MEPS Respondent Forms (RF) Section

Route Details: 01 Box = BOX_00, BOX_10, BOX_20, BOX_25, BOX_30, BOX_40, BOX_70, BOX_80, BOX_90, BOX_100, BOX_110, BOX_120, BOX_130, BOX_140

02 Loop = Loop 10, Loop 20, Loop 30

03 End Loop = END_LP10, END_LP20, END_LP30

04 Single Select = RF60, RF100, RF105_01, RF105_02, RF105_04, RF105_05, RF150_01, RF150_05

13 Address – Preloaded = RF70_01, RF70_02, RF70_03, RF70_04, RF70_05, RF70_06, RF70_07

14 Regular Date Entry = RF90_01, RF90_02, RF90_03, RF150_04

20 OS Text Field = RF105_06, RF150_02, RF150_06

23 Text Field = RF150_03

24 Information Screen = RFIntro, RF10, RF20, RF30, RF115, RF125, RF135, RF140_01, RF160

26 Regular Date Entry – Preloaded = RF80_01, RF80_02, RF80_03 Roster 2 = RF105_03

Route Details: Placeholder for Context header display instructions:

Note: Fall 2020 CAPI administration requires additional AF colors to support the extension of P23R6 and ongoing.

Panel MPC Pharmacy

P23 R8-9 Yellow Tan

P24 Green Gray

P25 White Orchid

P26 Blue Pink

P27 Goldenrod Ivory

CAPI WILL NOW DETERMINE WHICH, IF ANY, AUTHORIZATION FORMS ARE REQUIRED FOR THIS HOUSEHOLD. THIS PROCESS MAY TAKE A FEW MOMENTS.

ANY EVENTS ADDED AFTER THIS POINT WILL NOT GENERATE NEW AUTHORIZATION FORMS UNTIL THE NEXT ROUND.

Programmer Instructions: After ‘1’ is entered, CAPI will use the AF Rules to populate the AF array.

The rules for creating records that meet the authorization form (AF) definition are included here:

(https://mepspm.westat.com/FinalDesignDocsbyGroup/Respondent%20Form%20(RF)%20Section%20Supporting%20Documents/AF%20Rules_rev.xlsx)

(https://mepspm.westat.com/FinalDesignDocsbyGroup/Respondent%20Form%20(RF)%20Section%20Supporting%20Documents/AF%20Array_rev.xlsx)

Note: OF events added at any point in the RF section will not generate new AFs until the next Round.

Route Details: If:

Round 1 and at least one person-provider-pair eligible for MPC authorization form collection for the current round [at least one record where (AF.AFType=MPC) and (AF.RequestRd1=Yes)]

Not Round 1 (RndType<>First) and at least one person-provider-pair eligible for MPC or Pharmacy authorization form collection for the current round [at least one record where (AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]

Not Round 1 (RndType<>First) and at least one person that is part of this RU (MostRecentRU=RUUnit) rejoined the community this round from previously being institutionalized in a health care setting [at least one record where (AF.AFType=MPC-HCI (original)) and (AF.AFInstStatus=1 or 2)]

Continue with BOX_25.

Otherwise, go to BOX_140.

Route Details: If Fall 2022 rounds [Panel 27 Round 2, Panel 26 Round 4, Panel 24 Round 8], continue with BOX_30. Otherwise go to RF10.

RU Member Age Medical AFs (Preprinted) {MPCColor} Pharmacy AFs (Preprinted) {PharColor}

Display only RU members who are key (CtrlPersKey=Yes) or who were deceased in a previous round

institutionalized in a previous round and still institutionalized and have an outstanding authorization form [(AF.AFPersonStatus=5 or 6) and [at least one record where (AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]].

Display the first name (Pers. FName) of each RU member meeting the roster filter definition.

Display the age of the person. If age is missing, display the range for the age category.

For "MPCColor", display the color of the MPC form for that panel. See BOX_10 for specifications on color.

For "SS", display the count of the total number of MPC AFs for this RU Member. This count is the number of records for this RU member where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)] or [(RndType<>First) and (AF.AFType=MPC) and (AF.AFSuperceded=Empty)]. Display ‘0’ if none.

For "TT", display the count of the number of MPC preprinted AFs that are available for this RU member. This count is the number of records for this RU member where [(RndType<>First) and (AF.AFType=MPC) and (AF.AFSuperceded=Empty) and (AF.AFPreprinted=1 or 2)]. Display ‘0’ if none. Note: This count will always be ‘0’ in Round 1.

For "UU", sum all the counts in "SS". For "VV", sum all the counts in "TT". Column Header #4:

For "PharColor", display the color of the Pharmacy form for that panel. See BOX_10 for specifications on color.

For "WW", display the count of the total number of Pharmacy AFs for this RU Member. This count is the number of records for this RU member where [(RndType<>First) and (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)]. Display ‘0’ if none.

For "XX", display the count of the number of Pharmacy preprinted AFs that are available for this RU member. This count is the number of records for this RU member where [(RndType<>First) and (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty) and (AF.AFPreprinted=1 or 2)]. Display ‘0’ if none. This count will always be ‘0’ in Round 1.

Route Details: If not Round 1 (RndType<>First) and at least one person that is part of this RU (MostRecentRU=RUUnit) rejoined the community this round from previously being institutionalized in a health care setting [at least one record where (AF.AFType=MPC-HCI (original)) and (AF.AFInstStatus=1 or 2)], continue with RF20.

Otherwise, go to RF30.

{PERSON 1}, {PERSON 2}, {PERSON 3}, {PERSON 4}, {PERSON N} {HAVE/HAS} {REJOINED THE HOUSEHOLD} {OR} {DIED} AFTER BEING IN A HEALTH CARE FACILITY.

CAPI WILL ALSO PROMPT YOU TO COMPLETE AUTHORIZATION FORMS FOR INSTITUTIONAL STAYS THAT OCCURRED DURING THE TIME {HE/SHE/THEY} {WERE/WAS} AWAY AT A HEALTH CARE FACILITY.

This item uses the authorization form array to display RU-members. (AF.FName, AF.MName, AF.LName)

Display only those RU members who have returned from being institutionalized in a previous round [persons where (AF.AFType=MPC-HCI (original)) and (AF.AFInstStatus=1 or 2)].

Display RU members’ first, middle, and last names (AF.FName, AF.MName, AF.LName) in question text. If exactly two names displayed, separate names with the word "and" and no comma. If more than two names listed, separate names using commas, except for between the last two names displayed.

Display "HAVE" and "WERE" if more than one name displayed. Otherwise, display "HAS" and "WAS".

Display "REJOINED THE HOUSEHOLD" if there is at least one RU member listed who is living with the family after leaving the institution (AF.AFInstStatus=2). Otherwise, use a null display.

Display "DIED" if there is at least one RU member listed who died after leaving the institution (AF.AFInstStatus=1). Otherwise, use a null display.

Display "OR" if there is at least one RU member listed who is living with household and at least one RU member who is listed died after leaving institution. Otherwise, use a null display.

Display "HE" if only one RU member meets the roster filter conditions and that RU member is male.

Display "SHE" if only one RU member meets the roster filter conditions and that RU member is female. Otherwise, display "THEY".

{[As I mentioned during the last interview], we/We} request authorization to contact {medical providers} {and} {pharmacies} to obtain complete and accurate information about health care use and expenditures.

{I would like to get authorization from {MPC_PERSON 1, MPC_PERSON 2, MPC_PERSON 3, MPC_PERSON 4, MPC_PERSON N….} to contact medical providers for more information about the services they provide.}

{I would {also} like to get authorization from {PHAR_PERSON 1, PHAR_PERSON 2, PHAR_PERSON 3, PHAR_PERSON 4, PHAR_PERSON N….} to contact pharmacies to obtain a printed summary.}

{{In addition, we/We} would still like to get authorization to contact {medical providers} {and} {pharmacies} for {AF_PERSON 1, AF_PERSON 2, AF_PERSON 3, AF_PERSON 4, AF_PERSON N….} [although they have since passed away].}

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

Display Instructions: DISPLAY "[As I mentioned during the last interview], we" if not round 1. Otherwise, display "We".

Display "medical providers" if at least one person in the RU has at least one active MPC AF in the current round [at least one record where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)]] or [at least one record where [not Round 1 (RndType<>First) and (AF.AFType=MPC) and (AF.AFSuperceded=Empty)]]. Otherwise, use a null display.

Display "and" if there is at least at least one active MPC and one active Pharmacy AF in the current round. Otherwise, use a null display.

Display "pharmacies" if at least one person in the RU has at least one active Pharmacy AF in the current round [at least one record where (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)].

Display "I would like to get authorization from {MPC_PERSON 1, MPC_PERSON 2, MPC_PERSON 3, MPC_PERSON 4, MPC_PERSON N….} to contact medical providers for more information about the services they provide." if at least one person in the RU has at least one active MPC AF in the current round. Otherwise, use a null display.

For the second paragraph "{MPC_PERSON 1, MPC_PERSON 2, MPC_PERSON 3, MPC_PERSON 4, MPC_PERSON N….}," display the first names (AF.FName) of all RU members whose AF.AFPersonStatus=1, 2, 4, 6 and where that person has at least one active MPC AF in the current round. Substitute "you" for the person’s first name if the respondent is included in this list. If exactly two names displayed, separate names with the word "and" and no comma. If more than two names listed, separate names using commas, except for between the last two names displayed. Between the last two names displayed, separate names using the word "and".

Display "I would {also} like to get authorization from {PHAR_PERSON 1, PHAR_PERSON 2, PHAR_PERSON 3, PHAR_PERSON 4, PHAR_PERSON N….} to contact pharmacies to obtain a printed summary." if at least one person in the RU has at least one active Pharmacy AF in the current round. Otherwise, use a null display.

