Event Roster (EV) Section
BOX_00
======
----------------------------------------------------
| CONTEXT HEADER DISPLAY INSTRUCTIONS: |
| DISPLAY PERS.FULLNAME, PROV.DRFNAM, PROV.LORPNAME |
| (IF EVNT.PROVNUM ^= -1), EVNT.EVNTTYPE (IF SET), |
| EVNT.EVNTBEGM,D (EVNTBEGM ONLY FOR HH), |
| (PRND.BEGREFMM, DD FOR OM), EVNT.EVNTENDM, D (IF |
| EVNT = HS), (PRND.ENDREFMM, DD FOR OM). |
----------------------------------------------------
BOX_01
======
----------------------------------------------------
| IF COMING FROM WITHIN PERSON LOOP IN PROVIDER |
| PROBES, CODE EV01 AUTOMATICALLY BY CAPI WITH THE |
| CORRECT PERSON NAME AND GO TO EV02 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, CONTINUE WITH EV01 |
----------------------------------------------------
EV01
====
INTERVIEWER: SELECT CORRECT PERSON FOR THIS EVENT.
[1. First Name,[Middle Name],Last Name-65] ...
[2. First Name,[Middle Name],Last Name-65] ...
[3. First Name,[Middle Name],Last Name-65] ...
[Code One]
----------------------------------------------------
| ROSTER DETAILS: |
| TITLE: RU_MEMBERS_SELECTONE |
| |
| COL # 1 HEADER: PERSON-TYPE-PROVIDER |
| INSTRUCTIONS: DISPLAY RU MEMBERS’ FIRST, MIDDLE, |
| AND LAST NAMES (PERS.FULLNAME) |
----------------------------------------------------
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS THE |
| RU-MEMBERS-ROSTER FOR SELECTION OF RU MEMBERS. |
----------------------------------------------------
----------------------------------------------------
| ROSTER BEHAVIOR: |
| 1. SELECT ALLOWED. INTERVIEWER MAY SELECT ONE |
| FROM THE LISTED MEMBERS. |
| |
| 2. MULTIPLE SELECT DISALLOWED. |
| |
| 3. ADD, DELETE, AND EDIT DISALLOWED. |
----------------------------------------------------
----------------------------------------------------
| ROSTER FILTER: |
| NONE. DISPLAY ALL. |
----------------------------------------------------
EV02
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
INTERVIEWER: WHAT TYPE OF EVENT IS IT?
HOSPITAL STAY ......................... HS {BOX_02}
HOSPITAL EMERGENCY ROOM ............... ER {BOX_02}
HOSPITAL OUTPATIENT DEPARTMENT ........ OP {BOX_02}
MEDICAL PROVIDER VISIT ................ MV {BOX_02}
DENTAL CARE ........................... DN {BOX_02}
HOME HEALTH ........................... HH {EV06}
OTHER MEDICAL EXPENSES ................ OM
INSTITUTIONAL/LONG TERM CARE STAY ..... IC {BOX_02}
HELP AVAILABLE FOR DEFINITION OF EVENT TYPES.
[Code One]
----------------------------------------------------
| IF ROUNDS 3 OR 5 AND EV02 IS CODED ‘OM’, GO TO |
| EV02A |
----------------------------------------------------
----------------------------------------------------
| IF ROUNDS 1, 2, OR 4 AND EV02 IS CODED ‘OM’, |
| GO TO EV03 |
----------------------------------------------------
BOX_02
======
----------------------------------------------------
| ASK PROVIDER ROSTER (PV) SECTION FOR THIS EVENT |
----------------------------------------------------
----------------------------------------------------
| AT COMPLETION OF THE PV SECTION, GO TO BOX_03 |
----------------------------------------------------
EV02A
=====
{PERSON'S FIRST MIDDLE AND LAST NAME} {EV}
INTERVIEWER: SELECT GROUP TYPE OF OTHER MEDICAL EXPENSE (OM)
EVENT YOU NEED TO ADD:
NOTE: ONLY ONE OM GROUP TYPE MAY BE ADDED AT THIS SCREEN.
