MEPS Health Status Section - P19R5P20R3P21R1

HE01

{STR-DT}
{END-DT}

{Between {START DATE} and {END DATE}, did/Does} anyone in the family
receive help or supervision using the telephone, paying bills, taking
medications, preparing light meals, doing laundry, or going shopping
(because of an impairment or a physical or mental health problem)?

YES .................................... 1
NO ..................................... 2 {HE04}
REF ................................... -7 {HE04}
DK .................................... -8 {HE04}

HELP AVAILABLE FOR DEFINITION OF IMPAIRMENT AND HELP/SUPERVISION.

DISPLAY ‘Between {START DATE} and {END DATE},
did’ IF ROUND 5. OTHERWISE, DISPLAY ‘Does’.

IF CODED ‘1’ (YES) AND A SINGLE PERSON RU,
AUTOMATICALLY CODE PERSON AS ‘RECEIVES HELP’ AT
HE02 BY CAPI AND GO TO LOOP_01

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH HE02

HE02

{STR-DT}
{END-DT}

Who is that?

PROBE: Does anyone else receive help or supervision doing these
types of activities [such as using the telephone, paying bills,
taking medications, preparing light meals, doing laundry, or going
shopping]?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

FLAG ALL SELECTED PERSONS WHO ARE = OR > 13 YEARS
OLD OR IN AGE CATEGORIES 4-9 FOR THE LTC
SUPPLEMENT: IADL SECTION.

CONTINUE WITH LOOP_01

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS EXCLUDING DECEASED RU
MEMBERS.

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER,
ASK NAV_HE01 - END_LP01

LOOP DEFINITION: LOOP_01 DETERMINES IF PERSONS
RECEIVE HELP OR SUPERVISION WITH INSTRUMENTAL
ACTIVITIES OF DAILY LIVING BECAUSE OF AN
IMPAIRMENT OR PHYSICAL OR MENTAL HEALTH PROBLEM.
THIS LOOP CYCLES ON RU MEMBERS WHO MEET THE
FOLLOWING CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON RECEIVES HELP WITH INSTRUMENTAL
ACTIVITIES OF DAILY LIVING (I.E., PERSON
SELECTED AT HE02)
- PERSON IS <13 YEARS OF AGE OR IN AGE
CATEGORIES 1-3

NAVIGATOR DETAILS: LOOP_01 USES NAV_HE01 TO
CONTROL THE FLOW OF THE LOOP.

NAV_HE01

SERIES: Help with Daily Activities (e.g., using phone, paying bills,
taking medication, etc.)

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DETAILS:
COL # 1 HEADER: RU MEMBER
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)
COL # 2 HEADER: EMPTY
INSTRUCTIONS: DISPLAY THE MOST CURRENT NAVIGATOR
STATUS FOR EACH RU MEMBER EACH TIME THE NAVIGATOR
IS PRESENTED

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON RECEIVES HELP WITH INSTRUMENTAL
ACTIVITIES OF DAILY LIVING (I.E., PERSON
SELECTED AT HE02)
- PERSON IS <13 YEARS OF AGE OR IN AGE
CATEGORIES 1-3

CONTINUE WITH HE03 FOR SELECTED RU MEMBER.

HE03

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

{Do/Does} {you/{PERSON}} receive help or supervision using the
telephone, paying bills, taking medications, preparing light meals,
doing laundry or going shopping because of an impairment or a physical
or mental health problem?

YES .................................... 1 {END_LP01}
NO ..................................... 2 {END_LP01}
REF ................................... -7 {END_LP01}
DK .................................... -8 {END_LP01}

HELP AVAILABLE FOR DEFINITION OF HELP/SUPERVISION AND IMPAIRMENT.

IF CODED ‘1’ (YES), FLAG PERSON FOR THE LTC
SUPPLEMENT: IADL SECTION.

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_01 AND CONTINUE WITH HE04

HE04

{STR-DT}
{END-DT}

{Between {START DATE} and {END DATE}, did/Does} anyone in the family
receive help or supervision with personal care such as bathing,
dressing, or getting around the house (because of an impairment or
a physical or mental health problem)?

YES .................................... 1
NO ..................................... 2 {HE07}
REF ................................... -7 {HE07}
DK .................................... -8 {HE07}

HELP AVAILABLE FOR DEFINITION OF HELP/SUPERVISION.

