BOX_00
CONTEXT HEADER DISPLAY INSTRUCTIONS:
DISPLAY PERS.FULLNAME, COND.CONDNAM, PRND.BEGREFMM,
PRND.BEGREFDD, PRND.BEGREFYY, PRND.ENDREFMM,
PRND.ENDREFDD, PRND.ENDREFYY
BOX_01
IF AT LEAST ONE CONDITION ON PERSON’S-MEDICAL-
CONDITIONS-ROSTER MEETS THE FOLLOWING CONDITIONS:
- CONDITION IS FLAGGED AS ‘CREATED’ DURING THE
CURRENT ROUND
- CONDITION IS NOT A PRIORITY CONDITION, THAT IS,
IT IS NOT FLAGGED AS CREATED IN THE PE SECTION
- CONDITION IS NOT FLAGGED AS ‘UNLIKELY ACCIDENT/
INJURY’ (THIS FLAG WILL BE DETERMINED LATER AS
IT MAY BE SET FOR CERTAIN CONDITIONS THAT ARE
PART OF A CONDITION LOOK-UP TABLE AND ARE
DETERMINED TO BE UNLIKLY DUE TO AN ACCIDENT OR
INJURY)
CONTINUE WITH CN01
OTHERWISE, GO TO BOX_12
BOX_02
OMITTED.
CN01
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
[1. Medical Condition]
[2. Medical Condition]
[3. Medical Condition]
Now I’m going to read you a list of some of the health
conditions
that were reported for {you/{PERSON}} between {START
DATE} and {END
DATE}.
READ CONDITIONS ABOVE.
{Was this health condition/Were any of these health
conditions} due
to an accident or injury?
YES .................................... 1 {CN01A}
NO ..................................... 2 {BOX_12}
REF ................................... -7 {BOX_12}
DK .................................... -8 {BOX_12}
HELP AVAILABLE FOR DEFINITION OF ACCIDENT/INJURY.
DISPLAY ‘Was this health condition’ IF ONLY ONE
CONDITION DISPLAYED AT CN01. OTHERWISE, DISPLAY
‘Were any of these health conditions’.
THE THIRD CRITERION FOR DISPLAY IN THE ROSTER WILL
BE DETERMINED LATER AS THE FLAG MAY BE SET FOR
CERTAIN CONDITIONS THAT ARE PART OF A CONDITION
LOOK-UP TABLE AND ARE DETERMINED TO BE UNLIKLY DUE
TO AN ACCIDENT/INJURY.
ROSTER DETAILS:
Title: PERS_COND_1
COL #1 HEADER: CONDITION
INSTRUCTIONS: DISPLAY NAME OF MEDICAL CONDITION
(COND.CONDNAM)
ROSTER DEFINITION:
THIS ITEM DISPLAYS THE PERSON’S-CONDITIONS-
ROSTER.
ROSTER BEHAVIOR:
1. DISPLAY ONLY.
2. ADD, DELETE, SELECT, AND EDIT DISALLOWED.
ROSTER FILTER:
DISPLAY ONLY THE CONDITIONS FOR PERSON THAT ARE
- CREATED THIS ROUND
- NOT FLAGGED AS PRIORITY CONDITIONS (THAT IS,
THOSE NOT FLAGGED AS CREATED IN THE PE SECTION)
- NOT FLAGGED AS ‘UNLIKELY ACCIDENT/INJURY’
THE CONDITIONS ARE LISTED FOR DISPLAY ONLY; THEY
ARE NOT SELECTABLE.
CN01A
{PERSON'S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}
Which of {your/{PERSON}’s} health conditions were due
to an accident
or injury?
PROBE: Any other health conditions due to an accident
or injury?
[1. Medical Condition] .................
[2. Medical Condition] .................
[3. Medical Condition] .................
HELP AVAILABLE FOR DEFINITION OF ACCIDENT/INJURY.
FLAG ALL CONDITIONS SELECTED AT CN01A AS ‘DUE TO
ACCIDENT/INJURY’.