Display "also" if there is at least at least one active MPC and one active Pharmacy AF in the current round. Otherwise, use a null display.

For "{PHAR_PERSON 1, PHAR_PERSON 2, PHAR_PERSON 3, PHAR_PERSON 4, PHAR_PERSON N….}," display the first names (AF.FName) of all RU members who have an AF.AFPersonStatus=1, 2, 4, 6 and where that person has at least one active Pharmacy AF in the current round. Substitute "you" for the person’s first name if the respondent is included in this list. If exactly two names displayed, separate names with the word "and" and no comma. If more than two names listed, separate names using commas, except for between the last two names displayed. Between the last two names displayed, separate names using the word "and".

Display entire paragraph starting with "{In addition, we/We would} still like to get authorization..." if at least one person in the RU has an AF.AFPersonStatus=3 or 5.

Display "In addition, we" if at least one person with an AF.AFPersonStatus=1 ,2, 4, or 6 has at least one active MPC or one active Pharmacy AF and at least one person with an AF.AFPersonStatus=3 or 5 and has at least one eligible MPC or one Pharmacy AF".

Display "medical providers" if at least one person in the RU has an AF.AFPersonStatus= 3 or 5 and has at least one active MPC AF in the current round [at least one record where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)]] or [at least one record where [not Round 1 (RndType<>First) and (AF.AFType=MPC) and (AF.AFSuperceded=Empty)]]. Otherwise, use a null display.

Display "and" if at least one person in the RU has an AF.AFPersonStatus= 3 or 5 and there is at least at least one active MPC and one active Pharmacy AF in the current round. Otherwise, use a null display.

Display "pharmacies" if at least one person in the RU at least one person in the RU has an AF.AFPersonStatus= 3 or 5 and has at least one active Pharmacy AF in the current round [at least one Record where (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)]. Otherwise, use a null display.

For this paragraph, "{AF_PERSON 1, AF_PERSON 2, AF_PERSON 3, AF_PERSON 4, AF_PERSON _N}", display the first names (AF.FName) of all RU members who have an AF.AFPersonStatus= 3 or 5 and that person has at least one active MPC or Pharmacy AF in the current round. If exactly two names displayed, separate names with the word "and" and no comma. If more than two names listed, separate names using commas, except for between the last two names displayed.

Route Details: If not Round 1 (RndType<>First) and at least one person that is part of this RU (MostRecentRU=RUUnit) rejoined the community this round from previously being institutionalized in a health care setting [person has record where (AF.AFType=MPC- HCI (original)) and (AF.AFInstStatus=1 or 2)], continue with LOOP_10.

Otherwise, go to RF105_01.

Route Details: For each element in the RU-Members-Roster, ask LOOP_20 - END_LP10.

Loop Definition: LOOP_10 cycles on RU members who have returned from institution. This includes RU members that meet the following conditions:

Not Round 1 (RndType<>First) and person is part of this RU (MostRecentRU=RUUnit) and person rejoined the community this round from previously being institutionalized in a health care setting [person has record where (AF.AFType=MPC-HCI (original)) and (AF.AFInstStatus=1 or 2)].

Route Details: For each of the following:

Institution 1

Institution 2

Institution 3

Institution 4

Institution 5

Ask BOX_70-END_LP20.

Loop definition: LOOP_20 collects/verifies the name, address, admit and discharge dates of every health care institution a person who has rejoined the community resided in during the time they were not part of the MEPS interview. The response to RF100 determines if the loop cycles again. If RF100 is coded ‘1’ (YES), the loop cycles to collect the next health care institution. If RF100 is coded ‘2’ (NO), ‘RF’ (REFUSED), or ‘DK’ (DON’T KNOW), the loop ends. However, there can only be a maximum of 5 health care institutions, so RF100 will not be asked once there are 5 institutions.

Route Details: If first cycle of LOOP_20, continue with RF60.

Otherwise, go to RF70_01.

I have recorded that {you/{PERSON}} {rejoined the household/passed away} after being in a health care facility. I would like to collect the name, address, and telephone number for each nursing home or other long-term care institution that provided 24 hour skilled nursing care where {you/{PERSON}} resided between {DATE ORIG INSTITUTIONALIZED} and {DATE REJOINED COMMUNITY}.

In an earlier interview, I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME}. Is that correct?

Display Instructions: For "{PERSON}" display the full name of the person being looped on (Person.FullName). Display "rejoined the household" if person has returned to live in this RU [(AF.AFInstStatus=2) for the record where AF.AFType=MPC-HCI (original)]. Display "passed away" if person died after leaving the institution [(AF.AFInstStatus=1) for the record where AF.AFType=MPC- HCI (original)].

For "{DATE ORIG INSTITUTIONALIZED}", display the date the person was first institutionalized [(AF.OrigInstMM, DD, YYYY) for the record where AF.AFType=MPC-HCI (original)]. Display as full month, xx, YYYY - e.g., "January 1, 2016". Display "DK" or "RF" for missing values.

For "{DATE REJOINED COMMUNITY}", display the date the person left the health care facility [(AF.DtRejoinedMM, DD, YYYY) for the record where AF.AFType=MPC-HCI (original)]. (This is the date collected at RE200/RE220/RE240). Display as full month, xx, YYYY - e.g., "January 1, 2016". Display "DK" or "RF" for missing values.

For "{ORIG INSTITUTION NAME}", display the name of the health care facility the person reported when he/she was first institutionalized [Use AF.ProvName for the AF record where AF.AFType=MPC-HCI (orginal)].

{VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON} WAS LIVING./Please give me the name, address and telephone number of the nursing home or long term care institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living.}

General programming instructions for RF70_01 to RF70_06: If first cycle through LOOP_20 and RF60 is coded ‘1’ (YES), prefill each available address field in the response pane entry fields with health care institution information from the round the person was first institutionalized (RE450_01-RE450_06). Use AF.ProvName, AF.StrtAddr1, AF.StrtAddr2, AF.City, AF.State, and AF.Zip for the AF record where AF.AFType=MPC-HCI (orginal).

General programming instructions for RF70_01 to RF70_06: If first cycle through LOOP_20 and RF60 is coded ‘2’ (YES), ‘RF’ (REFUSED) or ‘DK’ (DON’T KNOW) or if not first cycle through LOOP_20, leave the response pane entry fields empty for completion. As name, address, and phone are collected, these values must be added to both the provider fields in the AF array as well as the provider array so that a ProvID can be created.

General programming instructions for RF70_07: Leave the response pane entry field empty for completion for all cycles of LOOP_20.

Set Provider.ProvID and AF.ProvID to MaxProvID +1. Set Provider.MPTP to 1 (Facility).

Set Provider.CreateQ to RF70. Set Provider.OrigRnd to current round. Set Provider.OrigRU to current RU. Set Provider.MPLName and AF.ProvName = RF70_01.

Display Instructions: Display RF70_01 through RF70_07 vertically on the same form pane.

Display "VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON} WAS LIVING." and "Is the name:" if first cycle through LOOP_20 and RF60 is coded ‘1’ (YES). Otherwise, display "Please give me the name, address and telephone number of the nursing home or long term care institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living." and "What is the name?"

For "{PERSON}" display the full name of the person being looped on (AF.FName, AF.MName, AF.LName).

Display address fields in the info pane with most recent health care institution address information. Use a null display if response entry fields are empty. As entries are updated in the current round, the display in the info pane should also be updated.

Display {INSTITUTION NAME} in the info pane in bold, black, but all other address display fields in lighter "grayed-out" text.

Display "VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON} WAS LIVING." and "Is the street address:" if first cycle through LOOP_20 and RF60 is coded ‘1’ (YES). Otherwise, display "Please give me the name, address and telephone number of the nursing home or long term care institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living." and "What is the street address?"

For "{PERSON}" display the full name of the person being looped on (AF.FName, AF.MName, AF.LName).

Display "VERIFY THE NAME…" or "Please give me…" in brackets and lighter "grayed-out" text when on RF70_02 through RF70_07.

Display {STREET ADDRESS1} in the info pane in bold, black, but all other address display fields in lighter "grayed-out" text.

{VERIFY/ENTER} BUILDING OR ADDITIONAL ADDRESS INFORMATION, AS NECESSARY. IF NONE, PRESS ENTER TO CONTINUE.

Display Instructions: Display RF70_01 through RF70_07 vertically on the same form pane.

Display "VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON} WAS LIVING." and "VERIFY:" if first cycle through LOOP_20 and RF60 is coded ‘1’ (YES). Otherwise, display "Please give me the name, address and telephone number of the nursing home or long term care institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living." and "ENTER".

For "{PERSON}" display the full name of the person being looped on (AF.FName, AF.MName, AF.LName).

Display "VERIFY THE NAME…" or "Please give me…" in brackets and lighter "grayed-out" text when on RF70_02 through RF70_07.

Display {STREET ADDRESS2} in the info pane in bold, black, but all other address display fields in lighter "grayed-out" text.

Display Instructions: Display RF70_01 through RF70_07 vertically on the same form pane.

Display "VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON} WAS LIVING." and "Is the city:" if first cycle through LOOP_20 and RF60 is coded ‘1’ (YES). Otherwise, display "Please give me the name, address and telephone number of the nursing home or long term care institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living." and "What is the city?"

For "{PERSON}" display the full name of the person being looped on (AF.FName, AF.MName, AF.LName).

Display "VERIFY THE NAME…" or "Please give me…" in brackets and lighter "grayed-out" text when on RF70_02 through RF70_07.

