Respondent Forms (RF) Section

BOX_00 (RF1000)

Route Details: 01 Box = BOX_00, BOX_10, BOX_20, BOX_30, BOX_40, BOX_50, BOX_60, BOX_70, BOX_80, BOX_90, BOX_100

02 Loop = LOOP_10, LOOP_20

03 End Loop = END_LP10, END_LP20

04 Single Select = RF50_01, RF50_05, RF60, RF100, RF120_01, RF120_05, RF130_01, RF130_03

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

14 Regular Date Entry = RF50_04, RF90_01, RF90_02, RF90_03, RF120_04

20 OS Text Field = RF50_02, RF50_06, RF120_02, RF120_06, RF130_02, RF130_04

23 Text Field = RF50_03, RF120_03

24 Information Screen = RFIntro, RF10, RF20, RF30, RF40_01, RF110_01

26 Regular Date Entry - Preloaded = RF80_01, RF80_02, RF80_03

BOX_10 (RF1005)

RFIntro (RF1006)

BLAISE NAME: RFIntro

Question Text:

CAPI WILL NOW DETERMINE WHICH, IF ANY, AUTHORIZATION FORMS AND HARD COPY DOCUMENTS 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.

PRESS 1 AND ENTER TO CONTINUE.

Responses: CONTINUE 1 BOX_20 (RF1010)

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/Final%20Design%20Docs%20by%20Group/Respondent%20Form%20(RF)%20Section%20Supporting%20Documents/AF%20Rules.xlsx

The specifications for the AF array are included here:

(https://mepspm.westat.com/Final%20Design%20Docs%20by%20Group/Respondent%20Form%20(RF)%20Section%20Supporting%20Documents/AF%20array.xlsx)

Display Instructions:

BOX_20 (RF1010)

RF10 (RF1015)

BLAISE NAME: AFSumm

Question Text:

FORM COLLECTION SUMMARY.

RU Member Age SAQ DCS Medical AFs Pharmacy AFs

(Preprinted) (Preprinted)

{MPCColor} {PharColor}

{PERSON FIRST NAME} {Age} {Text} {Text} {SS} ({TT}) {WW} ({XX})

{PERSON FIRST NAME} {Age} {Text} {Text} {SS} ({TT}) {WW} ({XX})

{PERSON FIRST NAME} {Age} {Text} {Text} {SS} ({TT}) {WW} ({XX})

{PERSON FIRST NAME} {Age} {Text} {Text} {SS} ({TT}) {WW} ({XX})

{PERSON FIRST NAME} {Age} {Text} {Text} {SS} ({TT}) {WW} ({XX})

Total {QQ {RR {UU} {(VV)} {YY} {(ZZ)} (Pending)} (Pending)

PRESS 1 AND ENTER TO CONTINUE.

Responses: CONTINUE 1 BOX_30 (RF1020)

Programmer Instructions: Roster behavior:

1. Add, edit, select disallowed.

Display Instructions: Roster 1 - Report Roster Definition:

This item displays the RU members roster for display only in the info pane.

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

This cell is active for this row if [(Person.SAQFlag=Yes or Person.SAQFlwUpFlag=YES) and (QS20_04 = 1 or 2)] or if [(Person.PSAQFlag=Yes or Person.PSAQFlwUpFlag=YES) and (QS20_ 04 = 1 or 2)]. Otherwise, leave cell empty. Cell display uses the value from QS20_04 (FormCmpl) or QS20_05 (FormCollect) for this person during the current round. Display “Completed” if QS20_05 was coded ‘1’ (COMPLETED AND GIVEN TO INTERVIEWER). Display “Refused” if QS20_05 was coded ‘5’ (REFUSED TO COMPLETE). Display “Pending” if QS20_ 04 was coded ‘2’ (NEEDS REPLACEMENT) or QS20_05 was coded ‘6’ (NOT COMPLETED, COLLECT UPDATED STATUS AT RESPONDENT FORM SECTION).

For “QQ”, display the count of the number of persons where the SAQ/PSAQ status is “pending”. Display ‘0’ if none. The word ‘(Pending)’ will display next to this count. (Note: The SAQ and PSAQ are never collected in the same round, thus they can share a column.)

Column Header #4: DCS

Display “Pending” if Person.DCSFlag=YES. Otherwise, leave cell empty.

For “RR”, display the count of the number of persons where Person.DCSFlag=YES. Display ‘0’ if none. The word ‘(Pending)’ will display next to this count. (Note: The DCS is only being distributed in the QS section and never statused. The RF section is the first time we will get a status for the DCS.)

Column Header #5: Medical AFs (Preprinted) {MPCColor}

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

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 [(Rounds 2-5) 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 #6: Pharmacy AFs (Preprinted) {PharColor}

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 [(Rounds 2-5) and (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)]. Display ‘0’ if none. Note: This count will always be ‘0’ in Round 1. 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 [(Rounds 2-5) 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.

For “YY”, sum all the counts in “WW”.

For “ZZ”, sum all the counts in “XX”.

Display the grid in the info pane in nonproportional text.

BOX_30 (RF1020)

RF20(RF1025)

BLAISE NAME: AFSumm2

Question Text:

FORM COLLECTION SUMMARY, CONTINUED.

{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.

PRESS 1 AND ENTER TO CONTINUE.

Responses: CONTINUE 1 BOX_40 (RF1030)

Programmer Instructions:

Display Instructions: Roster 1- Report

Roster definition:

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. Between the last two names displayed, separate names using the word “and”.