REGULAR (GLASSES OR CONTACTS, INSULIN,
OTHER DIABETIC SUPPLIES) .............. 1 {EV03}
ADDITIONAL (E.G., AMBULANCE SERVICES,
ORTHOPEDIC ITEMS, HEARING DEVICES,
MEDICAL EQUIPMENT, ETC.) .............. 2 {EV03A}
[Code One]
EV03
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {EV} {STR-DT}
{END-DT}
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE ASK: Did (PERSON) obtain glasses or contact
lenses, insulin, or other diabetic equipment or supplies
since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1 {BOX_06}
INSULIN ................................ 2 {BOX_06}
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3 {BOX_06}
[Code All That Apply]
----------------------------------------------------
| IF CODED ‘2’ (INSULIN), ADD ‘INSULIN’ TO |
| PERSON’S-PRESCRIBED-MEDICINES-ROSTER, CREATING |
| NECESSARY RECORDS FOR INSULIN. |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘3’ (OTHER DIABETIC EQUIPMENT OR |
| SUPPLIES), ADD ‘OTHER DIABETIC EQUIP/SUPPLIES’ |
| TO PERSON’S-PRESCRIBED-MEDICINES-ROSTER, CREATING |
| NECESSARY RECORDS FOR ‘OTHER DIABETIC |
| EQUIP/SUPPLIES’. |
----------------------------------------------------
EV03A
=====
{PERSON'S FIRST MIDDLE AND LAST NAME} {EV} JAN 01
DEC 31
SHOW CARD PP-4A OR PP-12
IF KNOWN, SELECT CORRECT ADDITIONAL OME ITEM GROUP
OTHERWISE ASK: Looking at this card, what type of other
medical expenses did (PERSON) obtain, purchase or rent during
the calendar year {YEAR}?
AMBULANCE SERVICES ....................... 1
ORTHOPEDIC ITEMS ......................... 2
HEARING DEVICES .......................... 3
PROSTHESES ............................... 4
BATHROOM AIDS ............................ 5
MEDICAL EQUIPMENT ........................ 6
DISPOSABLE SUPPLIES ...................... 7
ALTERATIONS/MODIFICATIONS ................ 8
OTHER ................................... 91
[Code All That Apply]
----------------------------------------------------
| (FOR SPECIFICATIONS ONLY, ‘YEAR’ IN PROGRAM IS |
| HARD-CODED.) IF ROUND 3, DISPLAY FIRST YEAR OF |
| PANEL FOR {YEAR}. IF ROUND 5, DISPLAY SECOND |
| YEAR OF PANEL FOR {YEAR}. |
----------------------------------------------------
----------------------------------------------------
| IF CODED ‘91’ (OTHER) ALONE OR IN COMBINATION |
| WITH ANY OTHER CODES, CONTINUE WITH EV03AOV |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_06 |
----------------------------------------------------
EV03AOV
=======
OTHER GROUPING OF OTHER MEDICAL EXPENSES:
[Enter Other Specify] ................ {BOX_06}
REF .................................. -7 {BOX_06}
DK ................................... -8 {BOX_06}
BOX_03
======
----------------------------------------------------
| IF EVENT TYPE IS HS OR IC, CONTINUE WITH EV04 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO EV05 |
----------------------------------------------------
EV04
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EV} {STR-DT}
{END-DT}
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER
PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to
and discharged from (PROVIDER)? Please tell me the dates of
all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter
(PROVIDER)? On what date did (PERSON) leave (PROVIDER)?
PROBE: Any other stays?
