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pdfMCBS Community Additions
MCBS Revision to Current Clearance
Proposed Changes to Community Interviews and Effect on Burden
Community Interview Deletions and
Revisions
Addition: Chronic Conditions - Sleep
Apnea
Section
HFQ:
Fall Round
Effect on
Annual
Burden
Question Text
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told (01) YES
Increase of [you/(SP)] that [you/(SP)] had...]
(02) NO
0.2 minutes
(-8) Don't Know
sleep apnea?
(-9) Refused
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told
[you/(SP)] that [you/(SP)] had...]
Addition: Chronic Conditions - Thyroid
Disease
HFQ:
Fall Round
Increase of
any type of thyroid disease, other than thyroid cancer?
0.3 minutes
[IF NEEDED: This includes Graves' disease, hypothyroidism, hyperthyroidism, Hashimoto's
disease, or goiter]
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told
[you/(SP)] that [you/(SP)] had...]
Addition: Chronic Conditions - Bowel
Disease
HFQ:
Fall Round
Response Options
Increase of
a bowel disease?
0.3 minutes
[IF NEEDED: This includes inflammatory bowel disease, irritable bowel syndrome, Crohn's
disease, ulcerative colitis, or Celiac disease]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
MCBS Community Deletions and Revisions
MCBS Revision to Current Clearance
Proposed Changes to Community Interviews and Effect on Burden
Community Interview Deletions and
Revisions
Deletion: Colorectal Cancer Screening
Section
HFQ:
Fall Round
Effect on
Annual
Burden
Question Text
Response Options
Now I'd like to talk about a different illness, colorectal or colon cancer, a disease of the lower (01) YES
Decrease of intestines.
(02) NO
0.5 minutes
(-8) Don't Know
Before today, had [you/SP] ever heard of colorectal or colon cancer?
(-9) Refused
Before today, [have you/has SP] ever heard of this home testing kit?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Before today, had [you/(SP)] ever heard of a sigmoidoscopy or colonoscopy?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Now I'd like to talk about a different illness, colorectal or colon cancer, a disease of the lower
intestines.
Revision: Colorectal Cancer Screening
HFQ:
Fall Round
N/A
The fecal occult blood test is a simple test for early signs of colon cancer. It detects invisible
traces of blood found in the stool. The doctor or other health professional can give the patient
a kit to collect stool samples at the patient’s home. The test is then sent to a laboratory for the
results to be determined.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Has a doctor or other health professional ever given [you/(SP)] a home testing kit to test for
blood in the stool?
Now I'd like to talk about a different illness, colorectal or colon cancer, a disease of the lower
intestines.
The fecal occult blood test is a simple test for early signs of colon cancer. It detects invisible
traces of blood found in the stool. The doctor or other health professional can give the patient
a kit to collect stool samples at the patient’s home. The test is then sent to a laboratory for the
results to be determined.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Since (SAMPLE_PERSON.DATE_FALLRND), has a doctor or other health professional
given [you/(SP)] a home testing kit to test for blood in the stool?
Deletion: Arthritis
HFQ:
Fall Round
N/A
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told (01) YES
[you/(SP)] that [you/(SP)] had...]
(02) NO
(-8) Don't Know
rheumatoid arthritis?
(-9) Refused
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told (01) YES
[you/(SP)] that [you/(SP)] had...]
(02) NO
(-8) Don't Know
osteoarthritis?
(-9) Refused
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told
(01) YES
[you/(SP)] that (you/(SP)) had...]
(02) NO
(-8) Don't Know
arthritis, other than rheumatoid or osteoarthritis?
(-9) Refused
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)]
that [you/(SP)] had arthritis, other than rheumatoid or osteoarthritis, in any part of
[your/(SP's)] body?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Revision: Arthritis
Section
HFQ:
Fall Round
Effect on
Annual
Burden
N/A
Question Text
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told
[you/(SP)] that [you/(SP)] had...]
(01) YES
(02) NO
any type of arthritis?
(-8) Don't Know
(-9) Refused
[IF NEEDED: This includes osteoarthritis, rheumatoid arthritis, or any other type of arthritis]
Which type of arthritis did the doctor or other health professional say that [you have/(SP)
has]? Was it...
[SELECT ALL THAT APPLY]
Deletion: Instrumental Activities of
Daily Living (IADL)
HFQ:
Fall Round
N/A
Response Options
(1) osteoarthritis
(2) rheumatoid arthritis, or
(3) some other type?
(-8) Don't know
(-9) Refused
[What is the name of the person and relationship to (SP)?]*
(01) CONTINUOUS ANSWER
[What is the name of the person and relationship to (SP)?]*
(01) CONTINUOUS ANSWER
[What is the name of the person and relationship to (SP)?]*
(02) SPOUSE
(56) PARTNER
(58) CHILD
(59) GRANDCHILD
(60) PARENT
(61) SIBLING
(91) OTHER
(-8) Don't Know
(-9) Refused
[What is the name of the person and relationship to (SP)?]*
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
* These deletions are repeated 6 times as this series of items is administered for each of the 6 IADLs.
