Quality Supplement (QS) Section

BOX_00 (QS1000)

Programmer Instructions: Placeholder for question types.

BOX_10 (QS1005)

BOX_20 (QS1010)

BOX_30 (QS1015)

Programmer Instructions: Determine the number of DCS’s and (P)SAQ’s required for this household: Set flags as described for each RU member that meets the required criteria.

DCS (rounds 3 and 5)

-If Round 3 or Round 5

AND

-person is => 18 years of age or in age categories 4-9

AND

-person is a current RU member (included in person array)

AND

-person is Key (CtrlPersKey=Yes)

AND

-person is not deceased (PersRndStatus ≠ Deceased)

AND

- 'DIABETES' is on person's-medical-conditions-roster and was created in the PE section (in any round), then set Person.DCSFlag=YES.

SAQ (rounds 2 and 4, core+CAHPS)

-[(If round 2 and panel year is odd (FirstPanYear=odd)) OR (If round 4 and panel year is even (FirstPanYear=even))]

AND

-person is a current RU member (included in person array)

AND

- person is Key (CtrlPersKey=Yes)

AND

-person is not deceased or institutionalized (PersRndStatus ≠ Deceased or institutionalized)

AND

-person is in the RU at the round 2 or 4 interview date (EndRefDt = EndRefM, EndRefD, EndRefY).

AND

-RU member is = > 18 years of age or in age categories 4-9 on July 1, {YEAR}, where ‘YEAR’ is the first calendar year of the panel (FirstPanYear), if round 2 or on July 1, {YEAR}, where ‘YEAR’ is the second calendar year of the panel (SecondPanYear), if round 4, or has turned 18 between July 1, {YEAR}, where ‘YEAR’ is the first calendar year of the panel, and the date of the interview if round 2, or July 1, {year}, where ‘YEAR’ is the second calendar year of the panel, and the date of the interview if round 4, then set Person.SAQFlag=YES.

SAQ Follow-up (rounds 3 and 5, core+CAHPS)

-[(If Panel 22, Round 3 or Panel 21, Round 5) or (If round 3 and panel year is odd (FirstPanYear=odd)) OR (If round 5 and panel year is even (FirstPanYear=even))]

AND

-person is a current RU member (included in person array)

AND

-person was prompted for an SAQ in Round 2 (if Round 3) or 4 (if Round 5) and that SAQ is outstanding [PL_Person.SAQRecCtrlStatus= ‘3’ (REFUSED), ‘5’ (BLANK), ‘6’ (WRONG TYPE), ‘7’ (WRONG YEAR USED), '8' (NOT RECEIVED)], then set Person.SAQFlagFlwUp=YES.

PSAQ (rounds 2 and 4, core+prevention)

-[(If round 2 and panel year is even (FirstPanYear=even)) OR (If round 4 and panel year is odd (FirstPanYear=odd))]

AND

-person is a current RU member (included in person array)

AND

- person is Key (CtrlPersKey=Yes)

AND

-person is not deceased or institutionalized (PersRndStatus ≠ Deceased or institutionalized)

AND

-person is in the RU at the round 2 or 4 interview date (EndRefDt = EndRefM, EndRefD, EndRefY).

AND

-RU member is = > 18 years of age or in age categories 4-9 on July 1, {YEAR}, where ‘YEAR’ is the first calendar year of the panel (FirstPanYear), if round 2 or on July 1, {YEAR}, where ‘YEAR’ is the second calendar year of the panel (SecondPanYear), if round 4, or has turned 18 between July 1, {YEAR}, where ‘YEAR’ is the first calendar year of the panel, and the date of the interview if round 2, or July 1, {year}, where ‘YEAR’ is the second calendar year of the panel, and the date of the interview if round 4, then set Person.PSAQFlag=YES.

PSAQ Follow-up (rounds 3 and 5, core+prevention)

-[(If round 3 and panel year is even (FirstPanYear=even)) OR (If round 5 and panel year is odd (FirstPanYear=odd))]

AND

-person is a current RU member (included in person array)

AND

-person was prompted for an PSAQ in Round 2 (if Round 3) or 4 (if Round 5) and that PSAQ is outstanding [PL_Person.PSAQRecCtrlStatus= ‘3’ (REFUSED), ‘5’ (BLANK), ‘6’ (WRONG TYPE), ‘7’ (WRONG YEAR USED), '8' (NOT RECEIVED)], then set Person.PSAQFlagFlwUp=YES.