Display {CITY} in the info pane in bold, black, but all other address display fields in lighter "grayed-out" text.

TYPE THE FIRST LETTER OF THE STATE, THEN USE ARROW KEYS IF NEEDED TO LOCATE STATE, AND PRESS ENTER TO SELECT.

Display Instructions: Display RF70_01 through RF70_07 vertically on the same form pane.

Display "VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON} WAS LIVING." and "Is the state:" if first cycle through LOOP_20 and RF60 is coded ‘1’ (YES). Otherwise, display "Please give me the name, address and telephone number of the nursing home or long term care institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living." and "What is the state?"

For "{PERSON}" display the full name of the person being looped on (AF.FName, AF.MName, AF.LName).

Display "VERIFY THE NAME…" or "Please give me…" in brackets and lighter "grayed-out" text when on RF70_02 through RF70_07.

Display {STATE} in the info pane in bold, black, but all other address display fields in lighter "grayed-out" text.

Hard check: Exactly 5 digit numeric entry required. If less than 5 numeric digits entered or any characters entered that are not numeric, display the following message: "ZIP CODE ENTRY REQUIRES EXACTLY 5 NUMBERS. PROBE AND RE-ENTER OR ENTER F5 (DON'T KNOW) IF FULL ZIP CODE IS NOT KNOWN."

Display Instructions: Display RF70_01 through RF70_07 vertically on the same form pane.

Display "VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON} WAS LIVING." and "Is the zip code:" if first cycle through LOOP_20 and RF60 is coded ‘1’ (YES). Otherwise, display "Please give me the name, address and telephone number of the nursing home or long term care institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living." and "What is the zip code?"

For "{PERSON}" display the full name of the person being looped on (AF.FName, AF.MName, AF.LName).

Display "VERIFY THE NAME…" or "Please give me…" in brackets and lighter "grayed-out" text when on RF70_02 through RF70_07.

Display {ZIP CODE} in the info pane in bold, black, but all other address display fields in lighter "grayed-out" text.

10-digit entry required; use number input mask (xxx-xxx-xxxx) in response field.

Hard check: Exactly 10 digit numeric entry required. If less than 10 numeric digits entered or any characters entered that are not numeric, display the following message: "PHONE ENTRY REQUIRES EXACTLY 10 NUMBERS. PROBE AND RE-ENTER OR ENTER F5 (DON'T KNOW) IF FULL PHONE NUMBER IS NOT KNOWN."

Display Instructions: Display RF70_01 through RF70_07 vertically on the same form pane.

Display "VERIFY THE NAME AND ADDRESS OF THE NURSING HOME OR LONG TERM CARE FACILITY WHERE {PERSON} WAS LIVING." if first cycle through LOOP_20 and RF60 is coded ‘1’ (YES). Otherwise, display "Please give me the name, address and telephone number of the nursing home or long term care institution (that provided 24 hour skilled nursing care) where {you were/{PERSON} was} living."

For "{PERSON}" display the full name of the person being looped on (AF.FName, AF.MName, AF.LName).

Display "VERIFY THE NAME…" or "Please give me…" in brackets and lighter "grayed-out" text when on RF70_02 through RF70_07.

Display {TELEPHONE NUMBER} in the info pane in bold, black, but all other address display fields in lighter "grayed-out" text.

{I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME} on {DATE ORIG INSTITUTIONALIZED}.

Is that correct?/What date {were you/was {PERSON}} admitted to {INSTITUTION NAME}?}

If first cycle through LOOP_20 and RF60 is coded ‘1’ (YES), prefill RF80_01 with AF.OrigInstMM.

Display Instructions: Display "I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME} on {DATE ORIG INSTITUTIONALIZED}. Is that correct?" and "VERIFY" if first cycle through LOOP_20 and RF60 is coded ‘1’ (YES). Otherwise, display "What date {were you/was {PERSON}} admitted to {INSTITUTION NAME}?" and "ENTER".

For "{PERSON}" display the full name of the person being looped on (AF.FName, AF.MName, AF.LName).

For "{INSTITUTION NAME}", display the name of the institution verified/entered at RF70_01 during this loop (also AF.ProvName for this record).

{I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME} on {DATE ORIG INSTITUTIONALIZED}.

Is that correct?/What date {were you/was {PERSON}} admitted to {INSTITUTION NAME}?}

Programmer Instructions: If first cycle through LOOP_20 and RF60 is coded ‘1’ (YES), prefill RF80_02 with AF.OrigInstDD.

{I recorded that {you/{PERSON}} entered {ORIG INSTITUTION NAME} on {DATE ORIG INSTITUTIONALIZED}.

Is that correct?/What date {were you/was {PERSON}} admitted to {INSTITUTION NAME}?}

If first cycle through LOOP_20 and RF60 is coded ‘1’ (YES), prefill RF80_03 with AF.OrigInstYYYY.

Hard check: For first cycle through LOOP_20 (cycling to admit date and institution name entered in prior interview), Month and Year entered at RF80_01 and RF80_03 must be on or before month and year rejoined community (AF.DtRejoinedMM, YYYY). For second and subsequent cycles through LOOP_20, Month and Year entered at RF80_01 and RF80_03 must be on or after month and year originally institutionalized (AF.OrigInstMM, YYYY) and on or before month and year rejoined community (AF.DtRejoinedMM, YYYY). If the month and year entered fall outside of this range, display the following message: "DATE ADMITTED TO HEALTH CARE FACILITY MUST BE BETWEEN THE DATE FIRST INSTITUTIONALIZED ({AF.OrigInstMM, DD, YYYY}) AND DATE {REJOINED COMMUNITY/DIED} ({AF.DtRejoinedMM, DD, YYYY}). VERIFY AND RE-ENTER DATE." Note: If any part of the dates for the month and year originally institutionalized (AF.OrigInstMM, YYYY) or the date rejoined community (AF.DtRejoinedMM, YYYY) are DK, RF, or empty, do not invoke the hard check. Only use month and year since those fields are required at these three items, whereas day is not.

In the hard check message, display "REJOINED COMMUNITY" IF [(AF.AFInstStatus=2) for the record where AF.AFType=MPC-HCI (original)]. Display "DIED" if person died after leaving the institution [(AF.AFInstStatus=1) for the record where AF.AFType=MPC-HCI (original)].

Display Instructions: For "{PERSON}" display the full name of the person being looped on (AF.FName, AF.MName, AF.LName).

For "{INSTITUTION NAME}", display the name of the institution verified/entered at RF70_01 during this loop (also AF.ProvName for this record).

Hard check: Month and Year entered at RF90_01 and RF90_03 must be on or after month and year originally institutionalized (AF.OrigInstMM, YYYY) and on or before month and year rejoined community (AF.DtRejoinedMM, YYYY). If the month and year entered fall outside of this range, display the following message: "DATE DISCHARGED FROM HEALTH CARE FACILITY MUST BE BETWEEN THE DATE FIRST INSTITUTIONALIZED ({AF.OrigInstMM, DD, YYYY}) AND DATE {REJOINED COMMUNITY/DIED} ({AF.DtRejoinedMM, DD, YYYY}). VERIFY AND RE-ENTER DATE." Note: If any part of the dates are DK, RF, or empty, do not invoke the hard check. Only using month and year since those fields are required at these three items, whereas day is not.

Route Details: If [(first cycle of LOOP_20) and (RF60 is coded ‘1’ (YES)) and (month and year at RF90_01 and RF90_03=AF.DtRejoinedMM, YYYY)], go to END_LP20 (Loop 20 will cycle only once).

Else, continue with RF100 if there are less than 5 health care institutions already recorded.

Between {DATE ORIG INSTITUTIONALIZED} and {DATE REJOINED COMMUNITY}, did {you/{PERSON}} stay in another nursing home or other long-term care institution that provided 24 hour skilled nursing care [other than {INSTITUTION NAME}]?

Programmer Instructions: If coded ‘1’ (YES), create a new record where: AF.AFType=MPC-HCI (additional). Set AF.OrigRnd and AF.AFYearRev. Set AF.ReqSignDt to RU reference period end date. From the MPC-HCI (original) record, copy over all the "info about person" variables to the new record. The next cycle of LOOP_20 will cycle to set the info about provider information for this newly created record.

Display Instructions: For "{DATE ORIG INSTITUTIONALIZED}", display the date the person was first institutionalized [(AF.OrigInstMM, DD, YYYY) for the record where AF.AFType=MPC-HCI (original)]. Display as full month, xx, YYYY - e.g., "January 1, 2016". Display "DK" or "RF" for missing values.

For "{PERSON}" display the full name of the person being looped on (AF.FName, AF.MName, AF.LName).

For "{INSTITUTION NAME}", display the name of the institution at RF70_01 verified/entered during this cycle of LOOP_20 (also AF.ProvName for this record).

Route Details: If RF100 is coded ‘1’ (YES), cycle to collect next institution if there are less than 5 health care institutions already recorded.

Otherwise, end LOOP_20 and continue with END_LP10.

Route Details: Cycle on the next person that meets the condition stated in the loop definition.

If no other person meets the stated condition, end LOOP_10 and continue with RF105_01.

[I need to confirm some information that will go on the authorization forms. Please let me know if any information needs to be updated.]

{I am recording that {you/{PERSON}} can provide {your/his/her} own authorization to contact {medical providers} {and} {pharmacies}.}

{I am recording that {PERSON} needs a proxy signer to provide authorization to contact {medical providers} {and} {pharmacies}.}

{Because {PERSON} is between the ages of 14 and 17, I am recording that a {parent/guardian} as well as {PERSON} needs to provide authorization to contact {medical providers} {and} {pharmacies}.}

{Because {PERSON} is under the age of 14, I am recording that a {parent/guardian} needs to provide authorization to contact {medical providers} {and} {pharmacies}.}

{Authorization forms for children between the ages of 14 and 17 require both the child and a parent or guardian signature.