DISPLAY ‘between {START DATE} and {END DATE}, did’
IF ROUND 5. OTHERWISE, DISPLAY ‘Does’.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AS ‘RECEIVES HELP’ AT
HE05 BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
LOOP_02

IF CODED ‘1’ (YES) AND MULTI-PERSON RU, CONTINUE
WITH HE05

HE05

{STR-DT}
{END-DT}

Who is that?

PROBE: Does anyone else receive help or supervision with personal
care [such as bathing, dressing, or getting around the house]?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

FLAG ALL SELECTED PERSONS WHO ARE = OR > 13 YEARS
OLD OR IN AGE CATEGORIES 4-9 FOR THE LTC
SUPPLEMENT: ADL SECTION.

CONTINUE WITH LOOP_02

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS EXCLUDING DECEASED RU
MEMBERS.

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER, ASK
NAV_HE02 - END_LP02

LOOP DEFINITION: LOOP_02 DETERMINES IF PERSONS
RECEIVE HELP OR SUPERVISION WITH PERSONAL CARE
(I.E., ACTIVITIES OF DAILY LIVING) BECAUSE OF AN
IMPAIRMENT OR PHYSICAL OR MENTAL HEALTH PROBLEM.
THIS LOOP CYCLES ON RU MEMBERS WHO MEET THE
FOLLOWING CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON RECEIVES HELP OR SUPERVISION WITH
PERSONAL CARE (I.E., ACTIVITIES OF DAILY LIVING,
THAT IS, THE PERSON IS SELECTED AT HE05)
- PERSON IS <13 YEARS OF AGE OR IN AGE
CATEGORIES 1-3

NAVIGATOR DETAILS: LOOP_02 USES NAV_HE02 TO
CONTROL THE FLOW OF THE LOOP.

NAV_HE02

SERIES: Help with Personal Care (e.g., bathing, dressing, getting
around the house)

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON RECEIVES HELP OR SUPERVISION WITH
PERSONAL CARE (I.E., ACTIVITIES OF DAILY LIVING,
THAT IS, THE PERSON IS SELECTED AT HE05)
- PERSON IS <13 YEARS OF AGE OR IN AGE
CATEGORIES 1-3

CONTINUE WITH HE06 FOR SELECTED RU MEMBER.

HE06

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

{Do/Does} {you/{PERSON}} receive help or supervision with personal
care such as bathing, dressing or getting around the house because
of an impairment or a physical or mental health problem?

YES .................................... 1 {END_LP02}
NO ..................................... 2 {END_LP02}
REF ................................... -7 {END_LP02}
DK .................................... -8 {END_LP02}

HELP AVAILABLE FOR DEFINITION OF HELP/SUPERVISION AND IMPAIRMENT.

IF CODED ‘1’ (YES), FLAG PERSON FOR THE LTC
SUPPLEMENT: ADL SECTION.

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_02 AND CONTINUE WITH HE07

HE07

{STR-DT}
{END-DT}

{Between {START DATE} and {END DATE}, did/Does} anyone in the family
use any aids such as a walker, grab bars in the bathtub or any other
special equipment for personal care or everyday activities (because of
an impairment or a physical or mental health problem)?

YES .................................... 1
NO ..................................... 2 {HE09}
REF ................................... -7 {HE09}
DK .................................... -8 {HE09}

HELP AVAILABLE FOR EXAMPLES OF AIDS/SPECIAL EQUIPMENT.

DISPLAY ‘Between {START DATE} and {END DATE},
did’ IF ROUND 5. OTHERWISE, DISPLAY ‘Does’.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AS ‘USES AIDS’ AT HE08
BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
HE09

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH HE08

HE08

{STR-DT}
{END-DT}

Who is that?

PROBE: Does anyone else use any aids [such as a walker, grab bars
in the bathtub or any other special equipment] for personal care or
everyday activities?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

FLAG ALL SELECTED PERSONS FOR THE LTC SUPPLEMENT:
AIDS/SPECIAL EQUIPMENT SECTION.

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS EXCLUDING DECEASED RU
MEMBERS.

HE09

{STR-DT}
{END-DT}

{Between {START DATE} and {END DATE}, did/Does} anyone in the family
have difficulties walking, climbing stairs, grasping objects, reaching
overhead, lifting, bending or stooping, or standing for long periods
of time (because of an impairment or a physical or mental health
problem)?