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

BOX_40 (RF1030)

RF30 (RF1035)

BLAISE NAME: AFRequest

Question Text:

{[As I mentioned during the last interview], we/We} request written 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.}

[HAND RESPONDENT THE AUTHORIZATION FORM BOOKLET.]

[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 while I prepare the forms.]

PRESS 1 AND ENTER TO CONTINUE.

Responses: CONTINUE 1 LOOP_10 (RF1040)

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 [(Rounds 2-5) and (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)]]. Otherwise, use a null display.

Display “and” if there is at least at least one active MPC and one active Phamacy 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 (Rounds 2-5) and (AF.AFType=Pharmacy) and (AF.AFSuperceded=Empty)]. Otherwise, use a null display.

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 “{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 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 Phamacy 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 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”.

LOOP_10 (RF1040)

BOX_50 (RF1045)

RF40_01 (RF1050)

BLAISE NAME: AFInfo

Question Text:

INTERVIEWER: {COMPLETE A NEW AF FOR THIS PAIR./TAKE OUT PREPRINTED AF FOR THIS PAIR. IF NOT AVAILABLE, FILL OUT A BLANK AF.}

{AF STATUS FROM PREVIOUS ROUND: {DISPLAY RECEIPT CONTROL STATUS}}

PROVIDER NAME: {Provider/Pharmacy Full Name}

ADDRESS: {Combined Street Address} {City}, {ST} {Zip Code} {Telephone}

PATIENT: {First,[Middle],Last Name}

DOB: {MM/DD/YYYY} AGE: {XXX} {ACTION: {Status Action}}

RU ID: {RUID} REGION: {Reg ID} PROVIDER ID: {ProvID} PID: {PID}

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

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

PRESS 1 AND ENTER WHEN FORM IS PREPARED.

CTRL-S: SWITCH TO A DIFFERENT RU MEMBER.

HELP: F1

Responses: AF FORM PREPARED 1

Programmer Instructions: Preloaded grid type – flexible navigation including RF40_01, RF40_02, RF40_03, RF40_04, RF40_N, as well as RF50_01, RF50_02, RF50_03, RF50_04, RF50_05, and RF50_06.

At grid completion, continue with RF50_01.

Display Instructions: Roster 1 – Report

Col #1 Header: Provider

Instructions: Display the name of the medical or pharmacy 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 and Pharmacy authorization forms that are active for this person for this round [records where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)] or [(Rounds 2-5) and (AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]]. This column is protected and uneditable.

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

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

Instructions: RF40_01, RF40_02, RF40_03, RF40_04, RF40_N entry field.

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 “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)

The labels PROVIDER NAME:, ADDRESS:, PATIENT:, DOB:, AGE:, RU ID:, REGION:, 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 “{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.

For “{Status Action}” display the following:

“{Verify} Child <=13. {If so,} Need Parent/Guardian Signature” if [(AF.AFPersonStatus=1 or 2) and [(AF.Age <=13) or (AF.AgeCat or AF.AgeGuess=1-3)]].

Otherwise, use a null display.

“{Verify} Child 14-17. {If so,} Need Patient and Parent/Guardian Signature” if [(AF.AFPersonStatus=1 or 2) and [(AF.Age 14-17) or (AF.AgeCat or AF.AgeGuess=4)]].

Display “Verify” and “If so,” AF.Age is RF/DK/empty and AF.AgeCat or AF.AgeGuess=4. Otherwise, use a null display.

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

Display “In Prior Round” if AF.AFPersonStatus=5.“Patient {Still} Institutionalized. Need Proxy Signature” if AF.AFPersonStatus=4 or 6.

Display “Still” if AF.AFPersonStatus=6.

For “{Reg ID}”, display the region of this CaseID. (May need to get from BFOS?)

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, truncation is okay).

RF50_01 (RF1055)

BLAISE NAME: AFStat

Question Text:

PROVIDER NAME: {Provider/Pharmacy Full Name}

PATIENT: {First,[Middle],Last Name}

REQUEST SIGNATURE AND THEN ENTER THE AUTHORIZATION FORM STATUS.

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

HELP: F1

Responses: SIGNED 1 RF50_03 (RF1065)

LEFT WITH RESPONDENT 2

MAILED TO RESPONDENT 3

REFUSED (NO FORM LEFT) 4 RF50_05 (RF1075)

OTHER (NOT SIGNED) 91 RF50_02 (RF1060)

Programmer Instructions: Preloaded Grid type 2 – flexible navigation, including items RF50_01, RF50_02, RF50_03, RF50_04, RF50_05, and RF50_06, as well as RF40_01, RF40_02, RF40_03, RF40_04, RF40_N.

Refused and Don’t Know disallowed.

If RF50_01 is coded ‘2’ (LEFT WITH RESPONDENT) or ‘3’ (MAILED TO RESPONDENT), return to RF50_01 for next authorization form on grid. At grid completion, go to BOX_60. Set AF.AFCAPIStatus=RF50_01.

Display Instructions: Roster 1 – Report

Col #1 Header: Provider

Instructions: Display the name of the medical or pharmacy 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 and Pharmacy authorization forms that are active for this person for this round [records where [(Round 1) and (AF.AFType=MPC) and (AF.RequestRd1=Yes)] or [(Rounds 2-5) and (AF.AFType=MPC or Pharmacy) and (AF.AFSuperceded=Empty)]]. This column is protected and uneditable.

Instructions: Display the Authorization form type – either “MPC” or “Pharmacy”. 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 RF40_01-RF40_N for each authorization form in a protected, uneditable field.