THE THIRD CRITERION FOR DISPLAY IN THE ROSTER WILL
BE DETERMINED LATER AS THE FLAG MAY BE SET FOR
CERTAIN CONDITIONS THAT ARE PART OF A CONDITION
LOOK-UP TABLE AND ARE DETERMINED TO BE UNLIKLY DUE
TO AN ACCIDENT/INJURY.
CONTINUE WITH BOX_03
ROSTER DETAILS:
Title: PERS_COND_1
COL #1 HEADER: CONDITION
INSTRUCTIONS: DISPLAY NAME OF MEDICAL CONDITION
(COND.CONDNAM)
ROSTER DEFINITION:
DISPLAY THE PERSON-MEDICAL-CONDITIONS-ROSTER FOR
SELECTION.
ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.
2. ADD, EDIT, AND DELETE DISALLOWED.
ROSTER FILTER:
DISPLAY CONDITIONS THAT MEET THE FOLLOWING:
1. CONDITION IS FLAGGED AS ‘CREATED’ DURING THE
CURRENT ROUND.
2. CONDITION IS NOT A PRIORITY CONDITION, THAT IS,
THE CONDITION IS NOT FLAGGED AS CREATED IN THE PE
SECTION.
3. CONDITION IS NOT FLAGGED AS ‘UNLIKELY
ACCIDENT/INJURY’.
CN02
OMITTED.
BOX_03
IF ANY CONDITIONS FLAGGED AS ‘DUE TO ACCIDENT/
INJURY’, CONTINUE WITH LOOP_01
OTHERWISE, GO TO BOX_12
LOOP_01
FOR EACH ELEMENT IN PERSON’S-MEDICAL-CONDITIONS-
ROSTER, ASK NAV_CN01 - END_LP01
LOOP DEFINITION: LOOP_01 COLLECTS INFORMATION
ABOUT MEDICAL CONDITIONS CREATED DURING THE
CURRENT ROUND THAT ARE DUE TO AN ACCIDENT OR
INJURY. THIS LOOP CYCLES ON MEDICAL CONDITIONS
THAT MEET THE FOLLOWING CONDITIONS:
- MEDICAL CONDITION IS FLAGGED AS ‘DUE TO AN
ACCIDENT OR INJURY’ (CONDITION SELECTED AT
CN01A)
- MEDICAL CONDITION IS FLAGGED AS ‘CREATED’
DURING THE CURRENT ROUND
NAVIGATOR DETAILS: LOOP_01 USES NAV_CN01 TO
CONTROL THE FLOW OF THE LOOP.
NAV_CN01
SERIES: Condition Details
USE THE LINKS BELOW TO COMPLETE ALL QUESTIONS WITHIN THIS SERIES.
WHEN ALL LINKS ARE MARKED "DONE," USE [Continue
Interview] TO GO
PAST THIS SERIES.
IF NEEDED, [Previous Page] WILL TAKE YOU TO QUESTIONS
BEFORE THIS
SERIES.
Condition
[1. Person’s Medical Condition-30] [Status-25]
[2. Person’s Medical Condition-30] [Status-25]
[3. Person’s Medical Condition-30] [Status-25]
ROSTER DETAILS:
COL # 1 HEADER: CONDITION
INSTRUCTIONS: DISPLAY PERSON’S MEDICAL CONDITION
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH CONDITION EACH TIME THE NAVIGATOR
IS PRESENTED
ROSTER DEFINITION:
THIS ITEM DISPLAYS PERSON’S-MEDICAL-CONDITION
ROSTER FOR SELECTION.
ROSTER BEHAVIOR:
1. SELECT ALLOWED.
2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.
ROSTER FILTER:
DISPLAY EACH CONDITION IN PERSON’S-MEDICAL-
CONDITIONS-ROSTER THAT MEETS THE FOLLOWING
CONDITIONS:
- MEDICAL CONDITION IS FLAGGED AS ‘DUE TO AN
ACCIDENT OR INJURY’ (CONDITION SELECTED AT
CN01A)
- MEDICAL CONDITION IS FLAGGED AS ‘CREATED’
DURING THE CURRENT ROUND
CONTINUE WITH CN06 FOR SELECTED CONDITION
BOX_04
OMITTED.