QS10 (QS1020)

BLAISE NAME: FormMatrl

Question Text:

FOR THIS SECTION, YOU WILL NEED THE FOLLOWING HARDCOPY MATERIALS FOR THIS HOUSEHOLD:

{{NUMBER 1} A SURVEY ABOUT YOUR DIABETES CARE FORMS (DCS) }

{{NUMBER 2} YOUR HEALTH AND HEALTH OPINION FORMS (SAQ) }

{{NUMBER 3} YOUR HEALTH AND HEALTH OPINION FORMS (PSAQ-MALE=BLUE)}

{{NUMBER 4} YOUR HEALTH AND HEALTH OPINION FORMS (PSAQ-FEMALE=PURPLE)}

PLEASE PULL THESE MATERIALS OUT NOW.

PRESS 1 AND ENTER TO CONTINUE.

Responses: CONTINUE 1 LOOP_10 (QS1025)

Display Instructions: Display “{NUMBER 1} ... (DCS)” if at least one person where Person.DCSFlag=Yes. Otherwise, use a null display. For “NUMBER 1”, display the count of Person.DCSFlag=Yes for this RU.

Display “{NUMBER 2} ... (SAQ)” if at least one person where Person.SAQFlag=Yes or Person.SAQFlagFlwUp=Yes. Otherwise, use a null display. For “NUMBER 2”, display the count of Person.SAQFlag=Yes and Person.SAQFlagFlwUp=Yes for this RU.

Display “{NUMBER 3} ... (PSAQ-MALE=BLUE)” if at least one male RU member where Person.PSAQFlag=Yes or Person.PSAQFlagFlwUp=Yes. Otherwise, use a null display. For “NUMBER 3”, display the count of male RU members where Person.PSAQFlag=Yes or Person.PSAQFlagFlwUp=Yes for this RU.

Display “{NUMBER 4} ... (PSAQ-FEMALE=PURPLE)” if at least one female (or gender=DK/RF)

RU member where Person.PSAQFlag=Yes or Person.PSAQFlagFlwUp=Yes. Otherwise, use a null display. For “NUMBER 4”, display the count of female (or gender=DK/RF) RU members where Person.PSAQFlag=Yes or Person.PSAQFlagFlwUp=Yes for this RU.

LOOP_10 (QS1025)

BOX_40 (QS1030)

Display Instructions:

Each flag that has been set should display a row for the corresponding hardcopy questionnaire.

-Display “DCS” on Col #1, Row #1 as an uneditable, protected cell

-Display “SAQ” on Col#1, Row #2 as an uneditable, protected cell

-Display “PSAQ” on Col#1, Row #3 as an uneditable, protected cell

Row #1 should display as active if Person.DCSFlag-YES.

Row #2 should display as active if Person.SAQFlag=Yes or Person.SAQFlwUpFlag=YES.

Row #3 should display as active if Person.PSAQFlag=Yes or Person.PSAQFlwUpFlag=YES.

(NOTE: An RU member will never have BOTH the SAQ and PSAQ active in the same round.)

Roster Report 1

Format the form pane column headers as follows:

Roster Definition: Display the hardcopy materials required for this RU member set at BOX_30

Col#2 Header: DCS Self or Proxy (QS20_01)

Col#3 Header: Proxy Reason (QS20_02)

Col#4 Header: Proxy Other (QS20_03)

Col#5 Header: {SAQ/PSAQ} Prompt (QS20_04)

Col#6 Header: Status of {SAQ/PSAQ} (QS20_05)

Col#7 Header: Reason for Refusal (QS20_06)

Col#8 Header: Other Reason for Refusal (QS20_07)

Col#9 Header: Distribute DCS/{SAQ/PSAQ} (QS20_08)

Programmer Instructions: For each flag RU member has set (Person.DCSFlag= YES, Person.SAQFlag=YES, Person.SAQFlagFlwUp=YES, Person.PSAQFlag=YES, Person.PSAQFlagFlwUp=YES) configure the QS20 grid in the following manner:

The grid should be Preloaded Grid Type 1: forced navigation, including QS20_01, QS20_02, QS20_03, QS20_04, QS20_05, QS20_06, QS20_07, and QS20_08.