Instructions: Item RF50_01. Always an active cell for every row.

Instructions: Item RF50_02. Display as an active cell if RF50_01 is coded ‘91’ (OTHER).

Instructions: Item RF50_03. Display as an active cell if RF50_01 is coded ‘1’ (SIGNED).

Instructions: Item RF50_04. Display as an active cell if RF50_01 is coded ‘1’ (SIGNED).

Instructions: Item RF50_05. Display as an active cell if RF50_01 is coded ‘4’ (REFUSED)

Instructions: Item RF50_06. Display as an active cell if RF50_05 is coded ‘91’ (OTHER SPECIFY).

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)

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.

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, truncation is okay).

RF50_02 (RF1060)

BLAISE NAME: AFStatOS

Question Text:

PROVIDER NAME: {Provider/Pharmacy Full Name}

PATIENT: {First,[Middle],Last Name}

SPECIFY OTHER AUTHORIZATION FORM STATUS:

Responses: 1

Programmer Instructions: Return to RF50_01 for next authorization form on grid.

Refused and Don’t Know disallowed.

Set AF.AFCAPIStatusOS=RF50_02.

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)

RF50_03 (RF1065)

BLAISE NAME: AFNum

Question Text:

PROVIDER NAME: {Provider/Pharmacy Full Name}

PATIENT: {First,[Middle],Last Name}

ENTER AUTHORIZATION FORM NUMBER:

Responses: 1 RF50_04 (RF1070)

Programmer Instructions: Refused and Don’t Know disallowed.

Set AF.AFFormID=RF50_03.

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 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.”

MPC Authorization Form Number Conventions Origin Letter 5-Number Check Digit Round Identifier Sequence P21 P22 P23

Pre-Generated A-M 00001-29499 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L

Field Generated A-M 29500-44999 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L

Home Office T 45000-49999 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L

Training/QC Y 96000-96399 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L

Pharmacy Authorization Form Number Conventions Origin Letter 5-Number Check Digit Round Identifier Sequence P21 P22 P23

Pre-Generated Q, R, S 70000-79999 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L

Field Generated Q, R, S 80000-89999 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L

Home Office Z 90000-95999 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L

Training/QC Y 96600-96799 Random (0-9) 1, 2, 3, 4, 5 A, B, C, D, E G, H, J, K, L

Note:

P24 will use round identifiers: M, N, P, Q, R. P25 will use round identifiers: S, T, U, V, W. P26 will use round identifiers: 1, 2, 3, 4, 5.

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)

RF50_04 (RF1070)

BLAISE NAME: AFDate

Question Text:

PROVIDER NAME: {Provider/Pharmacy Full Name}

PATIENT: {First,[Middle],Last Name}

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

ENTER AUTHORIZATION FORM SIGNATURE DATE:

PRESS THE ALT AND DOWN ARROW KEY TO SELECT THE DATE FROM THE CALENDAR.

PRESS ENTER TO CONTINUE.

Responses: 1

Programmer Instructions: Return to RF50_01 for next authorization form on grid.

Refused and Don’t Know disallowed.

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.”

Display Instructions: Display the date field for the signature date here.

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)

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.

RF50_05 (RF1075)

BLAISE NAME: AFRfResn

Question Text:

PROVIDER NAME: {Provider/Pharmacy Full Name}

PATIENT: {First,[Middle],Last Name}

SELECT MAIN REASON FOR REFUSAL:

Responses: DOESN'T WANT TO BOTHER PROVIDER 1

CONFIDENTIALITY/SENSITIVE INFO 2

PAYMENT PROBLEM WITH PROVIDER 3

HAS ALREADY GIVEN ENOUGH INFORMATION 4

WANTS MORE INFO BEFORE SIGNING 5

NOT INTERESTED IN STUDY 6

NO REASON GIVEN 7

OTHER SPECIFY 91 RF50_06 (RF1080)

Programmer Instructions: If coded ‘1’, ‘2’, ‘3’, ‘4’, ‘5’, ‘6’, or ‘7’, return to RF50_01 for next authorization form on grid.

Refused and Don’t Know disallowed.

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)

RF50_06 (RF1080)

BLAISE NAME: AFRfOS

Question Text:

PROVIDER NAME: {Provider/Pharmacy Full Name}

PATIENT: {First,[Middle],Last Name}

SPECIFY OTHER REASON FOR REFUSAL:

Responses: 1

Programmer Instructions: Return to RF50_01 for next authorization form on grid.

Refused and Don’t Know disallowed.

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)

BOX_60 (RF1085)

LOOP_20 (RF1090)

BOX_70 (RF1095)

RF60 (RF1100)

BLAISE NAME: HCIConf

Question Text:

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?

Responses: YES 1 RF70_01 (RF1105)

NO 2 RF70_01 (RF1105)

REFUSED RF RF70_01 (RF1105)

DON'T KNOW DK RF70_01 (RF1105)

Programmer Instructions: If coded ‘2’ (NO), ‘RF’ (REFUSED), or ‘DK’ (DON’T KNOW), set AF.AFSuperceded=Yes for the record where AF.AFType=MPC-HCI (original). Create a new record where: AF.AFType=MPC-HCI (additional). Set AF.OrigRnd and AF.AFYear. From the MPC-HCI (original) record, copy over all the “info about person” variables to the new record.

Set AF.ReqSignDt to RU reference period end date regardless of response to RF60.

Set AFYear to 1 if current round =1 or 2. Set AFYear to 2 if current round =3, 4 or 5 regardless of response to RF60.