CN03
OMITTED.
CN04
OMITTED.
CN05
OMITTED.
CN05OV1
OMITTED.
CN05OV2
OMITTED.
CN06
{PERSON'S FIRST MIDDLE AND LAST NAME} {PERSON'S CN
MEDICAL
CONDITION.} {STR-DT}
{END-DT}
Let’s talk about {CONDITION}.
When did the accident or injury happen?
{PROBE IF ANY EVENTS LISTED: The dates we have
recorded for
the medical care for {CONDITION} include (READ EVENT
DATES
BELOW).}
CN06_01. PROVIDER |
ROSTER. EVENT DATE |
CN06_03. EVENT TYPE |
1. Medical Provider-35 |
[Display Month Day Year-4] |
[Display Event Code] |
2. Medical Provider-35 |
[Display Month Day Year-4] |
[Display Event Code] |
3. Medical Provider-35 |
[Display Month Day Year-4] |
[Display Event Code] |
[Enter Year-4] .........................
REF ................................... -7 {CN06A}
DK .................................... -8 {CN06A}
IF THERE ARE NO EVENTS CREATED THIS ROUND RELATED
TO THE CONDITION BEING ASKED ABOUT, DO NOT DISPLAY
THE PROBE AND DISPLAY THE MESSAGE ‘THE EVENT
ROSTER IS EMPTY’. OTHERWISE, DISPLAY THE PROBE AND
EVENTS ROSTER.
IF YEAR IS REFERENCE YEAR OR REFERENCE YEAR MINUS
1, CONTINUE WITH CN06OV1
OTHERWISE, GO TO BOX_05
HARD CHECK:
EDIT: THE COMPLETE DATE CANNOT BE BEFORE THE
PERSON’S DATE OF BIRTH OR AFTER THE CURRENT
REFERENCE PERIOD END DATE FOR THIS PERSON.
ROSTER DETAILS:
Title: PERS_EVNT_2
COL #1 HEADER: PROVIDER
INSTRUCTIONS: DISPLAY MEDICAL PROVIDER
(EVPV.LORPNAME, EVPV.DRFNAM, EVPV.DRMNAM)
COL #2 HEADER: EVENT DATE
INSTRUCTIONS: DISPLAY EVENT DATE
(EVPV.EVNTBEGM, EVPV.EVNTBEGD, EVPV.EVNTBEGY)
COL #3 HEADER: EVENT TYPE
INSTRUCTIONS: DISPLAY EVENT CODE (EVPV.EVNTTYPE)
ROSTER DEFINITION:
DISPLAY THE PERSON-MEDICAL-EVENTS-ROSTER FOR
DISPLAY AS THE SECOND COLUMN. INCLUDE THE PROVIDER
AS THE FIRST COLUMN AND THE EVENT TYPE AS THE
THIRD COLUMN.
ROSTER BEHAVIOR:
1. DISPLAY ONLY.
2. ADD, DELETE, SELECT, AND EDIT DISALLOWED.
ROSTER FILTER:
DISPLAY EVENTS CREATED THIS ROUND THAT ARE LINKED
TO THE CONDITION BEING ASKED ABOUT EXCEPT PM
EVENTS.
CN06OV1
MONTH:
[Enter Month-2] ........................
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}
IF YEAR IS REFERENCE YEAR, CONTINUE WITH CN06OV2
OTHERWISE, GO TO BOX_05
HARD CHECK:
ENTRIES FOR MONTH FIELD MUST CORRESPOND TO
CALENDAR MONTHS. THAT IS, ALLOWABLE VALUES =
01 - 12.
MISSING VALUES = -7 AND -8 ALLOWED.