Should I record that {you/{PERSON}} {are/is} over 18 and can sign for {yourself/himself/herself}, or that {you/he/she} {need/needs} to sign along with a parent or guardian?}

{Authorization forms for children under the age of 14 require only a parent or guardian signature, while forms for children between the ages of 14 and 17 require both the child and a parent or guardian signature. Should I record that {PERSON} needs only a parent or guardian signature, or should they sign along with a parent or guardian?}

{RU MEMBERS BETWEEN THE AGES OF 14 AND 17, REQUIRE BOTH RU MEMBER AND A PARENT OR GUARDIAN AS SIGNERS.}

{RU MEMBERS 13 YEARS OR YOUNGER REQUIRE A PARENT OR GUARDIAN AS THE SIGNER. RU MEMBERS BETWEEN THE AGES OF 14 AND 17 REQUIRE BOTH TEEN AND A PARENT OR GUARDIAN AS SIGNERS.}

{IF INCORRECT MAKE NECESSARY CORRECTIONS. IF CORRECT, PRESS ENTER TO CONTINUE./RECORD REQUIRED SIGNATURES.}

Programmer Instructions: Preloaded Grid Type 2 including questions : RF105_01, RF105_02, RF105_03, RF105_04, RF105_05, RF105_06.

If RF_Person.eSigAppDone=Yes for an RU member upon backing up to the RF105 grid, that RU member’s cells for columns RF105_01, RF105_02, RF105_03, RF105_04 should become protected; no changes are allowed.

If RU Member’s age is 18 years old or older or in age categories 5-9, and they are not deceased; prefill RF105_01 answer field with ‘1’ (SELF).

If RU Member is deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5); prefill RF105_01 answer field with ‘6’ (PROXY).

If RU Member’s age is 14-17 inclusive, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5), and they have a parent, step parent, or foster parent in the RU (RE900= 1, 2, 15, 16, 34, or 35); prefill RF105_01 answer field with ‘4’ (TEEN AND PARENT). Otherwise, if RU Member’s age is 14-17 inclusive and are not deceased, prefill with ‘5’ (TEEN AND GUARDIAN).

If RU Member’s age is 13 or younger or in age categories 1-2, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5), and they have a parent, step parent, or foster parent in the RU (RE900= 1, 2, 15, 16, 34, or 35) in the RU; prefill RF105_ 01 answer field with ‘2’ (PARENT). Otherwise, if RU Member’s age is 13 or younger or in age categories 1-2 and are not deceased, prefill with ‘3’ (GUARDIAN).

If RU Member is in age category 3 or 4, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5), do not prefill RF105_01 answer field.

If coded ‘2’ (PARENT), ‘3’ (GUARDIAN), or ‘6’ (PROXY) set AFReqSign as ‘2’ (Proxy/Parent Only).

If coded ‘4’ (TEEN AND PARENT) or ‘5’ (TEEN AND GUARDIAN), set AFReqSign as ‘3’ (Both).

If coded ‘2’ (PARENT) or ‘3’ (GUARDIAN), set AFRsnSecSign as ‘1’ (Patient 13 or Younger).

If coded ‘4’ (TEEN AND PARENT) or ‘5’ (TEEN AND GUARDIAN), set AFRsnSecSign as ‘2’ (Patient 14-17).

Soft check: If RU Member’s age is 18 years old or older or in age categories 5-9, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5), and response is coded ‘2’ (PARENT), ‘3’ (GUARDIAN), ‘4’ (TEEN AND PARENT) or ‘5’ (TEEN AND GUARDIAN) display the error message "If RU Member is 18 years of age or older, they must sign their own AF unless a proxy is needed."

Soft check: If RU Member’s age is between 14 and 17 (inclusive), and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5), and response is coded ‘1’ (SELF), ‘2’ (PARENT), ‘3’ (GUARDIAN) or ‘6’ (PROXY) display the error message " If RU Member is between 14 and 17 years of age, both the patient and a parent or guardian are required to sign."

Soft check: If RU Member’s age is 13 or younger or in age categories 1-2, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5), and response is coded ‘1’ (SELF), ‘4’ (TEEN AND PARENT), ‘5’ (TEEN AND GUARDIAN) or ‘6’ (PROXY) display the error message "If RU Member is 13 years of age or younger, a parent or guardian must sign."

Soft check: If RU Member is in age category 3, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5), and response is coded ‘1’ (SELF) or ‘6’ (PROXY) display the error message "If RU Member is 13 years of age or younger, a parent or guardian is required to sign. If RU Member is between 14 and 15 years of age, both the patient and a parent or guardian are required to sign."

Soft check: If RU Member is in age category 4, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5), and response is coded ‘2’ (PARENT) or ‘3’ (GUARDIAN) display the error message "If RU Member is between 16 and 17 years of age, both the patient and a parent or guardian are required to sign. If RU Member is 18 years of age or older, they must sign their own AF unless a proxy is needed."

Soft check: If response is coded ‘7’ (WITNESS), display the error message "Please verify response. Witness signatures are rare and allowed only for adults. Paper authorization forms will be requested in this situation."

If coded ‘7’ (WITNESS) continue to next RU member on grid. At grid completion, continue with BOX_90. NOTE: AFMode and AFMode_AtBox_100 will be set to paper at Box_100.

Round 1 and person eligible for MPC authorization form collection for the current round [person has at least one record where (AF.AFType=MPC) and (AF.RequestRd1=Yes)] OR Not Round 1 (RndType<>First) and person eligible for MPC or Pharmacy authorization form collection for the current round [person has at least one record where (AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]

Not Round 1 (RndType<>First) and person that is part of this RU (MostRecentRU=RUUnit) rejoined the community this round from previously being institutionalized in a health care setting [person has record where (AF.AFType=MPC-HCI (original) or HCI(additional)) and (AF.AFInstStatus=1 or 2)]

Instructions: Item RF105_02. Display as an active cell if RF105_01 is coded ‘6’ (PROXY).

Instructions: Item RF105_03. Display as an active cell if RF105_01 is not coded ‘1’ (SELF) or ‘7’ (WITNESS).

Instructions: Item RF105_04. Display as an active cell if RF105_01 is not coded ‘7’ (WITNESS) or RF105_03 is not coded ‘98’ (SIGNER OUTSIDE THE RU).

Instructions: Item RF105_05. Display as an active cell if RF105_01 is not coded ‘7’ (WITNESS), or RF105_04 is not coded ‘3’ (IF VOLUNTEERED: {AT LEAST ONE} SIGNER UNWILLING), OR RF105_03 is not coded ‘98’ (SIGNER OUTSIDE THE RU).

Instructions: Item RF105_06. Display as an active cell if RF105_05 is coded ‘1’ (YES).

Display "I need to confirm some information that will go on the authorization forms. Please let me know if any information needs to be updated." in bold black text if it’s the first person in the grid.

Display "I am recording that {you/{PERSON} can provide {your/his/her} own authorization to contact {medical providers} {and} {pharmacies}." if RU Member’s age is 18 years old or older or in age categories 5-9, and they are not deceased (in the current round (Person.CtrlTrackSumm=1 or prior round (RF_Person.AFPersonStatus=5)). Otherwise, use a null display.

Display "I am recording that {PERSON} needs a proxy signer to provide authorization to contact {medical providers} {and} {pharmacies}." if RU Member is deceased in the current round (Person.CtrlTrackSumm=1) or prior round (RF_Person.AFPersonStatus=5). Otherwise, use a null display.

Display "{Because {PERSON} is between the ages of 14 and 17, I am recording that a {parent/guardian} as well as {PERSON} needs to provide authorization to contact {medical providers} {and} {pharmacies}." if RU Member’s age is 14-17 years old inclusive, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5). Otherwise, use a null display. Display "parent" if they have a parent, step parent, or foster parent in the RU (RE900= 1, 2, 15, 16, 34, or 35). Otherwise, display "guardian".

Display "{Because {PERSON} is under the age of 14, I am recording that a {parent/guardian} needs to provide authorization to contact {medical providers} {and} {pharmacies}." If RU Member’s age is 13 years old or younger or in age categories 1-2, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5). Otherwise, use a null display. Display "parent" if they have a parent, step parent, or foster parent in the RU (RE900= 1, 2, 15, 16, 34, or 35). Otherwise, display "guardian".

Display "Authorization forms for children between the ages of 14 and 17 require both the child and a parent or guardian signature. Should I record that {you/{PERSON}} {are/is} over 18 and can sign for {yourself/himself/herself} or that {you/he/she} {need/needs} to sign along with a parent or guardian?" if RU Member is in age category 4, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5). Otherwise, use a null display.

Display "Authorization forms for children under the age of 14 require only a parent or guardian signature, while forms for children between the ages of 14 and 17 require both the child and a parent or guardian signature. Should I record that {PERSON} needs only a parent or guardian signature, or should they sign along with a parent or guardian?" if RU Member is in age category 3, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5). Otherwise, use a null display.

Display "medical providers" if person being looped on has at least one active MPC AF in the current round [at least one record where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)]] or [at least one record where [not Round 1 (RndType<>First) and (AF.AFType=MPC) and (AF.AFSuperceded=Empty)]] or at least one active HCI AF in the current round (AF.AFType=MPC-HCI (original) or MPC-HCI (additional)). Otherwise, use a null display.