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)].

RF70_01 (RF1105)

BLAISE NAME: HCIName

Question Text:

{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.}

{Is the name:/What is the name?}

{INSTITUTION NAME}

{STREET ADDRESS1}

{STREET ADDRESS2}

{CITY}, {STATE} {ZIP CODE}

{TELEPHONE NUMBER}

Responses: 1 RF70_02 (RF1110)

Programmer Instructions: Refused and Don’t Know disallowed.

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.

RF70_02 (RF1110)

BLAISE NAME: HCIStrt

Question Text:

{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.}

{Is the street address:/What is the street address?}

{INSTITUTION NAME}

{STREET ADDRESS1}

{STREET ADDRESS2}

{CITY}, {STATE} {ZIP CODE}

{TELEPHONE NUMBER}

Responses: 1 RF70_03 (RF1115)

REFUSED RF RF70_03 (RF1115)

DON'T KNOW DK RF70_03 (RF1115)

Programmer Instructions: See general programming instructions at RF70_01.

Set Provider.MPStrt and AF.StrtAddr1 = RF70_02.

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

RF70_03 (RF1115)

BLAISE NAME: HCIStrt2

Question Text:

{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.}

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

{INSTITUTION NAME}

{STREET ADDRESS1}

{STREET ADDRESS2}

{CITY}, {STATE} {ZIP CODE}

{TELEPHONE NUMBER}

Responses: 1 RF70_04 (RF1120)

EMPTY Empty RF70_04 (RF1120)

REFUSED RF RF70_04 (RF1120)

DON'T KNOW DK RF70_04 (RF1120)

Programmer Instructions: See general programming instructions at RF70_01.

Set AF.StrtAddr2 = RF70_03. (There is no street address 2 in the provider array.)

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

RF70_04 (RF1120)

BLAISE NAME: HCICity

Question Text:

{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.}

{Is the city:/What is the city?}

{INSTITUTION NAME}

{STREET ADDRESS1}

{STREET ADDRESS2}

{CITY}, {STATE} {ZIP CODE}

{TELEPHONE NUMBER}

Responses: 1 RF70_05 (RF1125)

REFUSED RF RF70_05 (RF1125)

DON'T KNOW DK RF70_05 (RF1125)

Programmer Instructions: See general programming instructions at RF70_01.

Set Provider. ProvCity and AF.City = RF70_04.

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

RF70_05 (RF1125)

Question Text:

{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.}}

{Is the state:/What is the state?}

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

{INSTITUTION NAME}

{STREET ADDRESS1}

{STREET ADDRESS2}

{CITY}, {STATE} {ZIP CODE}

{TELEPHONE NUMBER}

Responses: 1 RF70_06 (RF1130)

REFUSED RF RF70_06 (RF1130)

DON'T KNOW DK RF70_06 (RF1130)

Programmer Instructions: See general programming instructions at RF70_01.

Use the state lookup file.

Set Provider.MPST and AF.State = RF70_05.

Note: The entry Foreign country (FC) is allowed.

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

RF70_06 (RF1130)

BLAISE NAME: HCIZip

Question Text:

{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.}

{Is the zip code:/What is the zip code?}

{INSTITUTION NAME}

{STREET ADDRESS1}

{STREET ADDRESS2}

{CITY}, {STATE} {ZIP CODE}

{TELEPHONE NUMBER}

Responses: 1 RF70_07 (RF1135)

REFUSED RF RF70_07 (RF1135)

DON'T KNOW DK RF70_07 (RF1135)

Programmer Instructions: See general programming instructions at RF70_01.

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."

Set Provider.ProvZip and AF.Zip = RF70_06.

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

RF70_07 (RF1135)

BLAISE NAME: HCIPhone

Question Text:

{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.}

What is the telephone number?

IF NO TELEPHONE, ENTER DON’T KNOW.

{INSTITUTION NAME}

{STREET ADDRESS1}

{STREET ADDRESS2}

{CITY}, {STATE} {ZIP CODE}

{TELEPHONE NUMBER}

Responses: 1 RF80_01 (RF1140)

REFUSED RF RF80_01 (RF1140)

DON'T KNOW DK RF80_01 (RF1140)

Programmer Instructions: See general programming instructions at RF70_01.

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."

Set Provider.ProvPhone and AF.Phone = RF70_07.

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

RF80_01 (RF1140)

BLAISE NAME: HCIAdmitMM

Question 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}?}

{VERIFY/ENTER} MONTH.

Responses: 1 RF80_02 (RF1145)

Programmer Instructions: DK AND RF disallowed for month.

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 “{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 “{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)].

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

Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.

RF80_02 (RF1145)

BLAISE NAME: HCIAdmitDD

Question 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}?}

{VERIFY/ENTER} DAY.

Responses: 1 RF80_03 (RF1150)

REFUSED RF RF80_03 (RF1150)

DON'T KNOW DK RF80_03 (RF1150)

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

Display Instructions: See display instructions at RF80_01.

Display the first paragraph in grayed-out text.

Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.

RF80_03 (RF1150)

BLAISE NAME: HCIAdmitYYYY

Question 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}?}

{VERIFY/ENTER} 4-DIGIT YEAR.

Responses: 1 RF90_01 (RF1155)

Programmer Instructions: DK and RF disallowed for year.

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

Hard check: 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 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.

Display Instructions: See display instructions at RF80_01.

Display the first paragraph in grayed-out text.

Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.

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)].