Who gives that help?
Revision: Instrumental Activities of
Daily Living (IADL)
HFQ:
Fall Round
Decrease of [PROBE: Is that person a spouse, a child, an other family member, a friend, a home health
0.5 minutes aide or home care worker, or a homemaker or house cleaner?]
SELECT ALL THAT APPLY**
(01) SPOUSE
(02) CHILD
(03) OTHER FAMILY MEMBER
(04) FRIEND
(05) HOME HEALTH AIDE/HOME CARE WORKER
(06) HOMEMAKER/HOUSE CLEANER
(-8) Don't Know
(-9) Refused
** This revision is repeated 6 times as it is administered for each of the 6 IADLs.
Deletion: Activities of Daily Living
(ADL)
HFQ:
Fall Round
Does someone usually stay nearby just in case [you need/(SP) needs] help with bathing or
Decrease of showering?
0.5 minutes
[That is, does someone usually stay or come into the room to check on [you/(SP)?]
How long [have you/has (SP)] needed help with bathing or showering? Has it been . . .
Does someone usually stay nearby just in case [you need/(SP) needs] help with dressing?
[That is, does someone usually stay or come into the room to check on [you/(SP)?]
How long [have you/has (SP)] needed help with dressing? Has it been . . .
Does someone usually stay nearby just in case [you need/(SP) needs] help with eating?
[That is, does someone usually stay or come into the room to check on [you/(SP)]?]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
How long [have you/has (SP)] needed help with eating? Has it been . . .
Does someone usually stay nearby just in case [you need/(SP) needs] help with getting in or
out of bed or chairs?
[That is, does someone usually stay or come into the room to check on [you/(SP))?]]
Response Options
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) less than three months,
(02) three months or more but less than one year, or
How long [have you/has (SP)] needed help with getting in or out of bed or chairs? Has it been
(03) one year or more?
...
(-8) Don't Know
(-9) Refused
[IF R IS IN A WHEELCHAIR OR CANNOT STAND DUE TO PERMANENT
DISABILITY ONLY, SELECT "NO" WITHOUT READING TEXT BELOW.]
Does someone usually stay nearby just in case [you need/(SP) needs] help with walking?
[That is, does someone usually stay or come into the room to check on [you/(SP))?]]
How long [have you/has (SP)] needed help with walking? Has it been . . .
Does someone usually stay nearby just in case [you need/(SP) needs] help with using the
toilet, including getting up and down?
[That is, does someone usually stay or come into the room to check on [you/(SP)]?]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
How long [have you/has (SP)] needed help with using the toilet? Has it been . . .
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused
[What is the name of the person and relationship to (SP)?]***
(01) CONTINUOUS ANSWER
[What is the name of the person and relationship to (SP)?]***
(01) CONTINUOUS ANSWER
[What is the name of the person and relationship to (SP)?]***
(02) SPOUSE
(56) PARTNER
(58) CHILD
(59) GRANDCHILD
(60) PARENT
(61) SIBLING
(91) OTHER
(-8) Don't Know
(-9) Refused
[What is the name of the person and relationship to (SP)?]***
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
Which of these persons gives [you/(SP)] the most help with these things?
SELECT ONLY ONE.
Display all persons selected at HFLA9, HFLB9, HFLC9,
HFLD9, HFLE9 and HFLF9 rosters.
*** These deletions are repeated 6 times as these items are administered for each of the 6 ADLs.
Revision: Activities of Daily Living
(ADL)
HFQ:
Fall Round
N/A
(01) SPOUSE
You mentioned that [you receive/(SP) receives] help with bathing and showering. Who gives
(02) CHILD
that help?
(03) OTHER FAMILY MEMBER
(04) FRIEND
[PROBE: Is that person a spouse, a child, an other family member, a friend, a home health
(05) HOME HEALTH AIDE/HOME CARE WORKER
aide or home care worker, or a homemaker or house cleaner?]
(06) HOMEMAKER/HOUSE CLEANER
(-8) Don't Know
SELECT ALL THAT APPLY
(-9) Refused
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
You mentioned that [you receive/(SP) receives] help with dressing. Who gives that help?
[PROBE: Is that person a spouse, a child, an other family member, a friend, a home health
aide or home care worker, or a homemaker or house cleaner?]
SELECT ALL THAT APPLY
You mentioned that [you receive/(SP) receives] help with eating. Who gives that help?
[PROBE: Is that person a spouse, a child, an other family member, a friend, a home health
aide or home care worker, or a homemaker or house cleaner?]