| [Enter Month,Day,Year-4] |
[Enter Month,Day,Year-4] |
| [Enter Month,Day,Year-4] |
[Enter Month,Day,Year-4] |
| [Enter Month,Day,Year-4] |
[Enter Month,Day,Year-4] |
----------------------------------------------------
| DISPLAY ‘OR RELEASED IN {YEAR}’ IF ROUND 5, WHERE |
| ‘YEAR’ IS THE CALENDAR YEAR SUBSEQUENT TO THE |
| SECOND YEAR OF THE PANEL. OTHERWISE, USE A NULL |
| DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| DISPLAY A RADIO BUTTON ON THE DATE ENTRY SCREEN |
| LABELED ‘CHECK IF STILL IN PROVIDER {OR RELEASED |
| IN {YEAR}}. |
----------------------------------------------------
----------------------------------------------------
| ALLOW RF AND DK FOR THE DAY AND YEAR BUT NOT FOR |
| THE MONTH. |
----------------------------------------------------
----------------------------------------------------
| HARD CHECK: |
| EDIT CHECK: |
| |
| IN ROUND 1 ONLY, ALLOW AN ADMIT DATE ONE YEAR |
| PRIOR TO THE RU MEMBER’S REFERENCE PERIOD START |
| DATE. |
----------------------------------------------------
----------------------------------------------------
| GO TO BOX_06 |
----------------------------------------------------
----------------------------------------------------
| ROSTER DETAILS: |
| TITLE: PERS_EVNT_ADD_1 |
| |
| COL # 1 HEADER: ADMIT DATE |
| INSTRUCTIONS: DISPLAY EVENT BEGIN DATE |
| (EVNT.EVNTBEGM, EVNT.EVNTBEGD, EVNT.EVNTBEGY) |
| |
| COL # 2 HEADER: DISCHARGE DATE |
| INSTRUCTIONS: DISPLAY EVENT END DATE |
| (EVNT.EVNTENDM, EVNT.EVNTENDD, EVNT.EVNTENDY) |
| |
----------------------------------------------------
----------------------------------------------------
| ROSTER DEFINITION: |
| THIS ITEM DISPLAYS THE PERSON'S-MEDICAL-EVENTS- |
| ROSTER FOR ADDING BEGIN AND END DATES. |
----------------------------------------------------
----------------------------------------------------
| ROSTER BEHAVIOR: |
| 1. EDIT AND SELECT DISALLOWED. |
| |
| 2. MULTIPLE ADD ALLOWED. INTERVIEWER SHOULD |
| RECORD THE EVENT BEGIN AND END DATES. |
| |
| 3. LIMITED DELETE ALLOWED. INTERVIEWER CAN DELETE |
| AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE |
| DELETE IS USED. THAT IS, AS LONG AS THE |
| INTERVIEWER HAS NOT LEFT THE SCREEN, THEY SHOULD |
| BE ABLE TO DELETE AN EVENT ENTERED IN ERROR. |
----------------------------------------------------
----------------------------------------------------
| ROSTER FILTER: |
| DISPLAY NO EVENTS ON ROSTER INITIALLY. THIS SCREEN|
| RELATES TO HS AND IC EVENT TYPES (EVNT.EVNTTYPE) |
| ONLY. |
----------------------------------------------------
EV05
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EV} {STR-DT}
{END-DT}
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER
PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When did (PERSON) visit (PROVIDER)?
Please tell me all the dates between (START DATE) and
(END DATE).
PROBE: Any other dates?
----------------------------
| [Enter Month,Day,Year-4] |
|----------------------------|
| [Enter Month,Day,Year-4] |
|----------------------------|
| [Enter Month,Day,Year-4] |
----------------------------
----------------------------------------------------
| DISPLAY ‘ADD EVENT DATE’, ‘EDIT EVENT DATE’, AND |
| ‘DELETE EVENT DATE’ BUTTONS ON THIS SCREEN. |
----------------------------------------------------
----------------------------------------------------
| ALLOW RF AND DK FOR THE DAY AND YEAR BUT NOT FOR |
| THE MONTH. |
----------------------------------------------------
----------------------------------------------------
| GO TO BOX_06 |
----------------------------------------------------
----------------------------------------------------
| ROSTER DETAILS: |
| TITLE: PERS_EVNT_ADD_2 |
| |
| COL # 1 HEADER: EVENT DATE |
| INSTRUCTIONS: DISPLAY EVENT BEGIN DATE |
| (EVNT.EVNTBEGM, EVNT.EVNTBEGD, EVNT.EVNTBEGY) |
----------------------------------------------------
----------------------------------------------------
| ROSTER DEFINITION: THIS ITEM DISPLAYS PERSON’S- |
| MEDICAL-EVENTS-ROSTER FOR ADDING EVENT BEGIN |
| DATES. |
----------------------------------------------------
----------------------------------------------------
| ROSTER BEHAVIOR: |
| THIS ITEM CAN COLLECT ONLY THOSE EVENTS THAT ARE |
| THE SAME PROVIDER, PERSON, AND EVENT TYPE AS THE |
| EVENT BEING ASKED ABOUT. |
| |
| 1. SELECT DISALLOWED. |
| |
| 2. MULTIPLE ADD ALLOWED. INTERVIEWER SHOULD |
| RECORD THE EVENT BEGIN DATES. |
| |
| 3. LIMITED DELETE ALLOWED. INTERVIEWER CAN DELETE |
| AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE |
| DELETE IS USED. THAT IS, AS LONG AS THE |
| INTERVIEWER HAS NOT LEFT THE SCREEN, THEY SHOULD |
| BE ABLE TO DELETE AN EVENT ENTERED IN ERROR. |
| |
| 4. LIMITED EDIT ALLOWED. INTERVIEWER CAN EDIT AN |
| EVENT THAT WAS ENTERED ON THE SCREEN WHERE EDIT |
| IS USED. THAT IS, AS LONG AS THE INTERVIEWER HAS |
| NOT LEFT THE SCREEN, THEY SHOULD BE ABLE TO EDIT |
| AN EVENT. |
----------------------------------------------------
----------------------------------------------------
| ROSTER FILTER: |
| DISPLAY NO EVENTS ON ROSTER INITIALLY. |
----------------------------------------------------
EV06
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {EV} {STR-DT}
{END-DT}
Thinking about the health care (PERSON) received at home, was
the person who provided the care a friend or neighbor,
a relative, a volunteer, or some type of provider who was paid?