YES .................................... 1
NO ..................................... 2 {HE19}
REF ................................... -7 {HE19}
DK .................................... -8 {HE19}

DISPLAY ‘Between {START DATE} and {END DATE},
did’ IF ROUND 5. OTHERWISE, DISPLAY ‘Does’.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AS ‘HAVING DIFFICULTY’
AT HE10 BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
LOOP_03

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU, CONTINUE
WITH HE10

HE10

{STR-DT}
{END-DT}

Who is that?

PROBE: Does anyone else have difficulties [walking, climbing stairs,
grasping objects, reaching overhead, lifting, bending or stooping, or
standing for long periods of time]?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

FLAG ALL SELECTED PERSONS WHO ARE = OR > 13 YEARS
OLD OR IN AGE CATEGORIES 4-9 FOR THE LTC
SUPPLEMENT: FUNCTIONAL LIMITATIONS SECTION.

CONTINUE WITH LOOP_03

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS EXCLUDING DECEASED RU
MEMBERS.

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER, ASK
NAV_HE03 - END_LP03

LOOP DEFINITION: LOOP_03 COLLECTS INFORMATION ON
THE LEVEL OF FUNCTIONAL LIMITATION WITH VARIOUS
PHYSICAL ACTIVITIES FOR PERSONS = OR > 13 YEARS
OF AGE. THIS LOOP CYCLES ON RU MEMBERS WHO MEET
THE FOLLOWING CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON HAS FUNCTIONAL LIMITATIONS (I.E., PERSON
SELECTED AT HE10)
- PERSON = OR > 13 YEARS OF AGE OR IN AGE
CATEGORIES 4-9

NAVIGATOR DETAILS: LOOP_03 USES NAV_HE03 TO
CONTROL THE FLOW OF THE LOOP.

NAV_HE03

SERIES: Difficulty Moving (e.g., walking, climbing stairs,
grasping, reaching overhead, etc.)

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON HAS FUNCTIONAL LIMITATIONS (I.E., PERSON
SELECTED AT HE10)
- PERSON = OR > 13 YEARS OF AGE OR IN AGE
CATEGORIES 4-9

CONTINUE WITH HE11 FOR SELECTED RU MEMBER.

HE11

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

SHOW CARD HE-1.

{For these next questions, I would like you to think about the time when
{you/{PERSON}} entered the institution and what {you/he/she} was able to
do at that time.}

Please look at this card and tell me how much difficulty {do/does}
{you/{PERSON}} have lifting something as heavy as 10 pounds, such as a
full bag of groceries? Would you say no difficulty, some difficulty, a
lot of difficulty, or completely unable to do it?

NO DIFFICULTY .......................... 1 {HE12}
SOME DIFFICULTY ........................ 2 {HE12}
A LOT OF DIFFICULTY .................... 3 {HE12}
COMPLETELY UNABLE TO DO IT ............. 4 {HE12}
REF ................................... -7 {HE12}
DK .................................... -8 {HE12}

[Code One]

DISPLAY ‘For these next questions, I would like
you to think about the time when {you/{PERSON}}
entered the institution and what {you/he/she} was
able to do at that time.}’ IF PERSON BEING ASKED
ABOUT CODED AS BEING INSTITUTIONALIZED AT END
DATE. IF PERSON BEING ASKED ABOUT IS A CURRENT
RU MEMBER LIVING IN THE RU, USE A NULL DISPLAY.

HE12

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

SHOW CARD HE-1.

How much difficulty {do/does} {you/{PERSON}} have walking up 10 steps
without resting?

PROBE: Would you say no difficulty, some difficulty, a lot of
difficulty, or completely unable to do it?

IF RESPONDENT VOLUNTEERS THAT PERSON IS COMPLETELY UNABLE TO WALK,
SELECT ‘COMPLETELY UNABLE TO WALK’.

NO DIFFICULTY .......................... 1 {HE13}
SOME DIFFICULTY ........................ 2 {HE13}
A LOT OF DIFFICULTY .................... 3 {HE13}
COMPLETELY UNABLE TO DO IT ............. 4 {HE13}
COMPLETELY UNABLE TO WALK .............. 5 {HE17}
REF ................................... -7 {HE13}
DK .................................... -8 {HE13}

[Code One]

IF CODED ‘5’ (COMPLETELY UNABLE TO WALK),
AUTOMATICALLY CODE HE13, HE14, HE15, AND HE16 AS
‘4’ (COMPLETELY UNABLE TO DO IT) BY CAPI.

HE13

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

SHOW CARD HE-1.