SELECT ALL THAT APPLY
You mentioned that [you receive/(SP) receives] help with getting in or out of bed or chairs.
Who gives that help?
[PROBE: Is that person a spouse, a child, an other family member, a friend, a home health
aide or home care worker, or a homemaker or house cleaner?]
SELECT ALL THAT APPLY
You mentioned that [you receive/(SP) receives] help with walking. Who gives that help?
[PROBE: Is that person a spouse, a child, an other family member, a friend, a home health
aide or home care worker, or a homemaker or house cleaner?]
SELECT ALL THAT APPLY
You mentioned that [you receive/(SP) receives] help with using the toilet. Who gives that
help?
[PROBE: Is that person a spouse, a child, an other family member, a friend, a home health
aide or home care worker, or a homemaker or house cleaner?]
SELECT ALL THAT APPLY
SHOW CARD SC1
Deletion: Satisfaction with Care Items
SCQ:
Fall Round
Decrease of
[Please tell me how satisfied or dissatisfied you have been with . . .]
1 minute
The information given to [you/you or (SP)] about what was wrong with [you/(SP)].
[Please tell me whether each of the following statements is true or false.]
[You/(SP)] will do just about anything to avoid going to the doctor.
[Please tell me whether each of the following statements is true or false.]
When [you/(SP)] [are/is] sick, [you/(SP)] [try/tries] to keep it to [yourself/themselves].
Revision: Satisfaction with Care Items
Administred Once per Panel Rather
Than Annually
SCQ:
Baseline, Fall
Round
Please tell me whether each of the following statements is true or false.
Decrease of
3 minutes
[You/(SP)] [worry/worries] about [your/(SP)'s] health more than other people [your/(SP)'s]
(Continuing
age.
interview
only)
[Is this statement true or false?]
Response Options
(01) SPOUSE
(02) CHILD
(03) OTHER FAMILY MEMBER
(04) FRIEND
(05) HOME HEALTH AIDE/HOME CARE WORKER
(06) HOMEMAKER/HOUSE CLEANER
(-8) Don't Know
(-9) Refused
(01) SPOUSE
(02) CHILD
(03) OTHER FAMILY MEMBER
(04) FRIEND
(05) HOME HEALTH AIDE/HOME CARE WORKER
(06) HOMEMAKER/HOUSE CLEANER
(-8) Don't Know
(-9) Refused
(01) SPOUSE
(02) CHILD
(03) OTHER FAMILY MEMBER
(04) FRIEND
(05) HOME HEALTH AIDE/HOME CARE WORKER
(06) HOMEMAKER/HOUSE CLEANER
(-8) Don't Know
(-9) Refused
(01) SPOUSE
(02) CHILD
(03) OTHER FAMILY MEMBER
(04) FRIEND
(05) HOME HEALTH AIDE/HOME CARE WORKER
(06) HOMEMAKER/HOUSE CLEANER
(-8) Don't Know
(-9) Refused
(01) SPOUSE
(02) CHILD
(03) OTHER FAMILY MEMBER
(04) FRIEND
(05) HOME HEALTH AIDE/HOME CARE WORKER
(06) HOMEMAKER/HOUSE CLEANER
(-8) Don't Know
(-9) Refused
(01) VERY SATISFIED
(02) SATISFIED
(03) DISSATISFIED
(04) VERY DISSATISFIED
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
(01) TRUE
(02) FALSE
(-8) Don't Know
(-9) Refused
(01) TRUE
(02) FALSE
(-8) Don't Know
(-9) Refused
(01) TRUE
(02) FALSE
(-8) Don't Know
(-9) Refused
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
[Please tell me whether each of the following statements is true or false.]
(01) TRUE
(02) FALSE
Usually, [you/(SP)] [go/goes] to the doctor or other health professional as soon as [you/(SP)] (-8) Don't Know
[start/starts] to feel bad.
(-9) Refused
Now I have some questions about how you make health care decisions. Answers to questions
like these will help Medicare better understand how people use medical services.
Please keep in mind that there are no right or wrong answers to these questions. Your
opinions and experiences are important to us.
SHOW CARD SC2
Doctors often give instructions about how you should care for yourself at home, like changing
a bandage, taking medicines on schedule, or applying ice packs. How confident are you that
you can follow instructions to care for yourself at home?
(01) CONTINUE
(-7) Empty
(01) VERY CONFIDENT
(02) CONFIDENT
(03) SOMEWHAT CONFIDENT
(04) NOT AT ALL CONFIDENT
(-8) Don't Know
(-9) Refused
(01) VERY CONFIDENT
SHOW CARD SC2
(02) CONFIDENT
Doctors also often give instructions about changing your habits or lifestyle, such as changing (03) SOMEWHAT CONFIDENT
your diet, stopping smoking, or getting regular exercise. How confident are you that you can (04) NOT AT ALL CONFIDENT
follow this kind of instruction, to change your habits or lifestyle?