NOTE TO PROGRAMMERS: This grid needs to be configurable to accommodate the addition of other required hardcopy materials as requested by the client in future panels.

QS20_01 (QS1035)

BLAISE NAME: FormType

Context Header: {PERSON’S FIRST MIDDLE AND LAST NAME}

Question Text:

{In this next section, I will be distributing {and collecting} some hardcopy materials for {you and} members of your household. Let’s start with {you/{PERSON}}./I now have some hard copy materials for {you/{PERSON}}.}

{During an earlier interview, it/It} was mentioned that {you/{PERSON}} {have/has} diabetes. To obtain more information on the care of adults with diabetes, we have a short questionnaire for {you/him/her}.

DETERMINE IF SELF OR PROXY DIABETES CARE SUPPLEMENT (DCS) SHOULD BE DISTRIBUTED: SELF DCS: FOR ANY CURRENT RU MEMBER (18 YEARS OR OLDER) WHO HAS DIABETES. PROXY DCS: FOR ANY RU MEMBER (18 OR OLDER) WHO IS INSTITUTIONALIZED, OR OTHERWISE INCAPACITATED.

ENTER TYPE OF DCS DISTRIBUTED NECESSARY FOR {PERSON}. {ACTION: PERSON IS INSTITUTIONALIZED AND MAY REQUIRE PROXY DCS.}

CTRL-S: SWITCH TO DISTRIBUTE DOCS FOR A DIFFERENT PERSON.

Responses: SELF 1 QS20_08 (QS1070)

PROXY 2 QS20_02 (QS1040)

Programmer Instructions: RF/DK not allowed.

Display Instructions: Display ‘CURRENT’ if the person being asked about is a current RU member (Display ‘CURRENT’ if the person being asked about is a current RU member (person included on person array) and is not institutionalized or deceased (PersRndStatus ≠ Institutionalized or Deceased). Display “INSTITUTIONALIZED” if the person being asked about is institutionalized (PersRndStatus=Institutionalized) for the current round.

Display “In this next section, I will be distributing {and collecting} some hardcopy materials for {you and} members your household. Let’s start with {you/{PERSON}}.” If first cycle of Loop_10. Otherwise, display “I now have some hard copy materials for {you/{PERSON}}.”

Display “and collecting” if at least one person in the RU has Person.SAQFlag=YES, or Person.SAQFlagFlwUp=YES or Person.PSAQFlag=YES or Person.PSAQFlagFlwUp=YES in the current round. Otherwise, use a null display.

Display ‘you and’ if the respondent has a Person.DCSFlag=YES, or Person.SAQFlag=YES, or Person.SAQFlagFlwUp=YES or Person.PSAQFlag=YES or Person.PSAQFlagFlwUp=YES in the current round. Otherwise, use a null display.

Display ‘During an earlier interview, it’ if diabetes was not created during the current round for the person being looped on. Display ‘It’ if diabetes created during the current round for the person being looped on.

Display “ACTION: PERSON IS INSTITUTIONALIZED AND MAY REQUIRE PROXY DCS.” if the person being asked about is institutionalized (PersRndStatus=Institutionalized) for the current round. Otherwise, use a null display.

The label ACTION: should be displayed in the traditional interviewer instruction font size – but in red. The text after “ACTION” should be displayed in the traditional blue interviewer instruction size and color.

QS20_02 (QS1040)

BLAISE NAME: FormProxyResn

Context Header: {PERSON'S FIRST MIDDLE AND LAST NAME}

Question Text:

ENTER REASON FOR PROXY DCS.

Responses: INSTITUTIONALIZED 2 QS20_08 (QS1070)

OTHER 3 QS20_03 (QS1045)

Programmer Instructions: RF/DK not allowed.

Display Instructions:

QS20_03 (QS1045)

BLAISE NAME: FormProxyResnOS

Context Header: {PERSON’S FIRST MIDDLE AND LAST NAME}

Question Text:

SPECIFY OTHER REASON FOR PROXY DCS:

Responses: 1 QS20_08 (QS1070)

Programmer Instructions: RF/DK not allowed.