Display "and" if current round is not the first round of the panel (RndType<>First) and person being looped on has at least one active MPC or HCI AF, and one active Pharmacy AF in the current round.

Display "pharmacies" if current round is not the first round of the panel (RndType<>First) and person being looped on has at least one active Pharmacy AF in the current round (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty). Otherwise, use a null display.

Display "ADULT RU MEMBERS SHOULD BE THE SIGNER (SELF) UNLESS A PROXY IS NEEDED." if RU Member’s age is 18 years old or older or in age categories 5-9 and they are not deceased in current (Person.CtrlTrackSumm=1) or prior round (RF_Person.AFPersonStatus=5).

Display "RU MEMBERS BETWEEN THE AGES OF 14 AND 17, REQUIRE BOTH RU MEMBER AND A PARENT OR GUARDIAN AS SIGNERS." if RU Member’s age is 14-17 years old inclusive or in age category 4, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5). Otherwise, use a null display.

Display "RU MEMBERS 13 YEARS OR YOUNGER REQUIRE A PARENT OR GUARDIAN AS THE SIGNER." if RU Member’s age is 13 years old or younger or in age categories 1-2, and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5). Otherwise, use a null display.

Display "{{PERSON} IS DECEASED. DECEASED RU MEMBERS REQUIRE A PROXY SIGNATURE.}" if RU member is deceased in the current (Person.CtrlTrackSumm=2) or prior round (RF_Person.AFPersonStatus=6). Otherwise, use a null display.

Display "RU MEMBERS 13 YEARS OR YOUNGER REQUIRE A PARENT OR GUARDIAN AS THE SIGNER. RU MEMBERS BETWEEN THE AGES OF 14 AND 17 REQUIRE BOTH TEEN AND A PARENT OR GUARDIAN AS SIGNERS." if RU member is in age category 3 and they are not deceased in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5). Otherwise, use a null display.

Display "{IF INCORRECT MAKE NECESSARY CORRECTIONS. IF CORRECT, PRESS ENTER TO CONTINUE./RECORD REQUIRED SIGNATURES.}" if RF105_01 has a prefilled answer in the answer area. Otherwise, display "RECORD REQUIRED SIGNATURES."

Use a null display for ‘SELF’, ‘PARENT’, ‘GUARDIAN’, ‘TEEN AND PARENT’, ‘TEEN AND GUARDIAN’, AND ‘WITNESS’ in the response options if person being asked about is deceased (in the current round (Person.CtrlTrackSumm=1) or deceased in a prior round (RF_Person.AFPersonStatus=5). Otherwise, display all response category options.

Display the interviewer instruction 'NAVIGATION: Complete the grid in order of respondent's answers.' in red text.

If person being asked about is deceased in the current round (Person.CtrlTrackSumm= 1) or deceased in a prior round (RF_Person.AFPersonStatus=5), autocode ‘1’ (DECEASED) for this person, then go to RF105_03.

If person being asked about is institutionalizing in the current round (Person.CtrlTrackSumm=2) or institutionalized in a prior round (RF_Person.AFPersonStatus=6), autocode ‘3’ (INSTITUTIONALIZED) for this person, then go to RF105_03.

If coded ‘2’ (DISABLED) or ‘3’ (INSTITUTIONALIZED), set AFRsnSecSign as ‘3’ (Patient Disabled/Institutionalized).

Display Instructions: Display the interviewer instruction 'NAVIGATION: Complete the grid in order of respondent's answers.' in red text.

Responses: {FIRST NAME [MIDDLE NAME] LAST NAME} – {FNAME}’S {RELATION} 1 RF105_04 (RF1187)

{FIRST NAME [MIDDLE NAME] LAST NAME} – {FNAME}’S {RELATION} 2 RF105_04 (RF1187)

{FIRST NAME [MIDDLE NAME] LAST NAME} – {FNAME}’S {RELATION} 3 RF105_04 (RF1187)

{FIRST NAME [MIDDLE NAME] LAST NAME} – {FNAME}’S {RELATION} 4 RF105_04 (RF1187)

{FIRST NAME [MIDDLE NAME] LAST NAME} – {FNAME}’S {RELATION} 5 RF105_04 (RF1187)

Set AFSignID as the PID for the person selected from the roster at RF105_03. If coded ‘98’ set AFSignID as ‘904’.

Set AFSignRel as the relationship coded at RE900 for the person selected from the roster for RF105_03.

If coded ‘98’ (SIGNER OUTSIDE THE RU) continue to next RU member on grid. At grid completion, continue with BOX_90. (NOTE: AFMode and AFMode_AtBox_100 will be set to paper at Box_100).

If person being asked about died in a prior round (RF_Person.AFPersonStatus=5) or was institutionalized in a prior round (RF_Person.AFPersonStatus=6) continue to the next RU member on the grid. At grid completion, continue with BOX_90. (NOTE: AFMode and AFMode_AtBox_100 will be set to paper at Box_100 ).

For "RELATION" display the relationship between the RU member listed in the roster to the person being looped on from RE900. Display RF or DK for relationships coded ‘RF’ (REFUSED) or ‘DK’ (DON’T KNOW). Otherwise, use a null display. For people who died in a prior round (RF_Person.AFPersonStatus=5) or were institutionalized in a prior round (RF_Person.AFPersonStatus=6), only display "{FIRST NAME [MIDDLE NAME] LAST NAME}".

Display "for" if RF105_01 is coded ‘2’ (PARENT), ‘3’ (GUARDIAN), or ‘6’ (PROXY).

Display "with" if RF105_01 is coded ‘4’ (TEEN AND PARENT) or ‘5’ (TEEN AND GUARDIAN).

Display "PARENT" if RF105_01 is coded ‘2’ (PARENT) or ‘4’ (TEEN AND PARENT).

Display "GUARDIAN" if RF105_01 is coded ‘3’ (GUARDIAN) or ‘5’ (TEEN AND GUARDIAN).

Display the interviewer instruction 'NAVIGATION: Complete the grid in order of respondent's answers.' in red text.

{CODE ‘2’ (SIGNER UNAVAILABLE) UNLESS RESPONDENT VOLUNTEERS THAT A SIGNER IS UNWILLING TO COMPLETE THE AUTHORIZATION FORM TASK.}

{{Are/Is} {you/{SIGNER 1}} available to sign the {medical} {and} {pharmacy} authorization forms for {yourself/{himself/herself/{PERSON}}} on my laptop now?}

{{Are both {you/{SIGNER 1}} and {you/{SIGNER 2}} available to sign the {medical} {and} {pharmacy} authorization forms for {you/{PERSON}} on my laptop now?}

ONLY CODE 1 ‘{BOTH} SIGNER{S} AVAILABLE IN-PERSON’ IF CONDUCTING IN-PERSON INTERVIEW.

Responses: {BOTH} SIGNER{S} AVAILABLE IN PERSON (ESIGNATURE) 1 RF105_05 (RF1188)

Programmer Instructions: If coded ‘3’ (IF VOLUNTEERED: {AT LEAST ONE} SIGNER UNWILLING) continue to next RU member on grid. At grid completion, continue with BOX_90.

Soft check: If response if coded ‘1’ (SIGNER{S} AVAILABLE IN-PERSON (ESIGNATURE)) and ST65 <> 1 ‘In-Person’ display the error message: "PLEASE VERIFY RESPONSE. ONLY CODE 1 ‘{BOTH} SIGNER{S} AVAILABLE IN-PERSON’ IF CONDUCTING IN-PERSON INTERVIEW."

Display Instructions: Display "CODE ‘2’ (SIGNER UNAVAILABLE) UNLESS RESPONDENT VOLUNTEERS THAT A SIGNER IS UNWILLING TO COMPLETE THE AUTHORIZATION FORM TASK." if ST65 is coded ‘2’ (BY TELEPHONE) or ‘3’ BY VIDEO (CAVI)). Otherwise, use a null display.

Display "{Are/Is} {you/{SIGNER 1}} available to sign the {medical} {and} {pharmacy} authorization forms for {yourself/{himself/herself/{PERSON}}} on my laptop now?" if ST65 is coded ‘1’ (IN-PERSON) and RF105_01 is coded ‘1’ (SELF), ‘2’ (PARENT), ‘3’ (GUARDIAN), or ‘6’ (PROXY).

Display ‘{SIGNER 1}’ and ‘{PERSON}’ if RF105_01 is coded ‘2’ (PARENT), ‘3’ (GUARDIAN), or ‘6’ (PROXY) and the PID of AFSignID is not the respondent. Otherwise, display ‘{SIGNER 1}’ and ‘himself/herself}’ [RF105_01 is coded ‘1’ (SELF) and person is not the respondent].

For ‘SIGNER 1’ display the RF_Person.FullName of the person being looped for this row if RF105_ 01 is coded ‘1’ (SELF). Otherwise, display the RF_Person.FullName of the person linked to the PID of AFSignID.

Display "Are both {you/{SIGNER 1}} and {you/{SIGNER 2}} available to sign the {medical} {and} {pharmacy} authorization forms for {you/{PERSON}} on my laptop now?" if ST65 is coded ‘1’ (IN-PERSON) and RF105_01 is coded ‘4’ (TEEN AND PARENT) or ‘5’ (TEEN AND GUARDIAN). Otherwise, use a null display.

For "{you/{SIGNER 1}}", display ‘you’ if person for this row is the respondent. Otherwise, display ‘{SIGNER 1}’. For ‘SIGNER 1’ display the RF_Person.FullName of the RU member.

For "{you/{SIGNER 2}", display ‘you’ if the PID of AFSignID is the respondent. Otherwise, display ‘{SIGNER 2}’. For ‘SIGNER 2’, display the RF_Person.FullName linked to the PID of AFSignID.