(-8) Don't Know
(-9) Refused
(01) VERY LIKELY
SHOW CARD SC3
(02) LIKELY
How likely are you to change doctors or other health professionals if you are dissatisfied with
(03) UNLIKELY
the way you and your doctor or other health professional communicate?
(04) VERY UNLIKELY
(-8) Don't Know
[Would you say very likely, likely, unlikely, or very unlikely?]
(-9) Refused
SHOW CARD SC3
How likely are you to tell your doctor or other health professional when you disagree with
them?
(01) VERY LIKELY
(02) LIKELY
(03) UNLIKELY
(04) VERY UNLIKELY
(-8) Don't Know
(-9) Refused
SHOW CARD SC4
These next questions are about practices sometimes associated with receiving medical care.
Please tell me if you always, usually, sometimes, or never do the following:
Do you always, usually, sometimes, or never read information about a new prescription, such
as side effects and precautions?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
Bring with you to your doctor or other health professional visits a list of questions or concerns
(-8) Don't Know
you want to cover?
(-9) Refused
SHOW CARD SC4
Do you always, usually, sometimes, or never...
SHOW CARD SC4
[Do you always, usually, sometimes, or never...]
Leave your doctor or other health professional's office feeling that all of your concerns or
questions have been fully answered?
SHOW CARD SC4
[Do you always, usually, sometimes, or never...]
Take a list of all of your prescribed medicines to your doctor or other health professional
visits?
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
(-8) Don't Know
(-9) Refused
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
(-8) Don't Know
(-9) Refused
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
Make sure you understand the results of any medical test or procedure such as an x-ray, blood
(-8) Don't Know
test, or EKG for heart conditions?
(-9) Refused
SHOW CARD SC4
[Do you always, usually, sometimes, or never...]
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
Talk with your doctor or other health professional about your options if you need tests, follow(-8) Don't Know
up care, or a referral for care by a medical specialist?
(-9) Refused
SHOW CARD SC4
[Do you always, usually, sometimes, or never...]
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
Contact your doctor or other health professional's office to get medical advice when you need
(-8) Don't Know
it.
(-9) Refused
SHOW CARD SC4
[Do you always, usually, sometimes, or never...]
HIQ:
Decrease of
What is the most important reason [you/(SP)] stopped the (CMS MEDICARE MANAGED
Deletion: Health Insurance Plan Details Winter, Summer, 0.3 minutes
CARE PLAN NAME) coverage?
and Fall Rounds each round
(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH QUALITY OF CARE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET BENEFIT COVERAGE OTHER THAN
RX
(05) PLAN WENT OUT OF BUSINESS/STOPPED
MEDICARE COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS
BOUGHT BY/MERGED WITH ANOTHER PLAN
(07) DOCTOR LEFT PLAN/DIED/RETIRED
(08) DIFFICULTIES GETTING APPTS OR SEEING
PARTICULAR PROVIDERS
(09) SP MOVED OUT OF PLAN AREA
(10) SP DIDN'T LIKE CHOICE OF DOCTORS
(11) SP WANTED CHOICE OF DOCTORS
(91) OTHER
(-8) Don't Know
(-9) Refused
OTHER (SPECIFY)
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
What is the most important reason [you/(SP)] stopped the (CMS MEDICARE MANAGED
CARE PLAN NAME) coverage?
(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH QUALITY OF CARE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET BENEFIT COVERAGE OTHER THAN
RX
(05) PLAN WENT OUT OF BUSINESS/STOPPED
MEDICARE COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS
BOUGHT BY/MERGED WITH ANOTHER PLAN
(07) DOCTOR LEFT PLAN/DIED/RETIRED
(08) DIFFICULTIES GETTING APPTS OR SEEING
PARTICULAR PROVIDERS
(09) SP MOVED OUT OF PLAN AREA
(10) SP DIDN'T LIKE CHOICE OF DOCTORS
(11) SP WANTED CHOICE OF DOCTORS
(91) OTHER
(-8) Don't Know
(-9) Refused
OTHER (SPECIFY)
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(Does/Did) [your/(SP’s)] Medicaid plan cover medicines prescribed by a doctor or other
health professional?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[We recorded that [you/(SP)] served in the Armed Forces of the United States.] Since
(REFERENCE DATE), [have you/has (SP) received/did (SP) receive] health care or health
services or prescribed medicines at a TRICARE Military Treatment Facility or MTF?
