(Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 5600 Fishers Lane, Rockville, MD 20857.)
DCS: READ THIS ALOUD ONLY IF REQUESTED BY RESPONDENT.
PRESS NEXT TO CONTINUE IN THIS EVENT FORM
PRESS BREAKOFF TO DISCONTINUE
Q1. Date Filled
Month: Day: Year:
DK/REF/RETRIEVABLE – CONTINUE TO Q2
Q2. Prescription information will be identified using:
NOTE: TRY TO OBTAIN NDC. USE DRUG NAME
ONLY IF NDC NOT AVAILABLE.
[IF Prescription Information = 1 (NDC), GO TO Q2a;
IF Prescription Information = 2 (Drug Name, Strength/Unit, & Dosage Form), GO TO Q2b]
Q2a. NDC
ENTER 11-DIGIT NDC WITHOUT DASHES OR SPACES.
NDC IS UNKNOWN OR REFUSED, RETURN TO PREVIOUS SCREEN AND SELECT DRUG NAME OPTION
________________
When Q2a is COMPLETE, GO TO Q3a/QTY
Q2b. Drug Name:
Q2b_1:
Compound drug?
Durable Medical Equipment: DME_1
IF DURABLE MEDICAL EQUIPMENT GO TO Q3A***
MJ? MJ_1
IF MJ GO TO Q3a***
When Drug Name is complete, send user to Q2c/STRENGTH
Q2c. Strength
________________
Q2d. Unit:
________________
Q2c2. Strength 2:
________________
Q2d2. Unit 2:
________________
Q2e. Dosage Form:
________________
After Q2e, CONTINUE TO Q3a/b.
Q2b - DK/REF/RETRIEVABLE – CONTINUE TO Q2c/d
Q2c/d - DK/REF/RETRIEVABLE – CONTINUE TO Q2e
Q2e - DK/REF/RETRIEVABLE – CONTINUE TO Q3a/b
Q3a. Quantity:
________________
Q3b. Unit:
________________
Q3b – DK/REF/RETRIEVABLE – CONTINUE TO Q4
Q4. How many days were supplied?
IF PRESCRIPTION WAS TO BE USED “AS NEEDED” ENTER 999
________________
Q4 – DK/REF/RETRIEVABLE – CONTINUE TO Q5
Q5. Patient Payment:
$________.____
Q5a. Were there any 3rd party payers?
Q6. Type of 3rd Party Payer
________________
Q7. 3rd Party Payment
$________.____
NOTE: IF PATIENT PAYMENT WAS $1 OR LESS, EXPECT THE 3rd PARTY PAYER TO BE A PUBLIC PROGRAM, E.G., MEDICAID OR OTHER STATE/LOCAL GOVT, ETC.
Any more 3rd Party Payers?
Q6/Q7 - ALLOW A MAXIMUM OF TWO 3rd PARTY PAYERS. IF USER SAYS “YES, MORE” THREE TIMES THEN THE
PROGRAM WILL GO TO FINISH SCREEN.
Q5 - DK/REF/RETRIEVABLE – CONTINUE TO Q5a.
Q5a - DK/REF/RETRIEVABLE – CONTINUE TO EXIT SCREEN.
Q6 - DK/REF/RETRIEVABLE – CONTINUE TO Q7.
Q7 - DK/REF/RETRIEVABLE – CONTINUE TO EXIT SCREEN.
FINISH SCREEN
PRESS VALIDATE TO COMPLETE THIS EVENT FORM.