For "{you/{PERSON}}", display ‘you’ if person for this row is the respondent. Otherwise, display ‘{PERSON}’.

Display "medical" if person being looped on has at least one active MPC AF in the current round [at least one record where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)]] or [at least one record where [not Round 1 (RndType<>First) and (AF.AFType=MPC) and (AF.AFSuperceded=Empty)]] or [at least one record where (AF.AFType=MPC-HCI (original) or HCI (additional)].

Display "and" if current round is not the first round of the panel (RndType<>First) and person being looped on has at least one active MPC and one active Pharmacy AF in the current round. Otherwise, use a null display.

Display "pharmacy" if current round is not the first round of the panel (RndType<>First) and person being looped on has at least one active Pharmacy AF in the current round [at least one record where (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)]. Otherwise, use a null display.

Display the interviewer instruction 'NAVIGATION: Complete the grid in order of respondent's answers.' in red text.

Programmer Instructions: If coded ‘2’, ‘RF’, or ‘DK’, continue to next RU member on grid. At grid completion, continue with BOX_90.

Display Instructions: Display the interviewer instruction 'NAVIGATION: Complete the grid in order of respondent's answers.' in red text.

Route Details: Continue with BOX_100.

Programmer Instructions: Before leaving the grid, CAPI should verify that all eligible fields per row of the grid have a valid answer entered. If not, display error message "ONE OR MORE QUESTIONS HAVE NOT BEEN ANSWERED. PRESS <OK> TO GO TO THE FIRST UNANSWERED QUESTION: {Question Tag} FOR {PERSON’S FIRST, MIDDLE AND LAST NAME}". CAPI will move to the first unanswered item/field, starting from the top left of the grid and moving to the next unanswered item, left to right by row, until all are complete.

Set AFMode = ‘1’ (ESIGNATURE) for all AFs for the RU member being looped on, if:

Set AFMode = ‘2’ (DOCUSIGN) for all AFs for the RU member being looped on, if:

RF105_01 is coded ‘1’ (SELF) and contact information is available for the RU member being looped on (either Person.EmailAddr is not empty or (Person.Cellphone is not empty and (Person.CMTextCell=1 (YES) or Person.CMTextCell=3 (PENDING)))) RF105_04 is coded ‘2’ (NO, {AT LEAST ONE} SIGNER UNAVAILABLE) and RF105_01 is coded ‘2’ (PARENT) or ‘3’ (GUARDIAN) and contact information is available for the PID stored at AFSignID (either Person.EmailAddr is not empty or (Person.Cellphone is not empty and (Person.CMTextCell=1 (YES) or Person.CMTextCell=3 (PENDING))) for the PersID linked to AFSignID) RF105_04 is coded ‘2’ (NO, {AT LEAST ONE} SIGNER UNAVAILABLE) and RF105_01 is coded ‘4’ (TEEN AND PARENT) or ‘5’ (TEEN AND GUARDIAN) and contact information is available for the PID stored at AFSignID (either Person.EmailAddr is not empty or (Person.Cellphone is not empty and (Person.CMTextCell=1 (YES) or Person.CMTextCell=3 (PENDING))) for the PersID linked to AFSignID) RF105_04 is coded ‘2’ (NO, {AT LEAST ONE} SIGNER UNAVAILABLE) and RF105_01 is coded ‘6’ (Proxy) and contact information is available for the PID stored at AFSignID (either Person.EmailAddr is not empty or (Person.Cellphone is not empty and (Person.CMTextCell=1 (YES) or Person.CMTextCell=3 (PENDING))) for the PersID linked to AFSignID)

Otherwise, set AFMode = ‘3’ (PAPER) for all AFs for the RU member being looped on.

Note: AFMode_AtBox_100 is also set according to the same rules above. AFMode_AtBox_100 will control the launching of the eSignature app. The values of AFMode_AtBox_100 may or may not be updated by backing up and changing answers at the RF105 grid. AFMode may be updated in the eSignature app when requesting paper. The values of AFMode are initialized at RF115 and may or may not be updated by backing up and changing answers at the RF105 grid.

Note: Please see the Backing up and Ctrl-S in RF document below on Sharepoint for information on which AF array variables may be impacted by backing up and when those variables need to be updated by.

https://mepspm.westat.com/FinalDesignDocsbyGroup/Respondent%20Form%20(RF)%20Section%20Supporting%20Documents/RF%20Reference%20Documents/Backing%20up%20and%20Ctrl-S%20in%20RF.xlsx

If AFReqSign=1 or 2, display only {SIGNER 1}. If AFReqSign=3, display both {SIGNER 1} and {SIGNER 2} separated by a comma.

For ‘SIGNER 1’ display the RF_Person.FullName linked to the PID of the Person if AFReqSign is coded ‘1’ (Patient only) or ‘3’ (BOTH). Display the RF_Person.FullName linked to the PID of AFSignID if AFReqSign is coded ‘2’ (Proxy/Parent only) and AFSignID<>904. Otherwise, display "SIGNER OUTSIDE THE RU" if AFSignID=904.

For ‘SIGNER 2’ display the RF_Person.FullName linked to the PID of AFSignID when AFReqSign=3 (BOTH) and AFSignID<>904. Otherwise, display "SIGNER OUTSIDE THE RU" if AFSignID=904.

Display the total number of all active AFs on the AF array for this person, where (Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)] or [(RndType<>First) and (AF.AFType=MPC or Pharmacy or HCI) and (AFSuperceded=empty). Note this count should include all outstanding MPC, Pharmacy and HCI AFs.

Route Details: For each person, ask RF125- END_LP30.

Loop definition: Loop collects the status and signatures of all eligible MPC, Pharmacy, and HCI Authorization Forms. This loop cycles on RU members that meet one of the following conditions:

Round 1 and person eligible for MPC authorization form collection for the current round [person has at least one record where (AF.AFType=MPC) and (AF.RequestRd1=Yes)]

Not Round 1 (RndType<>First) and person eligible for MPC or Pharmacy authorization form collection for the current round [person has at least one record where (AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]

[In this next section, we will be {collecting electronic signatures}{{and} collecting hardcopy authorization forms} {{and} discussing how to access Docusign authorization forms}.] {Let’s start with {you/{PERSON}}./Now {let’s collect the electronic signatures for{your/{PERSON}}’s authorization forms.} /{I have some hardcopy authorization forms for {you/{PERSON}}.}/ {let’s discuss {your/{PERSON}}’s Docusign authorization forms.}}

Display Instructions: Display "In this next section, we will be {collecting electronic signatures}{{and} collecting hardcopy authorization forms} {{and} discussing how to access Docusign authorization forms}." in bold black text if first cycle of LOOP_30. Otherwise, always display in brackets and "grayed-out" text.

Display "collecting electronic signatures"if there is at least one person in the RU with AFMode coded as ‘1’ (ESignature).

Display "{and} collecting hardcopy authorization forms" if there is at least one person in the RU with AFMode coded as ‘3’ (Paper). Display "and" if at least one person in the RU with AFMode coded as’1’ (ESignature).

Display "{and} discussing how to access Docusign authorization forms" if there is at least one person in the RU with AFMode coded as ‘2’ (Docusign). Display "and" if there is at least one person in the RU with AFMode coded as ‘2’ (Docusign) or ‘3’ (Paper).

Display "Let’s start with {you/{PERSON}}." if first cycle of LOOP_30. Otherwise, display "Now {let’s collect the electronic signature for{your/{PERSON}}’s authorization forms.}/{I have some hardcopy authorization forms for {you/{PERSON}}.}/{let’s discuss {your/{PERSON}}’s Docusign authorization forms.}"

Display "let’s collect the electronic signatures for{your/{PERSON}}’s authorization forms." if RU member being looped upon has AFMode coded as ‘1’ (Esignature).

Display "I have some hardcopy authorization forms for {you/{PERSON}}" if RU member being looped upon has AFMode coded as ‘3’ (Paper).

Display "let’s discuss {your/{PERSON}}’s Docusign authorization forms." if RU member being looped upon has AFMode coded as ‘2’ (Docusign).

Route Details: If at least one AF for the RU member being looped on has AFMode coded as ‘1’ (ESignature), continue with RF135.

Otherwise, go to BOX_120.

{ONLY LAUNCH ESIGNATURE APP IF IN-PERSON. BACK-UP AND RE-CODE RF105_04 IF CAVI OR TELEPHONE INTERVIEW.}

{Now I would like {you/{SIGNER 1}} to sign the {medical} {and} {pharmacy} authorization forms for {yourself/himself/herself/{PERSON}} on my laptop.}

{Now I would like both {you/{SIGNER 1}} and {you/{SIGNER 2}} to sign the {medical} {and} {pharmacy} authorization forms for {PERSON} on my laptop.}

{ONCE ESIGNATURE APP IS LAUNCHED, TURN THE LAPTOP TOWARDS THE SIGNER{S} AND HAND THEM A STYLUS SO THEY CAN SIGN./THE ESIGNATURE APP FOR {PERSON} HAS ALREADY BEEN COMPLETED AND CANNOT BE REOPENED.}

https://mepspm.westat.com/FinalDesignDocsbyGroup/Respondent%20Form%20(RF)%20Section%20Supporting%20Documents/Electronic%20Signature%20Specification/Esignature%20sPec_113021_prod_v1_4.docx

The ESignature App should not relaunch if all the AFs for the person being looped upon were assigned an eSignStatus by the app (RF_Person.eSigAppDone=Yes).