[EXPLAIN IF NECESSARY: A TRICARE Military Treatment Facility is any military
hospital, or clinic located on a military base or post around the world. MTFs are different
from VA facilities.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
SHOW CARD HIT2
Where [do you/does (SP)/did you/did (SP)] usually obtain [your/(SP)'s] medicines? [Do
you/Does (SP)/Did you/Did (SP)] usually obtain them at a TRICARE mail order pharmacy
(TMOP), a TRICARE retail pharmacy network pharmacy (TRRx), a military treatment
facility pharmacy (MTF), a non-network retail pharmacy, or somewhere else?
(01) A TRICARE MAIL ORDER PHARMACY (TMOP)
(02) A TRICARE RETAIL PHARMACY NETWORK
PHARMACY (TRRX)
(03) A MILITARY TREATMENT FACILITY
PHARMACY (MTF)
(04) A NON-NETWORK RETAIL PHARMACY
(91) SOMEWHERE ELSE
(-8) Don't Know
(-9) Refused
SOMEWHERE ELSE (SPECIFY)
(01) [Continuous Answer]
What is the most important reason [you/(SP)] stopped the (MEDICARE PRESCRIPTION
DRUG PLAN NAME) coverage?
(01) TOO EXPENSIVE OR COULDN'T AFFORD
(02) SP DISSATISFIED WITH PLAN'S COVERAGE
(03) TO GET RX COVERAGE IN ANOTHER PLAN
(04) TO GET DIFFERENT HEALTH CARE
COVERAGE
(05) PLAN NO LONGER CONTRACTS FOR
MEDICARE RX COVERAGE
(06) PLAN NAME CHANGED OR PLAN WAS
BOUGHT BY/MERGED WITH ANOTHER PLAN
(07) SP MOVED OUT OF PLAN AREA
(91) OTHER
(-8) Don't Know
(-9) Refused
OTHER (SPECIFY)
As you may know, every state now offers a health insurance marketplace, also referred to as
an exchange.
The marketplace[, known as (STATE MARKETPLACE NAME),] allows residents to
compare and purchase available health insurance options that meet their needs. While most
Medicare beneficiaries are not eligible for insurance from a health insurance marketplace,
there are some special circumstances that allow enrollment.
At any time [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION),] [have you/has (SP)/had (SP)] been
enrolled in or covered by one of these exchange plans?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[MEDICARE BENEFICIARIES ARE NOT ELIGIBLE TO OBTAIN INSURANCE
THROUGH THESE PLANS. THE RESPONSE TO THIS QUESTION SHOULD
ALMOST ALWAYS BE “NO”. HOWEVER, SOME RESPONDENTS MAY SIGN UP
FOR THESE PLANS DUE TO CONFUSION ABOUT THE PROGRAM.]
Deletion: Medicare Program
Information
KNQ:
Winter Round
Decrease of
0.5 minutes
SHOW CARD KN3
How interested are you in getting (more) information [for (SP)] about Medicare?
SHOW CARD KN9
How easy or difficult did you find (the parts you read/this book) to understand?
[PROBE IF NECESSARY: Would you say (they were/it was) very easy to understand,
somewhat easy to understand, somewhat difficult to understand, or very difficult to
understand?]
Deletion: Internet Use
KNQ:
Winter Round
Decrease of
[Do you/Does (SP)] personally ever use the Internet to get information of any kind?
0.25 minutes
(01) VERY INTERESTED
(02) SOMEWHAT INTERESTED
(03) NOT VERY INTERESTED
(04) NOT AT ALL INTERESTED
(-8) Don't Know
(-9) Refused
(01) VERY EASY
(02) SOMEWHAT EASY
(03) SOMEWHAT DIFFICULT
(04) VERY DIFFICULT
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
SHOW CARD KN10
What types of Medicare plans did [you/(SP)] compare with [your/(SP)'s] Medicare insurance
plan?
Deletion: Inflation Reduction Act
Knowledge
KNQ:
Winter Round
[EXPLAIN IF NECESSARY:
-Medicare Parts A and B, commonly referred to as “Original Medicare,” provide hospital and
medical insurance.
-Medicare Part C includes Medicare Advantage plans. These are plans offered to Medicare
beneficiaries by private companies (approved by Medicare) and provide beneficiaries with
Decrease of
their Part A and B benefits. Medical Advantage is an alternative to Original Medicare.
2.25 minutes
-Part D covers prescription drugs -- this type of plan is also known as an MPDP. Prescription
drug plans are offered by private companies (approved by Medicare).
- Medigap is a supplemental insurance plan sold by private companies for use with Original
Medicare. It cannot be used with Medicare Advantage. Medigap plans help pay some of the
health care costs that Original Medicare doesn't cover, like copayments, coinsurance and
deductibles.]
(01) Medicare Parts A and B (Original Medicare)
(02) Medicare Part C, Medicare Advantage (MA) Plans
(03) Medicare Part D, Medicare Prescription Drug Plans
(MPDPs)
(04) Medigap Plans
(-8) DON'T KNOW
(-9) REFUSED
[PLEASE INCLUDE SITUATIONS WHERE A PROXY OR SOMEONE ELSE
REVIEWS THE RESONDENT’S MEDICARE INSURANCE COVERAGE FOR OR
WITH THEM.]