RF90_01 (RF1155)

BLAISE NAME: HCIDischMM

Question Text:

What date {were you/was {PERSON}} discharged from {INSTITUTION NAME}?

ENTER MONTH.

Responses: 1 RF90_02 (RF1160)

Programmer Instructions: DK AND RF disallowed for month.

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

Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.

RF90_02 (RF1160)

BLAISE NAME: HCIDischDD

Question Text:

What date {were you/was {PERSON}} discharged from {INSTITUTION NAME}?

ENTER DAY.

Responses: 1 RF90_03 (RF1165)

REFUSED RF RF90_03 (RF1165)

DON'T KNOW DK RF90_03 (RF1165)

Display Instructions: See display instructions at RF90_01.

Display the first paragraph in grayed-out text.

Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.

RF90_03 (RF1165)

BLAISE NAME: HCIDischYYYY

Question Text:

What date {were you/was {PERSON}} discharged from {INSTITUTION NAME}?

ENTER 4-DIGIT YEAR.

Responses: 1 BOX_80 (RF1170)

Programmer Instructions: DK AND RF disallowed for year.

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.

Display Instructions: See display instructions at RF90_01.

Display the first paragraph in grayed-out text.

Display RF80_01 - RF80_03 and RF90_01-RF90_03 on the same form pane.

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)].

BOX_80 (RF1170)

RF100 (RF1175)

BLAISE NAME: HCIOth

Question Text:

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}]?

Responses: YES 1 END_LP20 (RF1180)

NO 2 END_LP20 (RF1180)

REFUSED RF END_LP20 (RF1180)

DON'T KNOW DK END_LP20 (RF1180)

Programmer Instructions: If coded ‘1’ (YES), create a new record where: AF.AFType=MPC-HCI (additional). Set AF.OrigRnd and AF.AFYear. 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 “{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 “{PERSON}” display the full name of the person being looped on (AF.FName, AF.MName, AF.LName).

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

END_LP20 (RF1180)

RF110_01 (RF1185)

BLAISE NAME: HCIInfo

Question Text:

INTERVIEWER: COMPLETE A NEW MPC AF FOR THIS PAIR. ON TOP LEFT CORNER OF FORM, PRINT “HCI”.

PROVIDER NAME: {Provider}

ADDRESS: {Combined Street Address} {City}, {ST} {Zip Code} {Telephone}

PATIENT: {First,[Middle],Last Name}

DOB: {MM/DD/YYYY} AGE: {XXX} ACTION: {Status Action}

RU ID: {RUID} REGION: {Reg ID} PROVIDER ID: {ProvID} PID: {PID}

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

PRESS 1 AND ENTER WHEN FORM IS PREPARED.

HELP: F1

Responses: AF FORM PREPARED 1

Programmer Instructions: Preloaded grid type – flexible navigation including RF110_01, RF110_02, RF110_03, RF110_ 04, RF110_N, as well as RF120_01, RF120_02, RF120_03, RF120_04, RF120_05, and RF120_06.

At grid completion, continue with RF120_01.

Display Instructions: Roster 1 – Report

Col #1 Header: Provider

Instructions: Display the name of the institutional provider for this row. This column is protected and uneditable. (AF.ProvName) Variable may need to be truncated for display in grid.)

Roster Filter:

Display only MPC authorization forms for health care institutions that are active for this person for this round [records where [(AF.AFType=MPC-HCI (original)) and (AF.Superceded=Empty)] or [AF.AFType=MPC-HCI (additional)]. This column is protected and uneditable.

Col #2 Header: Type

Instructions: Display the Authorization form type – “MPC-HCI”. This column is protected and uneditable.

Col #3 Header: Color

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

Col #4 Header: Prep

Instructions: RF110_01, RF110_02, RF110_03, RF110_04, RF110_N entry field.

The labels PROVIDER NAME:, ADDRESS:, PATIENT:, DOB:, AGE:, RU ID:, REGION:, AGE:, 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 “{Provider}” display the full name of the provider for this AF record. (Use AF.ProvName with no truncation).

For “{Combined Street Address}” display the street address of the provider 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 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) or if [(AF.AFPersonStatus=1 or 2) and [(AF.Age <=17) or (AF.AgeCat or AF.AgeGuess=1-4)]]. Otherwise, use a null display.

For “{Status Action}” display the following:

“{Verify} Child <=13. {If so,} Need Parent/Guardian Signature” if [(AF.AFPersonStatus=1 or 2) and [(AF.Age <=13) or (AF.AgeCat or AF.AgeGuess=1-3)]].

Display “Verify” and “If so,” AF.Age is RF/DK/empty and AF.AgeCat or AF.AgeGuess=1-3.

Otherwise, use a null display.

“{Verify} Child 14-17. {If so,} Need Patient and Parent/Guardian Signature” if [(AF.AFPersonStatus=1 or 2) and [(AF.Age 14-17) or (AF.AgeCat or AF.AgeGuess=4)]].

Display “Verify” and “If so,” AF.Age is RF/DK/empty and AF.AgeCat or AF.AgeGuess=4. Otherwise, use a null display.

“Patient Deceased. Need Proxy Signature” if AF.AFPersonStatus=3.

For “{RUID}”, display the CaseID.

For “{Reg ID}”, display the region of this CaseID. (May need to get from BFOS?)

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).

RF120_01 (RF1190)

BLAISE NAME: HCIStat

Question Text:

PROVIDER NAME: {Provider Full Name}

PATIENT: {First,[Middle],Last Name}

REQUEST SIGNATURE AND THEN ENTER THE AUTHORIZATION FORM STATUS.