How much difficulty {do/does} {you/{PERSON}} have walking about 3 city
blocks or about a quarter of a mile?

PROBE: Would you say no difficulty, some difficulty, a lot of
difficulty, or completely unable to do it?

NO DIFFICULTY .......................... 1 {HE14}
SOME DIFFICULTY ........................ 2 {HE14}
A LOT OF DIFFICULTY .................... 3 {HE14}
COMPLETELY UNABLE TO DO IT ............. 4 {HE15}
REF ................................... -7 {HE14}
DK .................................... -8 {HE14}

[Code One]

IF CODED ‘4’ (COMPLETELY UNABLE TO DO IT),
AUTOMATICALLY CODE HE14 AS ‘4’ (COMPLETELY UNABLE
TO DO IT) BY CAPI.

HE14

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

SHOW CARD HE-1.

How much difficulty {do/does} {you/{PERSON}} have walking a mile?

PROBE: Would you say no difficulty, some difficulty, a lot of
difficulty, or completely unable to do it?

NO DIFFICULTY .......................... 1 {HE15}
SOME DIFFICULTY ........................ 2 {HE15}
A LOT OF DIFFICULTY .................... 3 {HE15}
COMPLETELY UNABLE TO DO IT ............. 4 {HE15}
REF ................................... -7 {HE15}
DK .................................... -8 {HE15}

[Code One]

HE15

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

SHOW CARD HE-1.

How much difficulty {do/does} {you/{PERSON}} have standing for about
20 minutes?

PROBE: Would you say no difficulty, some difficulty, a lot of
difficulty, or completely unable to do it?

NO DIFFICULTY .......................... 1 {HE16}
SOME DIFFICULTY ........................ 2 {HE16}
A LOT OF DIFFICULTY .................... 3 {HE16}
COMPLETELY UNABLE TO DO IT ............. 4 {HE16}
REF ................................... -7 {HE16}
DK .................................... -8 {HE16}

[Code One]

HE16

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

SHOW CARD HE-1.

How much difficulty {do/does} {you/{PERSON}} have bending down or
stooping from a standing position to pick up an object from the floor
or tie a shoe?

PROBE: Would you say no difficulty, some difficulty, a lot of
difficulty, or completely unable to do it?

NO DIFFICULTY .......................... 1 {HE17}
SOME DIFFICULTY ........................ 2 {HE17}
A LOT OF DIFFICULTY .................... 3 {HE17}
COMPLETELY UNABLE TO DO IT ............. 4 {HE17}
REF ................................... -7 {HE17}
DK .................................... -8 {HE17}

[Code One]

HE17

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

SHOW CARD HE-1.

How much difficulty {do/does} {you/{PERSON}} have reaching up overhead,
for example to remove something from a shelf?

PROBE: Would you say no difficulty, some difficulty, a lot of
difficulty, or completely unable to do it?

NO DIFFICULTY .......................... 1 {HE18}
SOME DIFFICULTY ........................ 2 {HE18}
A LOT OF DIFFICULTY .................... 3 {HE18}
COMPLETELY UNABLE TO DO IT ............. 4 {HE18}
REF ................................... -7 {HE18}
DK .................................... -8 {HE18}

[Code One]

HE18

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

SHOW CARD HE-1.

How much difficulty {do/does} {you/{PERSON}} have using fingers to grasp
or handle something such as picking up a glass from a table or using a
pencil to write?

PROBE: Would you say no difficulty, some difficulty, a lot of
difficulty, or completely unable to do it?

NO DIFFICULTY .......................... 1 {END_LP03}
SOME DIFFICULTY ........................ 2 {END_LP03}
A LOT OF DIFFICULTY .................... 3 {END_LP03}
COMPLETELY UNABLE TO DO IT ............. 4 {END_LP03}
REF ................................... -7 {END_LP03}
DK .................................... -8 {END_LP03}

[Code One]

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_03 AND CONTINUE WITH HE19

HE19

{STR-DT}
{END-DT}

Is anyone in the family limited in any way in the ability to work at
a job, do housework, or go to school because of an impairment or a
physical or mental health problem?

YES .................................... 1
NO ..................................... 2 {HE22}
REF ................................... -7 {HE22}
DK .................................... -8 {HE22}

HELP AVAILABLE FOR DEFINITION OF LIMITED ABILITY
AND IMPAIRMENT.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AS ‘LIMITED ABILITY’ AT
HE20 BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
LOOP_04

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU, CONTINUE
WITH HE20

HE20

{STR-DT}
{END-DT}

Who is that?