As far as you know, is there a federal law in place that …
Requires the federal government to negotiate the price of some prescription drugs for people
with Medicare
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Places an annual limit on out-of-pocket prescription drug costs for people with Medicare
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Caps the cost of each insulin product for people with Medicare at $35 per month
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Removes out-of-pocket costs for recommended vaccines covered under Medicare Part D
(01) YES
(02) NO
[IF NEEDED: Vaccines covered under Medicare Part D protect against Shingles, Respiratory
(-8) Don't Know
Syncytial Virus (RSV), Hepatitis A, Hepatitis B, Measles, Mumps, and Rubella (MMR), and
(-9) Refused
others, including vaccines recommended for international travel.]
Allows Medicare Part D enrollees to spread their out-of-pocket prescription drug costs out
over the year
[IF NEEDED: Medicare beneficiaries can receive insurance coverage for prescription drugs
through Medicare Prescription Drug plans. These plans are also called "Medicare Part D"
plans.]
Deletion: Usual Source of Care
USQ:
Winter Round
Decrease of
OTHER (SPECIFY)
7.5 minutes
Is this [doctor or other health professional/medical clinic] associated with [your/(SP)'s]
[READ MANAGED CARE PLAN NAME(S) BELOW] plan?
What is the complete name of the [place/managed care plan or HMO center/(US2
RESPONSE)] that [you go to/(SP) goes to]?
[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE
DIRECTORY, APPOINTMENT CARD, ETC., FOR COMPLETE INFORMATION.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) CONTINUOUS ANSWER
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
(01) continuous answer
(-8) Don't Know
(-9) Refused
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
What is the complete name of that doctor or other health professional?
[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE
DIRECTORY, APPOINTMENT CARD, ETC., FOR COMPLETE INFORMATION.]
Response Options
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
(01) continuous answer
(-8) Don't Know
(-9) Refused
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02
Is (US5A PROVIDER NAME) a male or female?
(01) MALE
(02) FEMALE
(-8) DON’T KNOW
(-9) REFUSED
OTHER DR SPECIALTY (SPECIFY)
[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY
MENTION A 'GENERIC' SPECIALITY LIKE ‘HEART DOCTOR.’ IF RESPONDENT
(01) CONTINUOUS ANSWER
ONLY GIVES A 'GENERIC' SPECIALTY AND THE GENERIC WORD IS SHOWN IN
PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE RESPONSE
CATEGORY FOR THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE SELECT
'OTHER DR SPECIALTY'.]
In general, in what language [do you/does (SP)] prefer to receive [your/(SP)'s] medical care?
SHOW CARD US2
How well can [you/(SP)] and [(US5A PROVIDER NAME)/the providers at (US3A
PROVIDER NAME)] communicate in [LANGUAGE SPOKEN AT HOME/LEP1BLANGPFOS] about [your/(SP)'s] symptoms? Very well, well, not well, or not at all?
(01) CONTINUOUS ANSWER
(01) VERY WELL
(02) WELL
(03) NOT WELL
(04) NOT AT ALL
(-8) DON’T KNOW
(-9) REFUSED
(01) VERY WELL
(02) WELL
(03) NOT WELL
Without the aid of a translator, language assistant, or interpreter, how well can [you/(SP)] and
(04) NOT AT ALL
[(US5A PROVIDER NAME)/the providers at (US3A PROVIDER NAME)] communicate in
(-8) DON’T KNOW
English about [your/(SP)'s] symptoms? Very well, well, not well, or not at all?
(-9) REFUSED
SHOW CARD US2
SHOW CARD US3
Who helps [you/(SP)] communicate with [(US5A PROVIDER NAME)/the providers at
(US3A PROVIDER NAME)] – a professional interpreter, a staff person at [your/(SP)'s]
provider's office, a family member, a friend, [do you/does (SP)] do the best that [you/(SP)]
can in English, or does no one help [you/(SP)] because [you have/(SP) has] no trouble
communicating in English?
PROBE: Anyone else?
(01) PROFESSIONAL INTERPRETER
(02) STAFF PERSON AT MEDICAL PROVIDER’S
OFFICE
(03) FAMILY MEMBER
(04) FRIEND
(05) SOMEONE ELSE
(06) DOES BEST THAT CAN IN ENGLISH
(07) NO ONE HELPS; NO TROUBLE
COMMUNICATING IN ENGLISH
(-8) DON’T KNOW
(-9) REFUSED
SHOW CARD US3
(01) PROFESSIONAL INTERPRETER
(02) STAFF PERSON AT MEDICAL PROVIDER’S
Now think about all of [your/(SP)'s] medical providers other than [your/(SP)'s] usual
OFFICE
provider.