Display Instructions:

QS20_04 (QS1050)

BLAISE NAME: FormCmpl

Context Header: {PERSON’S FIRST MIDDLE AND LAST NAME}

Question Text:

{In this next section, I will be distributing {and collecting} some hardcopy materials for {you and} members of your household. Let’s start with {you/{PERSON}}./I now have some hard copy materials for {you/{PERSON}}.}

{Now} I would like to ask {you/{PERSON}} to complete a brief survey about health and health opinions. {You/{PERSON}} may have already received this in the mail.

I want to check if {you/{PERSON}} completed that questionnaire already or {need/needs} a replacement.

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

{COLLECT {MALE (BLUE)/FEMALE (PURPLE)} PSAQ. IF INCORRECT COLOR PSAQ COMPLETED, CODE ‘2’ (NEEDS REPLACEMENT) TO FILL OUT CORRECT COLOR PSAQ.}

{PERSON IS {DECEASED/INSTITUTIONALIZED/PARTIALLY ELIGIBLE - MOVED FROM RU}. IF {SAQ/PSAQ} ALREADY COMPLETED BECAUSE IT WAS MAILED TO HOUSEHOLD, COLLECT IT. HOWEVER, IF NOT ALREADY COMPLETED, CODE ‘3’ AND DO NOT DISTRIBUTE NEW {SAQ/PSAQ}.}

{CTRL-S: SWITCH TO DISTRIBUTE DOCS FOR A DIFFERENT PERSON.}

Responses: COMPLETED /RETURNING QUESTIONNAIRE 1 QS20_05 (QS1055)

NEEDS REPLACEMENT 2 QS20_08 (QS1070)

{NOT COMPLETED-NO REPLACEMENT NECESSARY} 3 BOX_50 (QS1075)

Programmer Instructions: RF/DK not allowed.

Display Instructions: Display “In this next section, I will be distributing {and collecting} some hardcopy materials for {you and} members your household. Let’s start with {you/{PERSON}}.” If first cycle of Loop_10 and QS20_01 was not on route for the person being looped on.

Display “I now have some hard copy materials for {you/{PERSON}}.” If not first cycle of Loop_10 and QS20_01 was not on route for the person being looped on. Otherwise (i.e., QS20_01 was on route), use a null display.

Display “and collecting” if at least one person in the RU has Person.SAQFlag=YES, or Person.SAQFlagFlwUp=YES or Person.PSAQFlag=YES or Person.PSAQFlagFlwUp=YES in the current round. Otherwise, use a null display.

Display ‘you and’ if the respondent has a Person.SAQFlag=YES, or Person.SAQFlagFlwUp=YES or Person.PSAQFlag=YES or Person.PSAQFlagFlwUp=YES in the current round. Otherwise, use a null display.

Display “Now” if QS20_01 was on route for the person being looped on. Otherwise, use a null display.

Display "{SAQ/PSAQ} STATUS FROM PREVIOUS ROUND: {PREVIOUS ROUND STATUS -40}” if Round 3 or 5 and person was prompted for an SAQ/PSAQ in Round 2 or 4 and that SAQ/PSAQ is outstanding (Person.SAQFlagFlwUp=YES or Person.PSAQFlagFlwUp=Yes). Otherwise, use a null display.

Display “SAQ” if Person.SAQFlag=YES or Person.SAQFlagFlwUp=YES for the person being looped on.

Display “PSAQ” if Person.PSAQFlag=YES or Person.PSAQFlagFlwUp=YES for the person being looped on.

For ‘PREVIOUS ROUND STATUS-40’, display the following text:

If PL_Person.SAQRecCtrlStatus=3 display 'REFUSED'.

If PL_Person.SAQRecCtrlStatus=5 display 'BLANK'.

If PL_Person.SAQRecCtrlStatus=6 display 'WRONG TYPE'.

If PL_Person.SAQRecCtrlStatus=7 display 'WRONG YEAR USED'.

If PL_Person.SAQRecCtrlStatus=8 display 'NOT RECEIVED'.

If PL_Person.PSAQRecCtrlStatus=3 display 'REFUSED'.

If PL_Person.PSAQRecCtrlStatus=5 display 'BLANK'.

If PL_Person.PSAQRecCtrlStatus=6 display 'WRONG TYPE'.