Please do not include health care received from friends
or relatives living here.
PROBE: Do you have a brochure, folder, binder of papers,
telephone listing, or anything which might help?
NOTE: SELECT ONLY ONE TYPE OF PROVIDER AT THIS TIME.
FRIEND/NEIGHBOR ........................ 1 {EV08}
RELATIVE ............................... 2 {EV07}
VOLUNTEER .............................. 3 {EV08}
OTHER-PAID ............................. 4 {EV06A}
VOLUNTEERED: MEAL DELIVERY SERVICE .... 5 {BOX_06}
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code One]
----------------------------------------------------
| IF CODED ‘5’ (VOLUNTEERED: MEAL DELIVERY SERVICE),|
| DO NOT CREATE AN EVENT RECORD. |
----------------------------------------------------
EV06A
=====
{PERSON'S FIRST MIDDLE AND LAST NAME} {EV} {STR-DT}
{END-DT}
Did this person work for a home health agency, hospital, or
nursing home or did they work for themselves?
PROBE: Do you have a brochure, folder, binder of papers,
telephone listing, or anything which might help?
WORKED FOR AGENCY, HOSPITAL, OR
NURSING HOME ........................... 1 {BOX_04}
WORKED FOR SELF ........................ 2 {BOX_04}
REF ................................... -7 {BOX_04}
DK .................................... -8 {BOX_04}
[Code One]
EV07
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {EV} {STR-DT}
{END-DT}
What is the relationship of the relative who provided home
care services to (PERSON)?
IF MORE THAN ONE DAUGHTER/DAUGHTER-IN-LAW/SON/SON-IN-LAW, CODE
ONLY ONE AT THIS TIME AND TREAT EACH AS A SEPARATE HOME HEALTH
EVENT.
INCLUDE ALL OTHER TYPES OF RELATIVES AS ONE GROUP AND CODE
‘OTHER-RELATIVE’ ONLY ONE TIME.
DAUGHTER ............................... 1 {BOX_04}
DAUGHTER-IN-LAW ........................ 2 {BOX_04}
SON .................................... 3 (BOX_04}
SON-IN-LAW ............................. 4 {BOX_04}
OTHER RELATIVE ......................... 5 {EV07OV1}
[Code One]
EV07OV1
=======
CODE RELATIONSHIPS OF ALL DIFFERENT TYPES OF RELATIVES WHO
PROVIDED HOME CARE SERVICES SINCE (START DATE) TO (PERSON).
MOTHER ................................. 1
FATHER ................................. 2
SISTER ................................. 3
BROTHER ................................ 4
GRANDPARENT ............................ 5
GRANDCHILD ............................. 6
AUNT/UNCLE ............................. 7
NIECE/NEPHEW ........................... 8
COUSIN ................................. 9
OTHER ................................. 91
REF ................................... -7
DK .................................... -8
HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
| FOR SPECIFICATION PURPOSES ONLY: CAPI DOES NOT |
| ALLOW ‘RF’ OR ‘DK’ IN COMBINATION WITH ANY OTHER |
| CODE. |
----------------------------------------------------
----------------------------------------------------
| IF EV07OV1 IS CODED ‘91’ (OTHER) ALONE OR IN |
| COMBINATION WITH ANY OTHER CODES, CONTINUE WITH |
| EV07OV2 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO EV08 |
----------------------------------------------------
EV07OV2
=======
OTHER:
[Enter Other Specify] .................. {EV08}
REF ................................... -7 {EV08}
DK .................................... -8 {EV08}
EV08
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {EV} {STR-DT}
{END-DT}
How many different {friends or neighbors/volunteers/relatives,
other than daughters, daughters-in-law, sons, and sons-in-law}
provided home care services for (PERSON) since (START DATE)?
