER: SELECT PERSON NAMED FROM ROSTER.

[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]

IF ‘SOMEONE OUTSIDE DU’ SELECTED AND CL53 IS
‘ENTER NEW ALTERNATE RESPONDENT INFORMATION,
CONTINUE WITH CL55.
ELSE IF ‘SOMEONE OUTSIDE DU’ SELECTED AND CL53 IS
‘ALTERNATE RESPONDENT INFORMATION NEEDS
CORRECTION’, CONTINUE WITH CL55_2.

OTHERWISE, GO TO CL57

ROSTER DETAILS:
TITLE: DU_MEMBERS_1

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

ROSTER DEFINITION:
DISPLAY PERSONS ON THE DU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ONE ALLOWED.
2. MULTIPLE SELECT, EDIT, ADD, DELETE DISALLOWED.
3. DISPLAY ‘SOMEONE OUTSIDE DU’ AS LAST ENTRY ON
ROSTER.

ROSTER FILTER:
DISPLAY THOSE DU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT CURRENT RESPONDENT
- PERSON IS NOT DECEASED

[What is the name, address, and phone number of that person?]

ENTER COMPLETE ALTERNATE RESPONDENT INFORMATION.

ENTER ‘NMN’ IF NO MIDDLE NAME.

Current Info: [ALTERNATE_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]

ALTERNATE_NAME: [_____________]
1ST_STR_ADDRESS: [_____________]
2ND_STR_ADDRESS: [_____________]
CITY: [_____________]
STATE: [_____________]
ZIP CODE: [_____________]
TELEPHONE: [_____________]

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

IF THERE IS NO CURRENT ALTERNATE RELATIONSHIP,
PROCEED TO CL56.
OTHERWISE, PROCEED TO CL56_2.

HARD CHECK:
AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT
SECOND STREET ADDRESS (REF AND DK ARE ALLOWED).

[What is the name, address, and phone number of that person?]

USE TAB TO MOVE THROUGH FIELDS REQUIRING NO CORRECFTION.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

ENTER ‘NMN’ IF NO MIDDLE NAME.

TYPE THREE Xs (XXX) TO DELETE 2ND STREET ADDRESS.

Current Info: [ALTERNATE_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]

ALTERNATE_NAME: [_____________]
1ST_STR_ADDRESS: [_____________]
2ND_STR_ADDRESS: [_____________]
CITY: [_____________]
STATE: [_____________]
ZIP CODE: [_____________]
TELEPHONE: [_____________]

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

IF THERE IS NO CURRENT ALTERNATE RELATIONSHIP,
PROCEED TO CL56.
OTHERWISE, PROCEED TO CL56_2.

What is {NAME OF ALTERNATE RESPONDENT CL55}’s relationship to
{NAME OF REFERENCE PERSON}?

ENTER COMPLETE ALTERNATE RESPONDENT RELATIONSHIP.

Current Info: [ALTERNATE_RELATIONSHIP]

ALTERNATE_RELATIONSHIP: [_____________] {CL57}

DISPLAY THE NAME ENTERED AT CL55 FOR ‘NAME OF
ALTERNATE RESPONDENT CL55’.

DISPLAY THE NAME OF THE REFERENCE PERSON FOR THE
RU FOR ‘NAME OF REFERENCE PERSON’.

HARD CHECK:
AN ENTRY MUST BE MADE (REF AND DK ARE ALLOWED).

[What is {NAME OF ALTERNATE RESPONDENT CL55}’s relationship to
{NAME OF REFERENCE PERSON}?]

UPDATE CURRENT ALTERNATE RESPONDENT.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

Current Info: [ALTERNATE_RELATIONSHIP]

ALTERNATE_RELATIONSHIP: [_____________] {CL57}

DISPLAY THE NAME ENTERED AT CL55 FOR ‘NAME OF
ALTERNATE RESPONDENT CL55’.

DISPLAY THE NAME OF THE REFERENCE PERSON FOR THE
RU FOR ‘NAME OF REFERENCE PERSON’.

Is anyone in the family planning to move within the next 3
months?

YES .................................... 1 {CL58}
NO ..................................... 2 {BOX_18}
REF ................................... -7 {BOX_18}
DK .................................... -8 {BOX_18}

Who is that?