PROBE: Is anyone else limited in the ability to work at a job, do
housework, or go to school because of an impairment or a physical or
mental health problem?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

FLAG ALL SELECTED PERSONS WHO ARE = OR > 5 YEARS
OLD OR IN AGE CATEGORIES 3-9 FOR THE LTC
SUPPLEMENT: WORK-HOUSEWORK-SCHOOL LIMITATIONS
SECTION.

CONTINUE WITH LOOP_04

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS EXCLUDING DECEASED RU
MEMBERS.

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER, ASK
NAV_HE04 - END_LP04

LOOP DEFINITION: LOOP_04 COLLECTS INFORMATION ON
WORK/HOUSEWORK/SCHOOL LIMITATIONS BECAUSE OF AN
IMPAIRMENT OR PHYSICAL OR MENTAL HEALTH PROBLEM
FOR PERSONS = OR > 5 YEARS OF AGE. THIS LOOP
CYCLES ON RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS LIMITED IN ABILITY TO WORK AT A JOB,
DO HOUSEWORK, OR GO TO SCHOOL (I.E., PERSON
SELECTED AT HE20)
- PERSON = OR > 5 YEARS OF AGE OR IN AGE
CATEGORIES 3-9

NAVIGATOR DETAILS: LOOP_04 USES NAV_HE04 TO
CONTROL THE FLOW OF THE LOOP.

NAV_HE04

SERIES: Limited Ability in Working, Doing Housework, Going to
School

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS LIMITED IN ABILITY TO WORK AT A JOB,
DO HOUSEWORK, OR GO TO SCHOOL (I.E., PERSON
SELECTED AT HE20)
- PERSON = OR > 5 YEARS OF AGE OR IN AGE
CATEGORIES 3-9

CONTINUE WITH HE20A FOR SELECTED RU MEMBER.

HE20A

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

Which activities {are/is} {you/{PERSON}} limited in doing because of an
impairment or a physical or mental health problem - working at a job,
doing housework, or going to school?

CHECK ALL THAT APPLY.

WORKING AT A JOB ....................... 1 {HE21}
DOING HOUSEWORK ........................ 2 {HE21}
GOING TO SCHOOL ........................ 3 {HE21}
REF ................................... -7 {HE21}
DK .................................... -8 {HE21}

[Code All That Apply]

HE21

{PERSON’S FIRST MIDDLE AND LAST NAME} {STR-DT}
{END-DT}

{At the time {you/{PERSON}} entered the institution, was/{Are/Is}}
{you/{PERSON}} completely unable to {work at a job}{,/ and}
{ do housework}{ and}{ go to school}?

YES .................................... 1 {END_LP04}
NO ..................................... 2 {END_LP04}
REF ................................... -7 {END_LP04}
DK .................................... -8 {END_LP04}

DISPLAY ‘At the time {you/{PERSON}} entered the
institution, was’. IF PERSON BEING ASKED ABOUT
CODED AS BEING INSTITUTIONALIZED AT END DATE.
DISPLAY ‘{Are/Is}’ IF PERSON BEING ASKED ABOUT IS
A CURRENT RU MEMBER LIVING IN THE RU.

DISPLAY ‘work at a job’ IF HE20A IS CODED ‘1’
(WORKING AT A JOB), EITHER ALONE OR IN COMBINATION
WITH OTHER CODES OR IF HE20A IS CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW). IF HE20A IS NOT
CODED ‘1’, ‘-7’, OR ‘-8’, USE A NULL DISPLAY.

DISPLAY ‘,’ IF HE20A IS CODED ‘1’, ‘2’, AND ‘3’
OR IF HE20A IS CODED EITHER ‘-7’ OR ‘-8’.
DISPLAY ‘ and’ IF HE20A IS CODED ‘1’ AND EITHER
‘2’ OR ‘3’. OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘ do housework’ IF HE20A IS CODED ‘2’
(DOING HOUSEWORK), EITHER ALONE OR IN COMBINATION
WITH OTHER CODES OR IF HE20A IS CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW). IF HE20A IS NOT
CODED ‘2’, ‘-7’, OR ‘-8’, USE A NULL DISPLAY.

DISPLAY ‘ and’ IF ONLY CODES ‘2’ AND ‘3’ ARE
SELECTED AT HE20A OR IF CODES ‘1’, ‘2’, AND ‘3’
ARE ALL SELECTED AT HE20A OR IF CODED EITHER ‘-7’
OR ‘-8’ AT HE20A. OTHERWISE, USE A NULL DISPLAY.