HELP: F1

Responses: SIGNED 1 RF120_03 (RF1200)

LEFT WITH RESPONDENT 2

MAILED TO RESPONDENT 3

REFUSED (NO FORM LEFT) 4 RF120_05 (RF1210)

OTHER (NOT SIGNED) 91 RF120_02 (RF1195)

Programmer Instructions: Preloaded Grid type 2 – flexible navigation, including items RF120_01, RF120_02, RF120_03, RF120_04, RF120_05, and RF120_06 as well as RF110_01, RF110_02, RF110_03, RF110_ 04, RF110_N.

Refused and Don’t Know disallowed.

If RF120_01 is coded ‘2’ (LEFT WITH RESPONDENT) or ‘3’ (MAILED TO

RESPONDENT), return to RF120_01 for next authorization form on grid. At grid completion, go to BOX_90.

Set AF.AFCAPIStatus=RF120_01.

Display Instructions: Roster 1 – Report

Col #1 Header: Provider

Instructions: Display the name of the institutional provider for this row. This column is protected and uneditable. (AF.ProvName) Variable may need to be truncated for display in grid.)

Roster Filter:

Display only MPC authorization forms for health care institutions that are active for this person for this round [records where [(AF.AFType=MPC-HCI (original)) and (AF.Superceded=Empty)] or [AF.AFType=MPC-HCI (additional)]. This column is protected and uneditable.

Col #2 Header: Type

Instructions: Display the Authorization form type – “MPC-HCI”. This column is protected and uneditable.

Col #3 Header: Color

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

Col #4 Header: Prep

Instructions: Display the entered responses from RF110_01-RF110_N for each authorization form in a protected, uneditable field.

Col #5 Header: Status

Instructions: Item RF120_01. Always an active cell for every row.

Instructions: Item RF120_02. Display as an active cell if RF120_01 is coded ‘91’ (OTHER).

Col #7 Header: AF Number

Instructions: Item RF120_03. Display as an active cell if RF120_01 is coded ‘1’ (SIGNED).

Col #8 Header: Signature Date

Instructions: Item RF120_04. Display as an active cell if RF120_01 is coded ‘1’ (SIGNED).

Col #9 Header: Refusal Reason

Instructions: Item RF120_05. Display as an active cell if RF120_01 is coded ‘4’ (REFUSED)

Col #10 Header: Specify Refusal

Instructions: Item RF50_06. Display as an active cell if RF120_05 is coded ‘91’ (OTHER SPECIFY).

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

For “{Provider Full Name}” display the full name of the provider 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)

RF120_02 (RF1195)

BLAISE NAME: HCIStatOS

Question Text:

PROVIDER NAME: {Provider Full Name}

PATIENT: {First,[Middle],Last Name}

SPECIFY OTHER AUTHORIZATION FORM STATUS:

Responses: 1

Programmer Instructions: Return to RF120_01 for next authorization form on grid.

Refused and Don’t Know disallowed.

Set AF.AFCAPIStatusOS=RF120_02.

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

For “{Provider Full Name}” display the full name of the provider 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)

RF120_03 (RF1200)

BLAISE NAME: HCINum

Question Text:

PROVIDER NAME: {Provider Full Name}

PATIENT: {First,[Middle],Last Name}

ENTER AUTHORIZATION FORM NUMBER:

Responses: 1 RF120_04 (RF1205)

Programmer Instructions: Refused and Don’t Know disallowed.

Set AF.AFFormID=RF120_03.

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-HCI: The Authorization form number entered must follow the conventions noted at RF50_03 (see earlier) for regular MPC forms. 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.”

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

For “{Provider Full Name}” display the full name of the provider 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)

RF120_04 (RF1205)

BLAISE NAME: HCIDate

Question Text:

PROVIDER NAME: {Provider Full Name}

PATIENT: {First,[Middle],Last Name}

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

ENTER AUTHORIZATION FORM SIGNATURE DATE:

PRESS THE ALT AND DOWN ARROW KEY TO SELECT THE DATE FROM THE CALENDAR.

PRESS ENTER TO CONTINUE.

Responses: 1

Programmer Instructions: Return to RF120_01 for next authorization form on grid.

Refused and Don’t Know disallowed.

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.”

Display Instructions: Display the date field for the signature date here

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

For “{Provider Full Name}” display the full name of the provider 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.

RF120_05 (RF1210)

BLAISE NAME: HCIRfResn

Question Text:

PROVIDER NAME: {Provider Full Name}

PATIENT: {First,[Middle],Last Name}

SELECT MAIN REASON FOR REFUSAL:

Responses: DOESN'T WANT TO BOTHER PROVIDER 1

CONFIDENTIALITY/SENSITIVE INFO 2

PAYMENT PROBLEM WITH PROVIDER 3

HAS ALREADY GIVEN ENOUGH INFORMATION 4

WANTS MORE INFO BEFORE SIGNING 5

NOT INTERESTED IN STUDY 6

NO REASON GIVEN 7

OTHER SPECIFY 91 RF120_06 (RF1215)

Programmer Instructions: Refused and Don’t Know disallowed.

If coded ‘1’, ‘2’, ‘3’, ‘4’, ‘5’, ‘6’, or ‘7’, return to RF120_01 for next authorization form on grid.