PROBE: Anyone else?

[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]

CONTINUE WITH LOOP_11

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

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

ROSTER DEFINITION:
DISPLAY THE RU-MEMBERS-ROSTER FOR SELECTION.

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

ROSTER FILTER:
DISPLAY ALL PERSONS WHO ARE CURRENT RU MEMBERS
(I.E., A MEMBER OF THE RU ON THE INTERVIEW DATE)

FOR EACH ELEMENT ON THE RU-MEMBERS-ROSTER, ASK
CL59 - END_LP11

LOOP DEFINITION: LOOP_11 COLLECTS ADDRESS
INFORMATION FOR POTENTIAL FUTURE MOVERS. THIS
LOOP CYCLES ON PERSONS ON THE RU-MEMBERS-ROSTER
WHO MEET THE FOLLOWING CONDITIONS:
- PERSON IS A CURRENT RU MEMBER (I.E., PERSON PART
OF THE RU ON INTERVIEW DATE)
- PERSON SELECTED AS A FUTURE MOVER (I.E.,
SELECTED AT CL58)
- PERSON NOT FLAGGED AS ‘PROCESSED FUTURE MOVER’
(I.E., PERSON HAS NOT YET BEEN PROCESSED THROUGH
THIS LOOP OR SELECTED AT CL61)

{PERSON’S FIRST MIDDLE AND LAST NAME}

Please give me the address and telephone number of the place
where {you/{PERSON}} {are/is} planning to move.

1ST_STR_ADDRESS: [_____________]
2ND_STR_ADDRESS: [_____________]
CITY: [_____________]
STATE: [_____________]
ZIP CODE: [_____________]
TELEPHONE: [_____________] {CL60}

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

REFUSED AND DON’T KNOW ALLOWED FOR EACH FIELD.

FLAG PERSON AS ‘PROCESSED FUTURE MOVER’.

IF ALL PERSONS SELECTED AS FUTURE MOVERS (I.E.,
SELECTED AT CL58) ARE FLAGGED AS ‘PROCESSED FUTURE
MOVER’, GO TO END_LP11

OTHERWISE, CONTINUE WITH CL60

HARD CHECK: CAPI REQUIRES AN ENTRY IN ALL FIELDS
EXCEPT SECOND STREET ADDRESS.

{PERSON’S FIRST MIDDLE AND LAST NAME}

IF KNOWN, CODE WITHOUT ASKING.

{Are/Is} {you/{PERSON}} planning to move with anyone in the family?

YES .................................... 1 {CL61}
NO ..................................... 2 {END_LP11}
REF ................................... -7 {END_LP11}
DK .................................... -8 {END_LP11}

{PERSON’S FIRST MIDDLE AND LAST NAME}

IF KNOWN, CODE WITHOUT ASKING.

Who {are/is} {you/{PERSON}} `planning to move with?

[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]
[First Name, [Middle Name], Last Name-65]

FLAG ALL SELECTED PERSONS AS ‘PROCESSED FUTURE
MOVER’.

CONTINUE WITH END_LP11

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

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

ROSTER DEFINITION:
DISPLAY PERSONS ON THE RU-MEMBERS-ROSTER FOR
SELECTION.

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

ROSTER FILTER:
DISPLAY ALL PERSONS IN THE RU-MEMBERS-ROSTER WHO
MEET THE FOLLOWING CONDITIONS:
- PERSON IS A CURRENT RU MEMBER (I.E., PERSON PART
OF THE RU ON INTERVIEW DATE)
- PERSON SELECTED AS A FUTURE MOVER (I.E.,
SELECTED AT CL58)
- PERSON NOT FLAGGED AS ‘PROCESSED FUTURE MOVER’

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

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_11 AND CONTINUE WITH BOX_18

IF CURRENT RESPONDENT IS A PROXY, CONTINUE WITH
CL61A

OTHERWISE, GO TO BOX_18A

FOR PROXY RESPONDENT: May I please have your address and
telephone number?

IF AVAILABLE, VERIFY CURRENT PROXY ADDRESS SHOWN BELOW.