Display Instructions: Display "ONLY LAUNCH ESIGNATURE APP IF IN-PERSON. BACK-UP AND RE-CODE RF105_04 IF CAVI OR TELEPHONE INTERVIEW." in red text if ST65 is coded ‘2’ (BY TELEPHONE) or ‘3’ BY VIDEO (CAVI)) and RF_Person.eSigAppDone=Empty. Otherwise, use a null display.

Display "Now I would like {you/{SIGNER 1}} to sign the {medical} {and} {pharmacy} authorization forms for {yourself/{himself/herself/{PERSON}}} on my laptop." if AFReqSign =’1’ (Patient Only) or ‘2’ (Proxy/Parent Only) and RF_Person.eSigAppDone=Empty. Otherwise, use a null display.

Display ‘you’ and ‘yourself’ if person being looped on is the respondent and RF105_01 is coded ‘1’ (SELF). Display ‘you’ and ‘{PERSON}’ if RF105_01 is coded ‘2’ (PARENT), ‘3’ (GUARDIAN), or ‘6’ (PROXY) and the PID of AFSignID is the respondent. Display ‘{SIGNER 1}’ and ‘{PERSON}’ if RF105_01 is coded ‘2’ (PARENT), ‘3’ (GUARDIAN), or ‘6’ (PROXY) and the PID of AFSignID is not the respondent. Otherwise, display ‘{SIGNER 1}’ and ‘himself/herself/{PERSON}}’ [RF105_01 is coded ‘1’ (SELF) and person is not the respondent].

For ‘SIGNER 1’ display the RF_Person.FullName of the person being looped on if RF105_ 01 is coded ‘1’ (SELF). Otherwise, display the RF_Person.FullName of the person linked to the PID of AFSignID.

Display "Now I would like both {you/{SIGNER 1}} and {you/{SIGNER 2}} to sign the {medical} {and} {pharmacy} authorization forms for {you/{PERSON}} on my laptop." if AFReqSign coded as ‘3’ (Both) and RF_Person.eSigAppDone=Empty. Otherwise, use a null display.

For "{you/{SIGNER 1}}", display ‘you’ if person being looped on is the respondent. Otherwise, display ‘{SIGNER 1}’. For ‘SIGNER 1’ display the RF_Person.FullName of the RU member.

For "{you/{PERSON}}", display ‘you’ if the person being looped on is the respondent. Otherwise, display ‘{PERSON}’.

Display "medical" if person being looped on has at least one active MPC AF in the current round [at least one record where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)]] or [at least one record where [not Round 1 (RndType<>First) and (AF.AFType=MPC) and (AF.AFSuperceded=Empty)]]. Or has at least one active HCI AF in the current round (AF.AFType=MPC-HCI (original).

Display "and" if current round is not the first round of the panel (RndType<>First) and person being looped on has at least at least one active MPC or HCI AF and one active Pharmacy AF in the current Round. Otherwise, use a null display.

Display "ONCE ESIGNATURE APP IS LAUNCHED, TURN THE LAPTOP TOWARDS THE SIGNER{S} AND HAND THEM A STYLUS SO THEY CAN SIGN." (in the standard blue interviewer instruction font color) if RF_Person.eSigAppDone=Empty. Otherwise, display "THE ESIGNATURE APP FOR {PERSON} HAS ALREADY BEEN COMPLETED AND CANNOT BE REOPENED." in bold, red text.

Display "LAUNCH THE ESIGNATURE APP" if RF_Person.eSigAppDone=Empty. Otherwise, display "CONTINUE".

Route Details: If at least one AF for the RU member being looped on has AFMode coded as ‘1’ (eSignature) and the eSignStatus for that AF is empty, update the AFMode for those AFs where (AF.AFMode=1 and AF.eSignStatus=empty) to ‘3’ (Paper).

If at least one AF for the RU member being looped on has AFMode coded as ‘3’ (Paper), then continue with RF140_01.

Otherwise, go to BOX_130.

Note: AFMode will be updated to '3' (Paper) by the eSignature app if eSignStatus=3 (Paper).

INTERVIEWER: {COMPLETE A NEW AF FOR THIS PAIR./TAKE OUT PREPRINTED AF FOR THIS PAIR. IF NOT AVAILABLE, FILL OUT A BLANK AF.} {ON TOP LEFT CORNER OF FORM, PRINT "HCI".}

DOB: {MM/DD/YYYY} AGE: {XXX} {ACTION: {Status Action}} {OTHER NAMES:{Other Names}}

{IF NECESSARY, SAY: Since {LINKED PROV NAMES} (is/are) associated with a larger practice, we will ask for authorization for just {PROVIDER FULL NAME}.}

Programmer Instructions: Preloaded grid type 2 – flexible navigation including RF140_01, RF140_02, RF140_03, RF140_04, RF140_N, as well as RF150_01, RF150_02, RF150_03, RF150_04, RF150_05, and RF150_06.

Instructions: Display the name of the medical, pharmacy, or institution provider for this row. This column is protected and uneditable. (Use AF.ProvName from the AF array. Variable may need to be truncated for display in grid.)

Display only MPC, Pharmacy, and HCI authorization forms that are active for this person for this round, records where:

[(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)] or [Not Round 1 (RndType<>First) and (AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]].

Not Round 1 (RndType<>First) and person that is part of this RU (MostRecentRU=RUUnit) rejoined the community this round from previously being institutionalized in a health care setting [person has Record where (AF.AFType=MPC-HCI (original) or HCI(additional)) and (AF.AFInstStatus=1 or 2)]

Instructions: Display the Authorization form type – either "MPC","Pharmacy", or "MPC- HCI". This column is protected and uneditable. (use AF.AFType)

Instructions: Display the color linked to this authorization form. (see BOX_10 rules)

Display "COMPLETE A NEW AF FOR THIS PAIR." if no preprinted AF exists for this record (AF.AFPreprinted=Empty). Otherwise display, "TAKE OUT PREPRINTED AF FOR THIS PAIR. IF NOT AVAILABLE, FILL OUT A BLANK AF."

Display "ON TOP LEFT CORNER OF FORM, PRINT "HCI"." if AF.AFType=MPC-HCI (original) or MPC-HCI (additional).

Display "AF STATUS FROM PREVIOUS ROUND: {DISPLAY RECEIPT CONTROL STATUS}" if this AF record was outstanding from the previous round and not replaced by a new person- provider Pair record [(AF.AFSuperceded=Empty) and (AF.OrigRnd< > current round) and (AF.PL_AFRecCtrlStatus<>Empty)]. Otherwise, use a null display.

For "{DISPLAY RECEIPT CONTROL STATUS}", display the label associated with the receipt control status. If the receipt control status is "Other, specify", display the other specify status text entry field. (Use AF.PL_AFRecCtrlStatus and AF.PL_AFRecCtrlStatusOS)

PROVIDER ID:, PID, AND SIGNATURE DATE…: should be displayed in the traditional blue font and size of interviewer instructions. However, display the contents after that label (i.e., the provider/pharmacy name, person name, etc.) in bold black. This will make the screen easier to read.

The label ACTION: should be displayed in the traditional interviewer instruction font size – but in red.

However, display the contents after that label (i.e., status action) in bold black.

For "{Other Names}" display the text string entered at RF105_06 (AF.OtherNames). If this field is empty, leave the field blank and do not display the label "OTHER NAMES".

For "{Provider/Pharmacy Full Name}" display the full name of the provider or pharmacy for this AF record. (Use AF.ProvName with no truncation).

For "{Combined Street Address}" display the street address of the provider or pharmacy for this AF record. (Concatenate AF.StrtAddr1 and AF.StrtAddr2 into one line separated with a space)

For "{City}, {ST} {Zip Code} {Telephone}" display the rest of the address of the provider or pharmacy for this AF record. (Use AF.City, AF.State, AF.Zip and AF.Phone)

For "{First,[Middle],Last Name}" display the name of the RU member for this AF record. (Use AF.FName, AF.MName, and AF.LName)

For (DOB) "{MM/DD/YYYY}" display the DOB of the RU member for this AF record. (Use AF.DOBM, AF.DOBD, AF.DOBY). If complete DOB is RF/DK/empty, leave the display empty. If part of the DOB is RF/DK/empty, display "RF" or "DK" or leave empty as appropriate for that field.

For "{XXX}" display the age or age range of the RU member for this AF record. (Use AF.Age. If Age=RF/DK/empty, use AF.AgeCat. If AF.AgeCat= RF/DK/empty, use AF.AgeGuess.)

Display "ACTION: {Status Action}" if (AF.AFPersonStatus=3, 4, 5, or 6) or if [(AF.AFPersonStatus=1 or 2) and [(AF.Age <=17) or (AF.AgeCat or AF.AgeGuess=1-4)]]. Otherwise, use a null display.

Display " Child <=13. Need Parent/Guardian Signature" if [(AF.AFPersonStatus=1 or 2) and [(AF.Age <=13) or (AF.Age is RF/DK/empty and AF.AgeCat or AF.AgeGuess= 1-3) and AFReqSign=2 (Proxy/Parent only)]]. Otherwise, use a null display.

Display " Child 14-17. Need Patient and Parent/Guardian Signature" if [(AF.AFPersonStatus= 1 or 2) and [(AF.Age 14-17) or (AF.Age is RF/DK/empty and AF.AgeCat or AF.AgeGuess= 3 or 4) and AFReqSign=3 (Both)]]. Otherwise, use a null display.

Display "Patient Deceased {In Prior Round}. Need Proxy Signature" if AF.AFPersonStatus=3 or 5.

Display "Patient {Still} Institutionalized. Need Proxy Signature" if AF.AFPersonStatus= 4 or 6 and AFReqSign=2 (Proxy/Parent only). Display "Still" if AF.AFPersonStatus=6. Otherwise, use a null display.