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

For “{Provider Full Name}” display the full name of the provider 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)

RF120_06 (RF1215)

BLAISE NAME: HCIRfOS

Question Text:

PROVIDER NAME: {Provider Full Name}

PATIENT: {First,[Middle],Last Name}

SPECIFY OTHER REASON FOR REFUSAL:

Responses: 1

Programmer Instructions: Return to RF120_01 for next authorization form on grid.

Refused and Don’t Know disallowed.

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

For “{Provider Full Name}” display the full name of the provider 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)

BOX_90 (RF1220)

RF130_01 (RF1225)

BLAISE NAME: FormCollectFinal

Question Text:

PERSON: {First Middle Last Name} PID: {PID} FORM: {SAQ/PSAQ ({BLUE/PURPLE})/DCS}

{Earlier we asked {you/{PERSON}} to complete a brief survey about health and health opinions./Earlier we asked {you/{PERSON}} to complete a few questions about the care received for diabetes./Earlier we asked that someone knowledgeable about {your/{PERSON}’s} diabetes to complete a few questions about the care received.} I would like to collect that form now.

COLLECT COMPLETED {MALE (BLUE)/FEMALE (PURPLE)} {SAQ/PSAQ/DCS}.

{{SAQ/PSAQ} WAS CODED AS {COMPLETED/REFUSED} EARLIER IN THE INTERVIEW. ENTER THROUGH THE FIELDS IF NO UPDATE TO STATUS IS NECESSARY.}

SELECT THE STATUS OF THE {SAQ/PSAQ/DCS}:

Responses: COMPLETED AND GIVEN TO INTERVIEWER 1

NOT COMPLETED, WILL PICK UP AT A LATER DATE 2

NOT COMPLETED, WILL MAIL TO OFFICE 3

MAILED TO RESPONDENT 4

REFUSED TO COMPLETE (NO FORM LEFT) 5 RF130_03 (RF1235)

{NOT COMPLETED, COLLECT UPDATED STATUS AT RESPONDENT FORM SECTION} 6

OTHER 91 RF130_02 (RF1230)

Programmer Instructions: The grid should be Preloaded Grid Type 1: forced navigation, including RF130_01, RF130_02, RF130_03, and RF130_04.

If coded ‘1’, ‘2’, ‘3’, or ‘4’, return to RF130_01 for next hard copy form on grid.

At grid completion, continue with BOX_100.

Refused and Don’t Know disallowed.

The number of rows in the grid will correspond to the hard copy flags set for this RU member (Person.DCSFlag= YES, [(Person.SAQFlag=Yes or Person.SAQFlwUpFlag=YES) and (QS20_04 = 1 or 2)], [(Person.PSAQFlag=Yes or Person.PSAQFlwUpFlag=YES) and (QS20_04 = 1 or 2)]

NOTE TO PROGRAMMERS: An RU member will never have BOTH the SAQ and PSAQ active in the same round. The maximum number of rows in the grid will be two. This grid needs to be configurable to accommodate the addition of other required hardcopy materials as requested by the client in future panels.

Display Instructions:

Do not display response category 6. It is reserved for the Quality Supplement (QS) Section.

Roster Report 1

Roster Definition: Display the hardcopy materials required for this RU member as described below.

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

Row #2 (SAQ) should display as active if [(Person.SAQFlag=Yes or Person.SAQFlwUpFlag=YES) and (QS20_04 = 1 or 2)].

Row #3 (PSAQ) should display as active if [(Person.PSAQFlag=Yes or Person.PSAQFlwUpFlag=YES) and (QS20_04 = 1 or 2)].

NOTE: If QS20_04 was coded ‘3’ (NOT COMPLETED-NO REPLACEMENT NECESSARY) for the SAQ/PSAQ for this person, this row is not eligible for display in the RF section. We will not update the status at all from the QS section for forms with this code.

Format the form pane column headers as follows:

Col #1 Header: Form Type Instructions:

-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

Col #2 Header: QS Status

Instructions: Display the status from the QS section as an uneditable, protected field. Display “Completed/Given to FI” if QS 20_05 was coded ‘1’ for this form. Display “Refused” if QS20_05 was coded ‘5’ for this form. Display “Pending” [if form type is DCS] or [if QS20_05 was coded ‘6’ for this form] or [if QS20_04 was coded ‘2’ for this form].

Col#3 Header: Final Status

Instructions: Item RF130_01. If QS Status (Col #2)=Pending, display this cell as empty and ready for completion. If QS Status (Col #2)=Completed/Given to FI or Refused, prefill this cell with the numeric value from QS20_05 (FormCollect) for this form. This cell is still editable and can be updated by the FI.

Col#4 Header: Specify Status

Instructions: Item RF130_02. Display as an active cell if RF130_01 is coded ‘91’ (OTHER).

Col#5 Header: Refusal Reason

Instructions: Item RF130_03. Display as an active cell if RF130_01 is coded ‘5’ (REFUSED TO COMPLETE). If QS Status (Col #2)=Pending, display this cell as empty and ready for completion (if RF130_01=5). If QS Status (Col #2)=Refused, prefill this cell with the numeric value from QS20_06 (FormRfResn) for this form. This cell is still editable and can be updated by the FI.

Col#6 Header: Specify Refusal

Instructions: Item RF130_04. Display as an active cell if RF130_03 is coded ‘91’ (OTHER). If QS Status (Col #2)=Pending, display this cell as empty and ready for completion (if RF130_03=91). If QS Status (Col #2)=Refused, prefill this cell with the text entry from QS20_07 (FormRfOS) for this form. This cell is still editable and can be updated by the FI.

For “{First Middle Last Name}”, display the first, middle and last names of the person being looped on. Use Person.FName, Person.MName, and Person.LName.