If PL_Person.PSAQRecCtrlStatus=7 display 'WRONG YEAR USED'.

If PL_Person.PSAQRecCtrlStatus=8 display 'NOT RECEIVED'.

Display “COLLECT {MALE (BLUE)/FEMALE (PURPLE)} PSAQ. IF INCORRECT COLOR PSAQ COMPLETED, CODE ‘2’ (NEEDS REPLACEMENT) TO FILL OUT CORRECT COLOR PSAQ..” If Person.PSAQFlag=YES or Person.PSAQFlagFlwUp=YES for the person being looped on. Otherwise, use a null display.

Display “MALE (BLUE)” if person being looped on is male. Otherwise, display “FEMALE (PURPLE)”.

If Person.SAQFlagFlwUp=YES or Person.PSAQFlagFlwUp=YES and (person is NOT in the RU at the round 3 or 5 interview date (EndRefDt ≠ EndRefM, EndRefD, EndRefY)), then display FI instruction “PERSON…NEW DOCUMENT.” and response option ‘3’ (NOT COMPLETED, NO REPLACEMENT NECESSARY). Otherwise, use a null display.

Display “DECEASED” if PersRndStatus=Deceased. Display “INSTITUTIONALIZED” if PersRndStatus=Institutionalized. Otherwise, display “PARTIALLY ELIGIBLE - MOVED FROM RU.”

Display “CTRL-S: SWITCH TO DISTRIBUTE DOCS FOR A DIFFERENT PERSON.” If QS20_01 was not on route for the person being looped on. Otherwise, use a null display.

QS20_05 (QS1055)

Context Header: {PERSON’S FIRST MIDDLE AND LAST NAME}

Question Text:

COLLECT {PERSON}’S COMPLETED {SAQ/PSAQ}.

Responses: COMPLETED AND GIVEN TO INTERVIEWER 1 BOX_50 (QS1075)

{NOT COMPLETED, WILL PICK UP AT A LATER DATE} 2 BOX_50 (QS1075)

{NOT COMPLETED, WILL MAIL TO OFFICE} 3 BOX_50 (QS1075)

{MAILED TO SAQ RESPONDENT} 4 BOX_50 (QS1075)

REFUSED TO COMPLETE (NO FORM LEFT) 5 QS20_06 (QS1060)

NOT COMPLETED, COLLECT UPDATED STATUS AT RESPONDENT FORM SECTION 6 BOX_50 (QS1075)

OTHER 91

Programmer Instructions: RF/DK not allowed.

Display Instructions: Do not display response categories 2, 3, or 4. Those are reserved for the Respondent Form (RF) Section.

Display “SAQ” if Person.SAQFlag=YES or Person.SAQFlagFlwUp=YES for the person being looped on.

Display “PSAQ” if Person.PSAQFlag=YES or Person.PSAQFlagFlwUp=YES for the person being looped on.

QS20_06 (QS1060)

BLAISE NAME: FormRfResn

Context Header: {PERSON’S FIRST MIDDLE AND LAST NAME}

Question Text:

SELECT MAIN REASON FOR REFUSAL:

Responses: TOO BUSY/NOT INTERESTED 1 BOX_50 (QS1075)

TOO PERSONAL/SENSITIVE INFORMATION 2 BOX_50 (QS1075)

TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP 3 BOX_50 (QS1075)

HAS ALREADY GIVEN ENOUGH INFORMATION 4 BOX_50 (QS1075)

WANTS MORE INFORMATION 5 BOX_50 (QS1075)

NOT INTERESTED 6 BOX_50 (QS1075)

NO REASON GIVEN 7 BOX_50 (QS1075)

OTHER 91 QS20_07 (QS1065)

Programmer Instructions: RF/DK not allowed.

Display Instructions:

QS20_07 (QS1065)

BLAISE NAME: FormRfOS

Context Header: {PERSON’S FIRST MIDDLE AND LAST NAME}

Question Text:

ENTER OTHER REASON FOR REFUSAL:

Responses: 1 END_LP10 (QS1080)

Programmer Instructions: RF/DK not allowed.

Display Instructions:

QS20_08 (QS1070)

BLAISE NAME: FormPrep

Context Header: {PERSON’S FIRST MIDDLE AND LAST NAME}

Question Text:

{PREPARE {SELF/PROXY} DIABETES CARE SUPPLEMENT (DCS) FOR {PERSON}: WRITE IN PERSON’S NAME, DOB, PID, AND RUID.