[Enter Number-2] ....................... {BOX_05}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}
----------------------------------------------------
| DISPLAY ‘friends or neighbors’ IF EV06 IS CODED |
| ‘1’ (FRIEND/NEIGHBOR). DISPLAY ‘volunteers’ IF |
| EV06 IS CODED ‘3’ (VOLUNTEER). DISPLAY ‘relatives,|
| other than daughters, daughters-in-law, sons, and |
| sons-in-law’ IF EV07 IS CODED ‘5’ |
| (OTHER-RELATIVE). |
----------------------------------------------------
----------------------------------------------------
| IF EV06 IS CODED ‘1’ (FRIEND/NEIGHBOR): |
| |
| - ADD ‘FRIEND/NEIGHBOR’ TO THE |
| RU-MEDICAL-PROVIDERS-ROSTER, PERSON-TYPE- |
| PROVIDER NAME COLUMN. NO ADDRESS INFORMATION |
| IS NECESSARY. |
| |
| - FLAG PROVIDER AS ‘INFORMAL’. |
----------------------------------------------------
----------------------------------------------------
| IF EV06 IS CODED ‘3’ (VOLUNTEER): |
| |
| - ADD ‘VOLUNTEER’ TO THE |
| RU-MEDICAL-PROVIDERS-ROSTER, PERSON-TYPE- |
| PROVIDER NAME COLUMN. NO ADDRESS INFORMATION |
| IS NECESSARY. |
| |
| - FLAG PROVIDER AS ‘INFORMAL’. |
----------------------------------------------------
----------------------------------------------------
| IF EV07 IS CODED ‘5’ (OTHER RELATIVE): |
| |
| - ADD ‘OTHER RELATIVE’ TO THE |
| RU-MEDICAL-PROVIDERS-ROSTER, PERSON-TYPE- |
| PROVIDER NAME COLUMN. NO ADDRESS INFORMATION |
| IS NECESSARY. |
| |
| - FLAG PROVIDER AS ‘INFORMAL’. |
----------------------------------------------------
BOX_04
======
----------------------------------------------------
| ASK PROVIDER ROSTER (PV) SECTION FOR THIS EVENT |
----------------------------------------------------
----------------------------------------------------
| AT COMPLETION OF THE PV SECTION, CONTINUE WITH |
| BOX_05 |
----------------------------------------------------
BOX_05
======
----------------------------------------------------
| IF EV06 IS CODED ‘1’ (FRIEND/NEIGHBOR) OR ‘3’ |
| (VOLUNTEER) AND ROUND 1, GO TO EV12 |
----------------------------------------------------
----------------------------------------------------
| IF EV06 IS CODED ‘1’ (FRIEND/NEIGHBOR) OR ‘3’ |
| (VOLUNTEER) AND NOT ROUND 1, GO TO EV13 |
----------------------------------------------------
----------------------------------------------------
| IF EV06 IS CODED ‘2’ (RELATIVE), FLAG PROVIDER |
| JUST COLLECTED IN PV SECTION AS ‘INFORMAL’ AND |
| GO TO EV13 |
----------------------------------------------------
----------------------------------------------------
| IF EV06A IS CODED ‘2’ (WORKED FOR SELF), ‘-7’ |
| (REFUSED), OR ‘-8’ (DON’T KNOW), FLAG PROVIDER |
| JUST COLLECTED IN PV SECTION AS ‘PAID INDEPENDENT’|
| AND GO TO EV10 |
----------------------------------------------------
----------------------------------------------------
| IF EV06A IS CODED ‘1’ (WORKED FOR AGENCY, |
| HOSPITAL, OR NURSING HOME), FLAG PROVIDER JUST |
| COLLECTED IN PV SECTION AS ‘AGENCY’ AND |
| CONTINUE WITH EV09 |
----------------------------------------------------
EV09
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EV} {STR-DT}
{END-DT}
How many people from (PROVIDER) provided home care services for
(PERSON)?