DISPLAY ‘ go to school’ IF HE20A IS CODED ‘3’
(GOING TO SCHOOL), EITHER ALONE OR IN COMBINATION
WITH OTHER CODES OR IF HE20A IS CODED ‘-7’
(REFUSED) OR ‘-8’ (DON’T KNOW). IF HE20A IS NOT
CODED ‘3’, ‘-7’, OR ‘-8’, USE A NULL DISPLAY.

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_04 AND CONTINUE WITH HE22

HE22

{STR-DT}
{END-DT}

(Besides the limitations we just talked about,) is anyone in the family
limited in participating in social, recreational, or family activities
because of an impairment or a physical or mental health problem?

YES .................................... 1
NO ..................................... 2 {HE24}
REF ................................... -7 {HE24}
DK .................................... -8 {HE24}

HELP AVAILABLE FOR DEFINITION OF LIMITED IN PARTICIPATING.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AS ‘LIMITED IN
PARTICIPATION’ AT HE23 BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
HE24

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU, CONTINUE
WITH HE23

HE23

{STR-DT}
{END-DT}

Who is that?

PROBE: Is anyone else limited in participating in social, recreational,
or family activities because of an impairment or a physical or mental
health problem?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

FLAG ALL SELECTED PERSONS WHO ARE = OR > 5 YEARS
OLD OR IN AGE CATEGORIES 3-9 FOR THE LTC
SUPPLEMENT: SOCIAL LIMITATIONS SECTION.

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS EXCLUDING DECEASED RU
MEMBERS.

HE24_01

Experience confusion
or memory loss such
that it interferes
with daily
activities? 1 2

REFUSED (-7) AND DON’T KNOW (-8) ALLOWED.

HE24_02

Have problems making
decisions to the
point that it
interferes with
daily activities? 1 2

REFUSED (-7) AND DON’T KNOW (-8) ALLOWED.

IF HE24_01, HE24_02, OR HE24_03 IS CODED ‘1’
(YES) AND A SINGLE-PERSON RU, AUTOMATICALLY CODE
AS ‘EXPERIENCES CONFUSION’ AT HE25 BY CAPI.

IF HE24_01, HE24_02, OR HE24_03 IS CODED ‘1’
(YES) AND A SINGLE-PERSON RU, GO TO BOX_10

IF HE24_01, HE24_02, AND HE24_03 ARE ALL CODED
‘2’ (NO), ‘-7’ (REFUSED), OR ‘-8’ (DON’T KNOW),
GO TO BOX_10

OTHERWISE, CONTINUE WITH HE25

HE25

{STR-DT}
{END-DT}

Who is that?

PROBE: Does anyone else {experience confusion or memory loss such that
it interferes with daily activities} {{or }have problems making
decisions to the point that it interferes with daily activities}
{{or }require supervision for their own safety}?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

DISPLAY ‘experience confusion or memory loss such
that it interferes with daily activities’ IF
HE24_01 CODED ‘1’ (YES).

DISPLAY ‘{or }have problems making decisions to
the point that it interferes with daily
activities’ IF HE24_02 CODED ‘1’ (YES). DISPLAY
THE ‘or ’ ONLY IF HE24_01 IS ALSO CODED ‘1’ (YES).

DISPLAY ‘{or }require supervision for their own
safety’ IF HE24_03 IS CODED ‘1’ (YES). DISPLAY
‘or ’ ONLY IF HE24_01 AND/OR HE24_02 ARE ALSO
CODED ‘1’ (YES).

FLAG ALL SELECTED PERSONS WHO ARE = OR > 18 YEARS
OLD OR IN AGE CATEGORIES 4-9 FOR THE LTC
SUPPLEMENT: COGNITIVE LIMITATIONS SECTION.

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS EXCLUDING DECEASED RU
MEMBERS.

HE26

With this next set of questions we want to learn about people who
have physical, mental, or emotional conditions that cause serious
difficulties with their daily activities.

{Please answer the next few questions for family members age 1 or
older.}

Is anyone in the family deaf or does anyone have serious difficulty
hearing?