(03) FAMILY MEMBER
(04) FRIEND
Who helps [you/(SP)] communicate with medical providers who do not speak [LANGUAGE (05) SOMEONE ELSE
SPOKEN AT HOME/LEP1B-LANGPFOS]– a professional interpreter, a staff person at
(06) DOES BEST THAT CAN IN ENGLISH
[your/(SP)'s] provider's office, a family member, a friend, [do you/does (SP)] do the best that (07) DOES NOT SEE A MEDICAL PROVIDER
[you/(SP)] can in English, or does no one help [you/(SP)] because [you have/(SP) has] no
(08) NO ONE HELPS; HAS NO TROUBLE
trouble communicating in English?
COMMUNICATING IN ENGLISH
(-8) DON’T KNOW
PROBE: Anyone else?
(-9) REFUSED
How [do you/does (SP)] usually get to [(US5A PROVIDER NAME)'S office/(US3A
PROVIDER NAME)]?
[EXPLAIN IF NECESSARY: [Do you/Does (SP)] get there by walking, driving, being
driven by someone else, by ambulance or other special vehicle for disabled people, by taxi,
other public transportation, or some other way?]
SOME OTHER WAY (SPECIFY)
(01) WALKING
(02) DRIVING
(03) BEING DRIVEN
(04) AMBULANCE OR OTHER SPECIAL VEHICLE
(05) TAXI
(06) OTHER PUBLIC TRANSPORTATION
(07) DR. USUALLY COMES TO HOME
(91) SOME OTHER WAY
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
[What is the name of the person and relationship to (SP)?]
(01) CONTINUOUS ANSWER
[What is the name of the person and relationship to (SP)?]
(01) CONTINUOUS ANSWER
[What is the name of the person and relationship to (SP)?]
(02) SPOUSE
(56) PARTNER
(58) CHILD
(59) GRANDCHILD
(60) PARENT
(61) SIBLING
(91) OTHER
(-8) Don't Know
(-9) Refused
[What is the name of the person and relationship to (SP)?]
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
OTHER (SPECIFY)
(01) continuous answer
The next questions ask about the care [you/(SP)] received from [(US5A PROVIDER
NAME)'S office/(US3A PROVIDER NAME)].
(01) YES
Some offices remind patients about appointments. Before [your/(SP)'s] most recent visit with (02) NO
[(US5A PROVIDER NAME)/(US3A PROVIDER NAME) ], did [you/(SP)] get a reminder (996) NOT APPLICABLE / R DID NOT HAVE
from [(US5A PROVIDER NAME)'S office /(US3A PROVIDER NAME)] about the
APPOINTMENT
appointment?
(-8) DON'T KNOW
(-9) REFUSED
REMINDERS INCLUDE PHONE CALLS, TEXT MESSAGES, E-MAILS, AND
MAILED CORRESPONDENCE.
Before [your/(SP)'s] most recent visit with [(US5A PROVIDER NAME)'s office/(US3A
PROVIDER NAME)], did [you/(SP)] get instructions telling [you/(SP)] what to expect or
how to prepare?
(01) YES
(02) NO
INSTRUCTIONS CAN INCLUDE ANYTHING THAT IS NEEDED OR PREPARED
(-8) DON'T KNOW
BEFORE THE APPOINTMENT, SUCH AS PREPARING OR ORGANIZING MEDICAL (-9) REFUSED
RECORDS, FASTING, ARRANGING TO HAVE SOMEONE ACCOMPANY MEDICAL
VISIT, ETC.
SHOW CARD US4
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
People have busy lives and miss appointments for many reasons. Since (TODAY'S MONTH (-8) Don't Know
AND YEAR-12 MONTHS), how often did [you/(SP)] miss an appointment with [(US5A
(-9) Refused
PROVIDER NAME)/(US3A PROVIDER NAME)]?
Now I’m going to read you questions about the medical providers [you have/SP has] seen in
the last twelve months, that is since {TODAY'S MONTH AND YEAR - 12 MONTHS}.
SHOW CARD US4
Since (TODAY'S MONTH AND YEAR-12 MONTHS), when [you/(SP)] missed an
appointment with US5A PROVIDER NAME/US3A PROVIDER NAME), how often did
someone from [(US5A PROVIDER NAME)'S office/(US3A PROVIDER NAME)] contact
[you/(SP)] to make a new appointment?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER
(04) ALWAYS
NAME)/the medical providers at (US3A PROVIDER NAME)] show respect for what
(-8) Don't Know
[you/(SP)] had to say?
(-9) Refused
SHOW CARD US4
(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER
(04) ALWAYS
NAME)/the medical providers at (US3A PROVIDER NAME)] spend enough time with
(-8) Don't Know
[you/(SP)]?