[Enter Number-2] ......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| IF ROUND 1, GO TO EV12 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO EV13 |
----------------------------------------------------
EV10
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EV} {STR-DT}
{END-DT}
Is (PROVIDER) a companion, a professional homemaker, a home
health or nurse’s aide, a health professional, or something
else?
PROBE: Health professionals include people like nurses, social
workers, therapists of any type.
COMPANION .............................. 1
DOMESTIC WORKER/HOUSE CLEANER .......... 2
HEALTH PROFESSIONAL .................... 3 {EV11}
HOMEMAKER .............................. 4
HOME HEALTH AIDE ....................... 5
NURSE’S AIDE ........................... 6
PERSONAL CARE ATTENDANT ................ 7
OTHER ................................. 91 {EV10OV}
REF ................................... -7
DK .................................... -8
HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.
----------------------------------------------------
| IF EV10 NOT CODED ‘3’ (HEALTH PROFESSIONAL), OR |
| ‘91’ (OTHER), AND ROUND 1, GO TO EV12 |
| OTHERWISE, GO TO EV13 |
----------------------------------------------------
EV10OV
======
OTHER:
[Enter Other Specify] .................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| IF ROUND 1, GO TO EV12 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO EV13 |
----------------------------------------------------
EV11
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EV} {STR-DT}
{END-DT}
What type of health professional is (PROVIDER)?
DIETITIAN/NUTRITIONIST ................. 1
HOME HEALTH AIDE ....................... 2
HOSPICE WORKER ......................... 3
I.V./INFUSION THERAPIST ................ 4
MEDICAL DOCTOR ......................... 5
NURSE/NURSE PRACTITIONER ............... 6
NURSE’S AIDE ........................... 7
OCCUPATIONAL THERAPIST ................. 8
PERSONAL CARE ATTENDANT ................ 9
PHYSICAL THERAPIST .................... 10
RESPIRATORY THERAPIST ................. 11
SOCIAL WORKER ......................... 12
SPEECH THERAPIST ...................... 13
OTHER ................................. 91 {EV11OV}
REF ................................... -7
DK .................................... -8
HELP AVAILABLE FOR DEFINITION OF ANSWER CATEGORIES.
----------------------------------------------------
| IF EV11 NOT CODED ‘91’ (OTHER), AND ROUND 1, |
| GO TO EV12 |
----------------------------------------------------
----------------------------------------------------
| IF EV11 NOT CODED ‘91’ (OTHER), AND ROUNDS 2-5, |
| GO TO EV13 |
----------------------------------------------------
EV11OV
======
OTHER:
[Enter Other Specify] ..................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| IF ROUND 1, CONTINUE WITH EV12 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO EV13 |
----------------------------------------------------
EV12
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EV} {STR-DT}
{END-DT}
Did {someone from} (PROVIDER) ever provide home care services
for (PERSON) before January 1, {YEAR}?
YES .................................... 1 {EV13}
NO ..................................... 2 {EV13}
REF ................................... -7 {EV13}
DK .................................... -8 {EV13}
----------------------------------------------------
| DISPLAY ‘someone from’ IF PROVIDER IS A FACILITY. |
| OTHERWISE, USE A NULL DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| (FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES |
| AUTOMATICALLY): ‘YEAR’ IN QUESTION TEXT IS FIRST |
| CALENDAR YEAR OF PANEL. |
----------------------------------------------------
EV13
====
{PERSON'S FIRST MIDDLE AND LAST NAME} {NAME OF MEDICAL CARE
PROVIDER......} {EV} {STR-DT}
{END-DT}
{Last time we recorded that (PERSON) received home care
services from (PROVIDER) during some part of {PRV RD INTV MTH}.
Did (PERSON) continue to receive home care services from
(PROVIDER) during the rest of {PRV RD INTV MTH}?}
Did {someone from} (PROVIDER) provide home care services for
(PERSON) during the month of (MONTH)?
How about in (MONTH)?