YES .................................... 1
NO ....,................................ 2 {HE29}
REF ................................... -7 {HE29}
DK .................................... -8 {HE29}

DISPLAY THE SENTENCE ‘Please answer ... age 1 or
older.’ IF ANY RU MEMBERS ARE < 1 YEAR OF AGE OR
IN AGE CATEGORY 1. OTHERWISE, USE A NULL DISPLAY.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AT HE27 BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
LOOP_05

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH HE27

HE27

Who is that?

PROBE: Anyone else?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

CONTINUE WITH LOOP_05

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ONLY RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS > OR = 1 YEAR OF AGE OR IN AGE
CATEGORIES 2-9

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER,
ASK NAV_HE05 - END_LP05

LOOP DEFINITION: LOOP_05 COLLECTS HEARING
IMPAIRMENT DETAILS FOR PERSONS HAVING DIFFICULTY
HEARING. THIS LOOP CYCLES ON RU MEMBERS WHO MEET
THE FOLLOWING CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON HAS DIFFICULTY HEARING (I.E., PERSON
SELECTED AT HE27)

NAVIGATOR DETAILS: LOOP_05 USES NAV_HE05 TO
CONTROL THE FLOW OF THE LOOP.

NAV_HE05

SERIES: Hearing Impairment Details (e.g., deaf?)

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON HAS DIFFICULTY HEARING (I.E., PERSON
SELECTED AT HE27)

CONTINUE WITH HE28 FOR SELECTED RU MEMBER

HE28

Can {you/{PERSON}} not hear any speech at all, that is, {are/is}
{you/{PERSON}} deaf?

YES .................................... 1 {END_LP05}
NO ..................................... 2 {END_LP05}
REF ................................... -7 {END_LP05}
DK .................................... -8 {END_LP05}

HELP AVAILABLE FOR DEFINITION OF DEAF.

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_05 AND CONTINUE WITH HE29

HE29

Is anyone in the family blind or does anyone have serious difficulty
seeing, even when wearing glasses?

YES .................................... 1
NO ..................................... 2 {HE32}
REF ................................... -7 {HE32}
DK .................................... -8 {HE32}

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AT HE30 BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
LOOP_06

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH HE30

HE30

Who is that?

PROBE: Anyone else?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

CONTINUE WITH LOOP_06

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ONLY RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS > OR = 1 YEAR OF AGE OR IN AGE
CATEGORIES 2-9

FOR EACH ELEMENT IN THE RU-MEMBERS-ROSTER, ASK
NAV_HE06 - END_LP06

LOOP DEFINITION: LOOP_06 COLLECTS VISION
IMPAIRMENT DETAILS FOR PERSONS HAVING DIFFICULTY
SEEING. THIS LOOP CYCLES ON RU MEMBERS WHO MEET
THE FOLLOWING CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON HAS DIFFICULTY SEEING (I.E., PERSON
SELECTED AT HE30)

NAVIGATOR DETAILS: LOOP_06 USES NAV_HE06 TO
CONTROL THE FLOW OF THE LOOP.

NAV_HE06

SERIES: Vision Impairment Details (e.g., blind?)

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.

RU Member

[1. First Name,[Middle Name],Last Name-65] [Status-25]
[2. First Name,[Middle Name],Last Name-65] [Status-25]
[3. First Name,[Middle Name],Last Name-65] [Status-25]

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. SELECT ALLOWED.

2. MULTIPLE SELECT, ADD, DELETE, AND EDIT
DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON HAS DIFFICULTY SEEING (I.E., PERSON
SELECTED AT HE30)

CONTINUE WITH HE31 FOR SELECTED RU MEMBER

HE31

Can {you/{PERSON}} not see anything at all, that is, {are/is}
{you/{PERSON}} blind?

YES .................................... 1 {END_LP06}
NO ..................................... 2 {END_LP06}
REF ................................... -7 {END_LP06}
DK .................................... -8 {END_LP06}

HELP AVAILABLE FOR DEFINITION OF BLIND.

CYCLE ON NEXT PERSON IN THE RU-MEMBERS-ROSTER WHO
MEETS THE CONDITIONS STATED IN THE LOOP DEFINITION

IF NO OTHER PERSONS MEET THE STATED CONDITIONS,
END LOOP_06 AND CONTINUE WITH HE32

HE32

{Please answer the next few questions for family members age 5 or
older.}

Because of a physical, mental, or emotional condition, does anyone in
the family have serious difficulty concentrating, remembering, or
making decisions?