For “{PID}”, display the Person ID for the person being looped on. Use PersID.

Display “SAQ” if on row for SAQ.

Display “PSAQ ({BLUE/PURPLE})” if on row for PSAQ. Display “(BLUE)” if person being looped on is male. Otherwise, display “(PURPLE)”.

Display “DCS” if on row for DCS.

Display the first line of interviewer instructions, PERSON, PID, FORM, in grayed out text.

Display “Earlier we asked {you/{PERSON}} to complete a brief survey about health and health opinions.” if on row for SAQ or PSAQ.

Display “Earlier we asked {you/{PERSON}} to complete a few questions about the care received for diabetes.” if on row for DCS and QS20_01 was coded ‘1’ (SELF) for the person being looped on.

Display “Earlier we asked that someone knowledgeable about {your/{PERSON}’s} diabetes to complete a few questions about the care received.” if on row for DCS and QS20_01 was coded ‘2’ (PROXY) for the person being looped on.

Display “{MALE (BLUE)/FEMALE (PURPLE)}” if on row for PSAQ. Otherwise, use a null display.

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

Display “{SAQ/PSAQ} WAS CODED AS {COMPLETED/REFUSED} EARLIER IN THE INTERVIEW. ENTER THROUGH THE FIELDS IF NO UPDATE TO STATUS IS NECESSARY.” if QS Status (Col #2)=Completed/Given to FI or Refused. Otherwise, use a null display.

Display “COMPLETED” if QS Status (Col #2)=Completed/Given to FI. Display “REFUSED” if QS Status (Col #2)= Refused.

If QS Status (Col #2)=Completed/Given to FI or Refused, display the first paragraph “Earlier … collect that form now.”, the interviewer instructions “COLLECT…/DCS}”, and the interviewer instruction “SELECT … /DCS}” in grayed out text. Otherwise, first paragraph and interviewer instructions should be formatted as specified in UI documentation.

RF130_02 (RF1230)

BLAISE NAME: FormCollectOSFinal

Question Text:

PERSON: {First Middle Last Name} PID: {PID} FORM: {SAQ/PSAQ ({BLUE/PURPLE})/DCS}

SPECIFY OTHER STATUS:

Responses: 1

Programmer Instructions: Return to RF130_01 for next hardcopy form on grid.

Refused and Don’t Know disallowed.

Display Instructions: For “{First Middle Last Name}”, display the first, middle and last names of the person being looped on. Use Person.FName, Person.MName, and Person.LName.

For “{PID}”, display the Person ID for the person being looped on. Use PersID. Display “SAQ” if on row for SAQ.

Display “PSAQ ({BLUE/PURPLE})” if on row for PSAQ. Display “(BLUE)” if person being looped on is male. Otherwise, display “(PURPLE)”.

Display “DCS” if on row for DCS.

Display the first line of interviewer instructions, PERSON, PID, FORM, in grayed out text.

RF130_03 (RF1235)

BLAISE NAME: FormRFResnFinal

Question Text:

PERSON: {First Middle Last Name} PID: {PID} FORM: {SAQ/PSAQ ({BLUE/PURPLE})/DCS}

SELECT MAIN REASON FOR {SAQ/PSAQ/DCS} REFUSAL:

TOO PERSONAL/SENSITIVE INFORMATION 2

TOO MUCH OF A PHYSICAL/MENTAL HARDSHIP 3

HAS ALREADY GIVEN ENOUGH INFORMATION 4

WANTS MORE INFORMATION 5

NOT INTERESTED 6

NO REASON GIVEN 7

OTHER 91 RF130_04(RF1240)

Programmer Instructions: If coded ‘1’, ‘2’, ‘3’, ‘4’, ‘5’, ‘6’, or ‘7’, return to RF130_01 for next hard copy form on grid.

Refused and Don’t Know disallowed.

Display Instructions: For “{First Middle Last Name}”, display the first, middle and last names of the person being looped Instructions: on. Use Person.FName, Person.MName, and Person.LName.

For “{PID}”, display the Person ID for the person being looped on. Use PersID. Display “SAQ” if on row for SAQ.

Display “PSAQ ({BLUE/PURPLE})” if on row for PSAQ. Display “(BLUE)” if person being looped on is male. Otherwise, display “(PURPLE)”.

Display “DCS” if on row for DCS.

Display the first line of interviewer instructions, PERSON, PID, FORM, in grayed out text.

RF130_04 (RF1240)

BLAISE NAME: FormRFOSFinal

Question Text:

PERSON: {First Middle Last Name} PID: {PID} FORM: {SAQ/PSAQ ({BLUE/PURPLE})/DCS}

SPECIFY OTHER REASON FOR REFUSAL:

Responses: 1

Programmer Instructions: Return to RF130_01 for next hardcopy form on grid.

Refused and Don’t Know disallowed.

Display Instructions: For “{First Middle Last Name}”, display the first, middle and last names of the person being looped on. Use Person.FName, Person.MName, and Person.LName.

For “{PID}”, display the Person ID for the person being looped on. Use PersID. Display “SAQ” if on row for SAQ.

Display “PSAQ ({BLUE/PURPLE})” if on row for PSAQ. Display “(BLUE)” if person being looped on is male. Otherwise, display “(PURPLE)”.

Display “DCS” if on row for DCS.

Display the first line of interviewer instructions, PERSON, PID, FORM, in grayed out text.

END_LP10 (RF1245)

BOX_100 (RF1250)

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