YES NO REF DK
EV13_01
=======
{MONTH} 1 2 -7 -8
EV13_02
=======
{MONTH} 1 2 -7 -8
EV13_03
=======
{MONTH} 1 2 -7 -8
EV13_04
=======
{MONTH} 1 2 -7 -8
----------------------------------------------------
| DISPLAY FIRST PARAGRAPH IF A HOME HEALTH EVENT FOR|
| THE MONTH OF THE PREVIOUS ROUND’S INTERVIEW |
| FOR THIS PERSON-PROVIDER PAIR WAS CREATED DURING |
| THE PREVIOUS ROUND. (HOWEVER, IT WOULD NOT HAVE |
| BEEN ASKED ABOUT.) OTHERWISE, USE A NULL DISPLAY.|
| |
| DISPLAY THE MONTH OF THE PREVIOUS ROUND’S |
| INTERVIEW DATE FOR ‘{PRV RD INTV MTH}’. |
| |
| DISPLAY ‘someone from’ IF PROVIDER IS A FACILITY. |
| OTHERWISE, USE A NULL DISPLAY. |
----------------------------------------------------
----------------------------------------------------
| EV13 SCREEN DISPLAY SPECIFICATIONS: |
| |
| 1. THE NUMBER AND NAMES OF THE MONTHS LISTED ARE |
| DETERMINED BY THE NUMBER OF MONTHS BETWEEN THE |
| MONTH OF THE START DATE AND THE MONTH OF THE |
| END DATE FOR THIS PERSON. FOR EXAMPLE, IF THE |
| START DATE IS JANUARY 1 AND THE END DATE IS |
| APRIL 10 FOR THIS PERSON’S REFERENCE PERIOD, |
| ‘JANUARY’, 'FEBRUARY', 'MARCH', AND ‘APRIL’ |
| ARE DISPLAYED. THAT IS, THE MONTHS ARE ALL THE|
| MONTHS OF THE PERSON’S REFERENCE PERIOD. |
| |
| 2. ‘-7’ (REFUSED) AND ‘-8’ (DON’T KNOW) ARE |
| ALLOWED FOR EV13_01, EV13_02, EV13_03, AND |
| EV13_04. HOWEVER, THEY WILL BE TREATED AS A |
| ‘NO’ WHEN CREATING EVENTS. |
| |
| 3. THE MONTHS ARE DISPLAYED IN GRID FORMAT WITH |
| YES/NO/DK/RF RADIO BUTTONS. |
| |
| 4. EV13 HAS TO ACCOMMODATE AT LEAST 10 MONTHS. |
| |
| 5. A SEAM MONTH WILL BE ASKED ONLY ONE HOME |
| HEALTH UTILIZATION SECTION WHENEVER IT |
| RECEIVES (OR RECEIVED) A CODE OF ‘1’ (YES) IN |
| EITHER THE CURRENT ROUND OR THE PREVIOUS ROUND.|
| |
| MESSAGE: IF CURRENT INTERVIEW MONTH IS CODED ‘1’ |
| (YES), DISPLAY THE FOLLOWING MESSAGE: “HOME |
| HEALTH UTILIZATION SEC FOR {INT MONTH} WILL NOT |
| BE ASKED UNTIL NEXT ROUND.” |
| |
| EACH MONTH CODED ‘1’ (YES) BECOMES A SEPARATE HOME|
| HEALTH EVENT FOR THIS PERSON-PROVIDER PAIR. |
| HOWEVER, IF THE CURRENT INTERVIEW MONTH IS CODED |
| ‘1’ (YES), IT WILL NOT BE ASKED ABOUT UNTIL THE |
| NEXT ROUND. IF THE MONTH OF THE PREVIOUS ROUND’S |
| INTERVIEW DATE IS CODED ‘1’ (YES), IT IS ASKED |
| ONE TIME. THAT IS, IT IS NOT A SEPARATE EVENT FOR|
| BOTH THE PREVIOUS ROUND AND THIS ROUND, IT IS |
| ONLY ONE EVENT. |
----------------------------------------------------
----------------------------------------------------
| HARD CHECK: |
| EDIT: CAPI REQUIRES A RESPONSE FOR EACH MONTH |
| DISPLAYED. ALL MONTHS DURING THE REFERENCE PERIOD|
| CANNOT BE CODED ‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ |
| (DON’T KNOW). IF ALL ARE, WVS ERROR HANDLER WILL |
| FORCE THE INTERVIEWER TO RECTIFY THE DATA. |
----------------------------------------------------
BOX_06
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| RETURN TO ORIGINAL QUESTIONNAIRE SECTION IN PP |
| OR ED. |
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