YES .................................... 1
NO ..................................... 2 {HE34}
REF ................................... -7 {HE34}
DK .................................... -8 {HE34}

DISPLAY THE SENTENCE ‘Please answer ... age 5 or
older.’ IF ANY RU MEMBERS ARE < 5 YEARS OF AGE OR
IN AGE CATEGORIES 1 OR 2. OTHERWISE, USE A NULL
DISPLAY.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AT HE33 BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
HE34

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH HE33

HE33

Who is that?

PROBE: Anyone else?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ONLY RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS > OR = 5 YEARS OF AGE OR IN AGE
CATEGORIES 3-9

HE34

Does anyone in the family have serious difficulty walking or climbing
stairs?

YES .................................... 1
NO ..................................... 2 {HE36}
REF ................................... -7 {HE36}
DK .................................... -8 {HE36}

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AT HE35 BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
HE36

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH HE35

HE35

Who is that?

PROBE: Anyone else?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ONLY RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS > OR = 5 YEARS OF AGE OR IN AGE
CATEGORIES 3-9

HE36

Does anyone in the family have difficulty dressing or bathing?

YES .................................... 1
NO ..................................... 2 {HE38}
REF ................................... -7 {HE38}
DK .................................... -8 {HE38}

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AT HE37 BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
HE38

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH HE37

HE37

Who is that?

PROBE: Anyone else?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ONLY RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS > OR = 5 YEARS OF AGE OR IN AGE
CATEGORIES 3-9

HE38

{Please answer the next few questions for family members age 15 or
older.}

Because of a physical, mental, or emotional condition, does anyone
in the family have difficulty doing errands alone such as visiting
a doctor’s office or shopping?

YES .................................... 1
NO ..................................... 2 {HE40}
REF ................................... -7 {HE40}
DK .................................... -8 {HE40}

DISPLAY THE SENTENCE ‘Please answer ... age 15 or
older.’ IF ANY RU MEMBERS ARE < 15 YEARS OF AGE OR
IN AGE CATEGORIES 1 - 3. OTHERWISE, USE A NULL
DISPLAY.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AT HE39 BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
HE40

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH HE39

HE39

Who is that?

PROBE: Anyone else?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ONLY RU MEMBERS WHO MEET THE FOLLOWING
CONDITIONS:
- PERSON IS NOT DECEASED
- PERSON IS > OR = 15 YEARS OF AGE OR IN AGE
CATEGORIES 4-9

HE40

{Please answer the next few questions for family members of all ages.}

Does anyone in the family wear a hearing aid?

YES .................................... 1
NO ..................................... 2 {HE42}
REF ................................... -7 {HE42}
DK .................................... -8 {HE42}

DISPLAY THE SENTENCE ‘Please answer ... of all
ages.’ IF ANY RU MEMBERS ARE <15 YEARS OF AGE OR
IN AGE CATEGORIES 1-3. OTHERWISE, USE A NULL
DISPLAY.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AT HE41 BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
HE42

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH HE41

HE41

Who is that?

PROBE: Does anyone else wear a hearing aid?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

ROSTER DETAILS:
TITLE: RU_MEMBERS_1

COL # 1 HEADER: NAME
INSTRUCTIONS: DISPLAY RU MEMBER’S FIRST, MIDDLE,
AND LAST NAMES (PERS.FULLNAME)

ROSTER DEFINITION:
THIS ITEM DISPLAYS RU-MEMBERS-ROSTER FOR
SELECTION.

ROSTER BEHAVIOR:
1. MULTIPLE SELECT ALLOWED.

2. ADD, DELETE, AND EDIT DISALLOWED.

ROSTER FILTER:
DISPLAY ALL RU MEMBERS EXCLUDING DECEASED RU
MEMBERS.

HE42

Does anyone in the family wear eyeglasses or contact lenses?

YES .................................... 1
NO ..................................... 2 {BOX_10}
REF ................................... -7 {BOX_10}
DK .................................... -8 {BOX_10}

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU,
AUTOMATICALLY CODE PERSON AT HE43 BY CAPI.

IF CODED ‘1’ (YES) AND A SINGLE-PERSON RU, GO TO
BOX_10

IF CODED ‘1’ (YES) AND A MULTI-PERSON RU,
CONTINUE WITH HE43

HE43

Who is that?

PROBE: Does anyone else wear eyeglasses or contact lenses?

[1. First Name,[Middle Name],Last Name-65]
[2. First Name,[Middle Name],Last Name-65]
[3. First Name,[Middle Name],Last Name-65]

Health Status (HE) Section