EDIT: THE COMPLETE DATE CANNOT BE BEFORE THE
PERSON’S DATE OF BIRTH OR AFTER THE CURRENT
REFERENCE PERIOD END DATE FOR THIS PERSON.
CN06OV2
DAY:
[Enter Day-2] ........................... {BOX_05}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}
HARD CHECK:
ENTRIES FOR DAY FIELD MUST CORRESPOND TO CALENDAR
DAYS. THAT IS,
- ALLOWABLE VALUES = 01 - 31 IF MONTH CODED
‘01’, ‘03’, ‘05’, ‘07’, ‘08’, ‘10’, ‘12’;
- ALLOWABLE VALUES = 01 - 30 IF MONTH CODED
‘04’, ‘06’, ‘09’, ‘11’;
- ALLOWABLE VALUES = 01 - 29 IF MONTH CODED
‘02’ AND YEAR IS 1996, 2000, 2004 OR 2008
(LEAP YEAR);
- ALLOWABLE VALUES = 01 - 28 IF MONTH CODED
‘02’ AND YEAR IS NOT 1996, 2000, 2004 OR
2008 (I.E., NOT LEAP YEAR).
MISSING VALUES = -7 AND -8 ALLOWED.
EDIT: THE COMPLETE DATE CANNOT BE BEFORE THE
PERSON’S DATE OF BIRTH OR AFTER THE CURRENT
REFERENCE PERIOD END DATE FOR THIS PERSON.
CN06A
{PERSON'S FIRST MIDDLE AND LAST NAME} {PERSON'S CN
MEDICAL
CONDITION.} {STR-DT}
{END-DT}
Did the {CONDITION} occur before or after January 1,
{YEAR}?
BEFORE ................................. 1 {BOX_05}
AFTER .................................. 2 {BOX_05}
REF ................................... -7 {BOX_05}
DK .................................... -8 {BOX_05}
[Code One]
(FOR SPECIFICATIONS PURPOSES ONLY; CAPI HANDLES
AUTOMATICALLY): IF ROUNDS 1 AND 2, DISPLAY THE
FIRST YEAR OF THE PANEL FOR ‘YEAR’. IF ROUNDS 3,
4, AND 5, DISPLAY THE SECOND YEAR OF THE PANEL
BOX_05
IF PERSON IS = OR > 16 YEARS OF AGE OR IN AGE
CATEGORIES 4-9, CONTINUE WITH CN07
OTHERWISE, GO TO END_LP01
CN07
{PERSON'S FIRST MIDDLE AND LAST NAME} {PERSON'S CN
MEDICAL
CONDITION.} {STR-DT}
{END-DT}
Did the {CONDITION} happen while {you/{PERSON}}
{were/was} at
work?
YES .................................... 1 {END_LP01}
NO ..................................... 2 {END_LP01}
DOES NOT WORK .......................... 3 {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}
[Code One]
CN08
OMITTED.
CN09
OMITTED.
CN10
OMITTED.
BOX_06
OMITTED.
CN11
OMITTED.
CN12
OMITTED.
CN13
OMITTED.
CN13OV
OMITTED.
CN14
OMITTED.
CN15
====
OMITTED.
END_LP01
CYCLE ON NEXT CONDITION IN PERSON’S-MEDICAL-
CONDITIONS-ROSTER THAT MEETS THE CONDITIONS STATED
IN THE LOOP DEFINITION.
IF NO OTHER CONDITIONS MEET THE STATED CONDITIONS,
END LOOP_01 AND CONTINUE WITH BOX_12
BOX_07
OMITTED.
BOX_08
OMITTED.
LOOP_02
OMITTED.
CN16
OMITTED.
CN17
OMITTED.
CN18
OMITTED.
CN19
OMITTED.
CN19OV
OMITTED.
END_LP02
OMITTED.
BOX_09
OMITTED.
BOX_10
OMITTED.
BOX_11
OMITTED.
CN20
OMITTED.
CN21
OMITTED.
BOX_12
GO TO NEXT QUESTIONNAIRE SECTION
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