NAME: {FIRST NAME} {MIDDLE NAME} {LAST NAME}

DOB: {MM/DD/YYYY} PID: {PID}

RU ID: {RU ID}

STATUS: {CURRENT/INSTITUTIONALIZED}

HAND PREPARED {SELF/PROXY} DCS TO RESPONDENT AND SAY:

We hope that {you/{PERSON}}/you or someone else in the family} would be able to fill out this short questionnaire on the care {you/{PERSON}} {get/gets} for diabetes. {You/He/She} can give it to me before I leave today, or I can pick it up later.

{PREPARE {MALE (BLUE)/FEMALE (PURPLE)} {SAQ/PSAQ} FOR {PERSON} USING THE INFORMATION BELOW:

REGION: {REGION} RU ID: {RU ID} PID: {PID}

NAME: {FIRST NAME} {MIDDLE NAME} {LAST NAME}

DOB: {MM/DD/YYYY}

HAND PREPARED {SAQ/PSAQ} TO RESPONDENT AND SAY:

We hope {you/{PERSON}} will be able to fill out this short questionnaire about {health and health opinions/health choices}. {You/He/She} can give it to me before I leave today, or I can pick it up later.

PRESS 1 AND ENTER TO CONTINUE.

HELP:F1

Responses: CONTINUE 1 BOX_50 (QS1075)

Programmer Instructions: When asking about DCS for this RU member display ‘PREPARE {SELF/PROXY} DIABETES… or I can pick it up later.’ Do not display the other fills on SAQ. When asking about SAQ use a null display.

Display 'SELF' and '{you/{PERSON}}' if QS10_01 is coded ‘1’ (SELF).

Display 'PROXY' and 'you or someone else in the family' if QS10_01 is coded ‘2’ (PROXY).

Display date of birth for person being asked about for 'MM/DD/YYYY.' Display PID of person being asked about for 'PID'.

Display the RU ID for the current case for 'RUID'.

Display ‘CURRENT’ if the person being asked about is a current RU member (person included on person array) and is not institutionalized or deceased (PersRndStatus ≠ Institutionalized or Deceased).

Display “INSTITUTIONALIZED” if the person being asked about is institutionalized (PersRndStatus=Institutionalized).

When asking about SAQ/PSAQ for this RU member display ‘PREPARE {MALE (BLUE)/FEMALE (PURPLE)} {SAQ/PSAQ}FOR {PERSON}…or I can pick it up later.’

Do not display the other fills on DCS. When asking about DCS use a null display.

Display region for the current case being asked about for ‘REGION’. Display the RU ID for the current case for 'RUID'.

Display PID of RU member being asked about for 'PID'.

Display date of birth for RU member being asked about for 'MM/DD/YYYY.'

RF/DK not allowed.

Display Instructions: When asking about the DCS, display all the fill text in bold black, “FIRST NAME”, “MIDDLE NAME”, “LAST NAME”, “MM/DD/YYYY”, “PID”, “RUID” “CURRENT/INSTITUTIONALIZED”. All other text should adhere to the UI document specifications.

When asking about the SAQ/PSAQ, display all the fill text in bold black: “REGION”, “RUID”, “PID” “FIRST NAME”, “MIDDLE NAME”, “LAST NAME”, “MM/DD/YYYY”. All other text should adhere to the UI document specifications.

Display “{MALE (BLUE)/FEMALE (PURPLE)}” If Person.PSAQFlag=YES or Person.PSAQFlagFlwUp=YES for the person being looped on. Otherwise, use a null display.

Display “MALE (BLUE)” if person being looped on is male. Otherwise, display “FEMALE (PURPLE)”.

Display “SAQ” if Person.SAQFlag=YES or Person.SAQFlagFlwUp=YES for the person being looped on.

Display “PSAQ” if Person.PSAQFlag=YES or Person.PSAQFlagFlwUp=YES for the person being looped on.

"Display 'health and health opinions' when asking about the SAQ. Display 'health choices' when asking about PSAQ.

BOX_50 (QS1075)

END_LP10 (QS1080)

BOX_60 (QS1085)

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