For "{ProvID}", display the provider ID of the provider or pharmacy for this AF record (ProvID). For "{PID}", display the AF.PersID of the RU member for this AF record.

For (SIGNATURE DATE) "{MM/DD/YYYY}", display the required signature date for this AF record (Use AF.ReqSignDt).

Display "IF NECESSARY, SAY: Since {LINKED PROV NAMES} (is/are) associated with a larger practice, we will ask for authorization for just {PROV NAME}." if there are linked provider names for this AF record (AF.LinkedAF.ProvNames < > Empty). Otherwise, use a null display.

For "{LINKED PROV NAMES}" display the text entry associated with this field for this AF record.

This will be a string of provider first and last names. (Use AF.LinkedAF.ProvNames).

For "{PROVIDER FULL NAME}" display the full name of the provider for this AF record. (Use AF.ProvName).

{IF NECESSARY, SAY: Since {LINKED PROV NAMES} (is/are) associated with a larger practice, we will ask for authorization for just {PROVIDER FULL NAME}.}

Programmer Instructions: Preloaded Grid type 2 – flexible navigation, including items RF150_01, RF150_02, RF50_03, RF150_04, RF150_05, and RF150_06, as well as RF140_01, RF140_02, RF140_03, RF140_04, RF140_N.

If RF150_02 is coded ‘2’ (LEFT WITH RESPONDENT) or ‘3’ (MAILED TO RESPONDENT), return to RF140_01 for next authorization form on grid. At grid completion, go to BOX_130.

Instructions: Display the name of the medical, pharmacy, or institution provider for this row. This column is protected and uneditable. (use AF.ProvName from the AF array. Variable may need to be truncated for display in grid.)

Display only MPC, Pharmacy, and HCI authorization forms that are active for this person for this round, records where:

[Not Round 1 (RndType<>First) and (AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]].

Instructions: Display the Authorization form type – either "MPC","Pharmacy", or "MPC-HCI". This column is protected and uneditable. (use AF.AFType)

Instructions: Display the color linked to this authorization form. (see BOX_10 rules)

Instructions: Display the entered responses from RF140_01-RF140_N for each authorization form in a protected, uneditable field.

Instructions: Item RF150_02. Display as an active cell if RF150_01 is coded ‘91’ (OTHER).

Instructions: Item RF150_03. Display as an active cell if RF150_01 is coded ‘1’ (SIGNED).

Instructions: Item RF150_04. Display as an active cell if RF150_01 is coded ‘1’ (SIGNED).

Instructions: Item RF150_05. Display as an active cell if RF150_01 is coded ‘4’ (REFUSED).

Instructions: Item RF150_06. Display as an active cell if RF150_01 is coded ‘91’ (OTHER SPECIFY).

For "{Provider/Pharmacy Full Name}" display the full name of the provider or pharmacy for this AF record as grayed out text. (Use AF.ProvName with no truncation).

Programmer Instructions: Return to RF140_01 for next authorization form on grid.

Display Instructions: Display the labels PROVIDER NAME: and PATIENT: as grayed out text.

For "{Provider/Pharmacy Full Name}" display the full name of the provider or pharmacy for this AF record as grayed out text. (Use AF.ProvName with no truncation).

For "{First,[Middle],Last Name}" display the name of the RU member for this AF record as grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Note: Each authorization form has a pre-assigned authorization form number. This number is linked to the authorization form type, panel and round.

Hard check: Exactly 8 digit alpha-numeric entry required. If less than 8 characters entered, display the following message: "AUTHORIZATION FORM NUMBER REQUIRES EXACTLY 8 LETTERS/NUMBERS. VERIFY FORM NUMBER AND FORM TYPE AND RE-ENTER."

Hard Check – MPC/Pharmacy/HCI Authorization Forms: The Authorization form number entered must follow the conventions noted below for the panel and AF type. If an authorization form number is entered that does not meet the conventions, display the following message:

"INVALID AUTHORIZATION FORM NUMBER ENTERED. VERIFY FORM NUMBER AND FORM TYPE AND RE-ENTER."

For the MPC and Pharmacy AF numbering conventions, see the MEPS AF Numbering Memo

https://mepspm.westat.com/FinalDesignDocsbyGroup/Forms/AllItems.aspx?RootFolder=%2FFinalDesignDocsbyGroup%2FRespondent%20Form%20%28RF%29%20Section%20Support ing%20Documents%2FAF%20Numbering%20Memos&FolderCTID=0x012000CE0FAA87D 31EF94CB16570AFD8729C46&View=%7BB0F5D183%2DE0BB%2D4DB4%2DB308%2D B130405E7963%7D

Display Instructions: Display the labels PROVIDER NAME: and PATIENT: as grayed out text.

For "{Provider/Pharmacy Full Name}" display the full name of the provider or pharmacy for this AF record as grayed out text. (Use AF.ProvName with no truncation).

For "{First,[Middle],Last Name}" display the name of the RU member for this AF record as grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Programmer Instructions: Return to RF140_01 for next authorization form on grid.

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 (use AF.ReqSignDt), but cannot be after ‘Today’s’ Date’ (the current date set on the laptop, which may be different from RU reference period end date). If date is before correct date, display the following message: "AUTHORIZATION FORM MUST BE SIGNED ON OR AFTER ABOVE DATE. VERIFY AND RE-ENTER DATE OR COMPLETE NEW AF."

For "{Provider/Pharmacy Full Name}" display the full name of the provider or pharmacy for this AF record as grayed out text. (Use AF.ProvName with no truncation).

For "{First,[Middle],Last Name}" display the name of the RU member for this AF record as grayed out text. (Use AF.FName, AF.MName, and AF.LName)

For (SIGNATURE DATE) "{MM/DD/YYYY}", display the required signature date for this AF record (Use AF.ReqSignDt). This date should be displayed in bold black.

Programmer Instructions: If coded ‘1’, ‘2’, ‘3’, ‘4’, ‘5’, ‘6’, or ‘7’, go to RF140_01 for next authorization form on grid.

Display Instructions: Display the labels PROVIDER NAME: and PATIENT: as grayed out text.

For "{Provider/Pharmacy Full Name}" display the full name of the provider or pharmacy for this AF record as grayed out text. (Use AF.ProvName with no truncation).

For "{First,[Middle],Last Name}" display the name of the RU member for this AF record as grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Programmer Instructions: Return to RF140_01 for next authorization form on grid.

Display Instructions: Display the labels PROVIDER NAME: and PATIENT: as grayed out text.

For "{Provider/Pharmacy Full Name}" display the full name of the provider or pharmacy for this AF record as grayed out text. (Use AF.ProvName with no truncation).

For "{First,[Middle],Last Name}" display the name of the RU member for this AF record as grayed out text. (Use AF.FName, AF.MName, and AF.LName)

Route Details: If at least one AF for the RU member being looped on has AFMode coded as ‘2’ (Docusign), continue with RF160.

Otherwise, go to END_LP30.

In a few days, {{SIGNER 1}/{SIGNER 2}} will receive {an email} {and} {a text} from MEPS inviting {you/them} to review and sign some authorization forms for {yourself/{PERSON}} through a secure electronic signature website called DocuSign.

Please {remind them to} review and sign the authorization forms as soon as possible after {you/they} receive {your/their} invitation.

Display Instructions: Display ‘{SIGNER 1}’ if AFReqSign is coded ‘1’ (Patient Only) substituting ‘you’ for SIGNER 1 if RF105_01 is coded ‘1’ (SELF) and the person being looped on is the respondent. Otherwise, display RF_Person.FullName linked to the PID of the person being looped on.

Display ‘{SIGNER 1}’ if AFReqSign is coded ‘2’ (Proxy/Parent only) substituting ‘you’ if the PID of AFSignID is the respondent. Otherwise, display the RF_Person.FullName linked to the PID of AFSignID.

Display ‘{SIGNER 2}’ if AFReqSign is coded ‘3’ (Both) substituting ‘you’ if the PID of AFSignID is the respondent. Otherwise, display the RF_Person.FullName linked to the PID of AFSignID.

Display ‘an email’ if an email is available for the PID stored at AFSignID and AFReqSign is coded ‘2’ (Proxy/Parent) or ‘3’ (Both), or if AFReqSign is coded ‘1’ (Patient Only) and an email is available for the RU member being looped on (Person.EmailAddr is not empty).

Display ‘and’ if an email and phone with permission to text given or pending is available for the PID stored at AFSignID and AFReqSign is coded ‘2’ (Proxy/Parent) or ‘3’ (Both), or if AFReqSign is coded ‘1’ (Patient Only) and an email and phone with permission to text given or pending is available for the RU member being looped on (Person.EmailAddr is not empty and (Person.CMTextCell=1 or Person.CMTextCell=3)). Otherwise, use a null display.

Display ‘a text’ if a phone with permission to text given or pending is available for the PID stored at AFSignID and AFReqSign is coded ‘2’ (Proxy/Parent) or ‘3’ (Both), or if AFReqSign is coded ‘1’ (Patient Only) and a phone with permission to text given or pending is available for the RU member being looped on (either Person.CMTextCell=1 or Person.CMTextCell=3). Otherwise, use a null display.

For "{yourself/{PERSON}}", display ‘yourself’ if the person being looped on is the respondent.

Display ‘remind them to’ if AFReqSign is coded ‘1’ (Patient Only) and the person being looped on is not the respondent or if AFReqSign is coded ‘2’ (Proxy/Parent only) and the PID of AFSignID is the not respondent Otherwise, use a null display.

Route Details: Cycle on next person that meets the condition stated in the loop definition.

If no more people meet the stated conditions, end LOOP_30 and continue with BOX_140.