Current Info: [PROXY_NAME]
[1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]

YES, ENTER NEW PROXY ADDRESS AND
TELEPHONE ............................ 1 {CL61B}
YES, PROXY ADDRESS AND TELEPHONE ABOVE
CORRECT .............................. 2 {BOX_18A}
YES, PROXY ADDRESS OR TELEPHONE ABOVE
NEEDS CORRECTION ..................... 3 {CL61B_2}
NO ..................................... 4 {BOX_18A}
REF ................................... -7 {BOX_18A}
DK .................................... -8 {BOX_18A}

HARD CHECK:
CODES ‘2’ (YES, PROXY ADDRESS AND TELEPHONE ABOVE
CORRECT) AND ‘3’ (YES, PROXY ADDRESS OR TELEPHONE
ABOVE NEEDS CORRECTION) CANNOT BE SELECTED IF NO
CURRENT PROXY ADDRESS INFORMATION AVAILABLE. IF
CODES ‘2’ OR ‘3’ SELECTED WHEN NO CURRENT PROXY
ADDRESS, DISPLAY THE FOLLOWING MESSAGE: ‘CODE
NOT AVAILABLE. NO CURRENT PROXY ADDRESS. VERIFY
AND RE-ENTER.’

What is your address and phone number?

ENTER COMPLETE PROXY ADDRESS.

Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]

1ST_STR_ADDRESS: [_____________]
2ND_STR_ADDRESS: [_____________]
CITY: [_____________]
STATE: [_____________]
ZIP CODE: [_____________]
TELEPHONE: [_____________]

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

FLAG PROXY ADDRESS INFORMATION FOR THE RU WITH THE
ADDRESS AND PHONE ENTERED OR CORRECTED AT CL61B
FOR THE CURRENT ROUND.

CONTINUE WITH BOX_18A

HARD CHECK:
AN ENTRY MUST BE MADE FOR EVERY FIELD EXCEPT
SECOND STREET ADDRESS (REF AND DK ARE ALLOWED).

[What is your address and phone number?]

USE TAB TO MOVE THROUGH FIELDS REQUIRING NO CORRECTION.

TO CORRECT OR ENTER NEW INFORMATION, TYPE ENTIRE FIELD.

TYPE THREE Xs (XXX) TO DELETE 2ND STREET ADDRESS.

Current Info: [1ST_STR_ADDRESS]
[2ND_STR_ADDRESS]
[CITY], [STATE] [ZIP CODE]
[TELEPHONE]

1ST_STR_ADDRESS: [_____________]
2ND_STR_ADDRESS: [_____________]
CITY: [_____________]
STATE: [_____________]
ZIP CODE: [_____________]
TELEPHONE: [_____________]

USE HELP TO VIEW LIST OF STATE ABBREVIATIONS.

FLAG PROXY ADDRESS INFORMATION FOR THE RU WITH THE
ADDRESS AND PHONE ENTERED OR CORRECTED AT CL61B
FOR THE CURRENT ROUND.

CONTINUE WITH BOX_18A

IF ROUND 1, GO TO CL67

OTHERWISE, CONTINUE WITH BOX_18B

IF AT LEAST ONE RU MEMBER COMPLETED THE SAQ [CL36
IS CODED ‘1’ (COMPLETED AND GIVEN TO INTERVIEWER)
FOR AT LEAST ONE RU MEMBER AND IF PANEL 17, ROUND
4 OR CL39 IS CODED ‘1’ (COMPLETED AND GIVEN TO
INTERVIEWER) FOR AT LEAST ONE RU MEMBER AND IF
PANEL 17, ROUND 5], CONTINUE WITH CL64A

OTHERWISE, GO TO CL67

NOTE: STARTING IN PANEL 18, PAYMENT WILL NO
LONGER BE MADE FOR COMPLETED SAQ FORMS.

INTERVIEWER: FILL OUT SAQ CHECK(S) WITH SAQ RESPONDENT NAME(S).
THEN RECORD PAYMENT TYPE AND CHECK NUMBER(S) (IF APPLICABLE).

ROSTER DETAILS:
TITLE: RU_MEMBERS

COL # 1 HEADER: PID
INSTRUCTIONS: DISPLAY RU MEMBERS’ 3-DIGIT ID
(PERS.PID)

COL # 2 HEADER: RU MEMBER
INSTRUCTIONS: DISPLAY RU MEMBERS’ FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

COL # 3 HEADER: PAYMENT TYPE
INSTRUCTIONS: SELECT PAYMENT TYPE

COL # 4 HEADER: CHECK NUMBER
INSTRUCTIONS: ENTER CHECK NUMBER

ROSTER DEFINITION:
DISPLAY PERSONS ON THE RU-MEMBERS-ROSTER FOR
DISPLAY ONLY.

ROSTER BEHAVIOR:
1. THE PID COLUMN IS PROTECTED; NO CHANGES ARE
ALLOWED.

2. THE NAME COLUMN IS PROTECTED; NO CHANGES ARE
ALLOWED.

3. THE PAYMENT TYPE COLUMN IS A DROP DOWN
SELECTION BOX WITH TWO CHOICES: CHECK AND CASH.

4. THE CHECK NUMBER COLUMN IS A 7 DIGIT NUMERIC
ENTRY FIELD.

5. THE CHECK NUMBER COLUMN SHOULD BE INACTIVE OR
"GRAYED OUT" UNTIL A SELECTION IS MADE IN THE
PAYMENT TYPE COLUMN. IF ‘CHECK’ IS SELECTED,
THE CURSOR MOVES TO THE CHECK NUMBER COLUMN FOR
COMPLETION. IF ‘CASH’ IS SELECTED THE CHECK
NUMBER COLUMN REMAINS INACTIVE AND THE CURSOR
MOVES TO THE PAYMENT TYPE COLUMN FOR THE NEXT
RU MEMBER ON THE ROSTER.

6. SELECT, ADD, AND DELETE DISALLOWED.

ROSTER FILTER:
DISPLAY ALL PERSONS ON THE RU-MEMBERS-ROSTER THAT
HAVE COMPLETED AN SAQ FOR THIS ROUND. THAT IS,
DISPLAY ALL RU MEMBERS THAT MEET THE FOLLOWING
CONDITION:

- IF ROUNDS 2 OR 4: CL36 IS CODED ‘1’ (COMPLETED
AND GIVEN TO INTERVIEWER) FOR THIS PERSON
OR
- IF ROUNDS 3 OR 5: CL39 IS CODED ‘1’ (COMPLETED
AND GIVEN TO INTERVIEWER) FOR THIS PERSON

READ IF RESPONDENT REFERRED TO RECORDS DURING THE INTERVIEW:
Thank you for your cooperation in this important research. And I
especially wanted to thank you for referring to records during the
interview to help answer the questions. We’ve learned over the
years that using records can help the interview move along a little
more easily.

REVIEW WITH THE RESPONDENT WHICH OF THE FOLLOWING MEMORY AIDS WERE
USED DURING THE INTERVIEW AND CODE ANY APPLICABLE. ENCOURAGE RECORD
USE FOR NEXT ROUND. REFER TO RECORDS JOB AID AS APPROPRIATE.

ELECTRONIC RECORDS YES NO
(E.G., ONLINE PATIENT PORTALS, MOBILE HEALTH APPS, ETC.)

IF CL67_13 IS CODED '1' (YES), CONTINUE WITH
CL67OV

OTHERWISE, GO TO CL65

INTERVIEWER: FILL OUT INTERVIEW CHECK WITH RESPONDENT’S NAME.
THEN RECORD PAYMENT TYPE AND CHECK NUMBER BELOW (IF APPLICABLE).

GIVE CHECK TO RESPONDENT. THANK RESPONDENT FOR THIS INTERVIEW.
(READ STATEMENT BELOW)

Thank you again for your cooperation in this important research.
This check is a gift to show our appreciation. {The next interview
will take place in about six months.}

{GIVE RESPONDENT GIFT./GIVE RESPONDENT CERTIFICATE: I would also like
to thank you on behalf of the two Department of Health and Human
Services agencies that sponsor this study – the Agency for Healthcare
Research and Quality and the Centers for Disease Control and Prevention.
As a token of their appreciation, they would like you to have this
certificate recognizing your time and effort participating in the
Medical Expenditure Panel Survey.}

CHECK .................................. 1 {CL65OV}
CASH ................................... 2 {BOX_20}

Closing (CL) Section