(-9) Refused
SHOW CARD US4
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER
(04) ALWAYS
NAME)/the medical providers at (US3A PROVIDER NAME)] ask whether [you/(SP)] had
(-8) Don't Know
ideas about how to improve [your/(SP)'s] health?
(-9) Refused
SHOW CARD US4
SHOW CARD US5
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did the care [you/(SP)] received
from [(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)]
help [you/(SP)] meet [your/(SP)'s] goals?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
SHOW CARD US6
Think about the care [you receive/(SP) receives] from (US5A PROVIDER NAME/US3A
PROVIDER NAME). For each statement, please tell me whether you strongly agree, agree,
disagree, or strongly disagree.
[(US5A PROVIDER NAME) is/The doctors or other health professionals at (US3A
PROVIDER NAME) are] very careful to check everything when examining [you/(SP)].
SHOW CARD US6
[(US5A PROVIDER NAME) has/The doctors or other health professionals at (US3A
PROVIDER NAME) have] a complete understanding of the things that are wrong with
[you/(SP)].
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
People often get instructions about their health from more than one person in the same office,
such as other medical providers, nurses, nutritionists, and social workers.
(01) YES
(02) NO
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] get any instructions (-8) DON'T KNOW
about your health from any other staff [in (US5A PROVIDER NAME)'s office/ at (US3A
(-9) REFUSED
PROVIDER NAME)]?
Did these other staff seem up-to-date about the care [you were/(SP) was] receiving from
[(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)]?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Did these other staff talk with [you/(SP)] about care [you/he/she] [were/was] receiving from
[(US5A PROVIDER NAME)/the medical providers at (US3A PROVIDER NAME)]?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Did these other staff seem to know the important information about [your/(SP)'s] medical
history?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
The next set of questions ask about the care [you/(SP)] received from [(US5A PROVIDER
NAME)/the medical providers at (US3A PROVIDER NAME)].
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [(US5A PROVIDER
NAME)/the medical providers at (US3A PROVIDER NAME)] order a blood test, x-ray, or
other test for [you/(SP)]?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), when [(US5A PROVIDER
(04) ALWAYS
NAME)/the medical providers at (US3A PROVIDER NAME)] ordered a blood test, x-ray, or
(05) NOT APPLICABLE
other test for [you/(SP)], how often did [(US5A PROVIDER NAME)/the medical providers at
(-8) Don't Know
(US3A PROVIDER NAME)] follow up to give [you/(SP)] those results?
(-9) Refused
SHOW CARD US4
SHOW CARD US4
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [you/(SP)] have to
request [your/(SP)'s] test results before [you/(SP)] got them?
SHOW CARD US4
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often were [your/(SP)'s] test
results presented in a way that was easy to understand?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] need services at
home to help [you/(SP)] take care of [your/(SP)'s] health?
Response Options
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER
(04) ALWAYS
NAME)/the medical providers at (US3A PROVIDER NAME)] help [you/(SP)] get these
(-8) Don't Know
services at home to take care of [your/(SP)'s] health?
(-9) Refused
SHOW CARD US4
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [(US5A PROVIDER
NAME)/the medical providers at (US3A PROVIDER NAME)] give [you/(SP)] instructions
about how to take care of [your/(SP)'s] health?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] take any prescription
(01) YES
medicine?
(02) NO
(-8) DON'T KNOW
[THIS IS DIFFERENT FROM THE PRESCRIPTION DRUG WHERE WE ASK IF THE R
(-9) REFUSED
HAD ANY PRESCRIPTIONS FILLED]
(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER
(04) ALWAYS
NAME)/the medical providers at (US3A PROVIDER NAME)] talk with [you/(SP)] about
(-8) Don't Know
how [you were/(SP) was] supposed to take [your/(SP)'s] medicine?
(-9) Refused
SHOW CARD US4
SHOW CARD US4
(01) NEVER
(02) SOMETIMES
There are many reasons why people may not always be able to take their medicines as
(03) USUALLY
prescribed.
(04) ALWAYS
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often [were you/was (SP)] able (-8) Don't Know
to take [your/(SP)'s] medicine as prescribed?
(-9) Refused
(01) NEVER
(02) SOMETIMES
(03) USUALLY
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [(US5A PROVIDER
(04) ALWAYS
NAME)/the medical providers at (US3A PROVIDER NAME)] talk with [you/(SP)] about
(-8) Don't Know
what to do if [you have/(SP) has] a bad reaction to [your/(SP)'s] medicine?
(-9) Refused
SHOW CARD US4
SHOW CARD US4
In general, how often [do you/does(SP)] have to remind [(US5A PROVIDER NAME)/the
doctors or other health professionals at (US3A PROVIDER NAME)] about care [you
receive/(SP) receives] from specialists?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) YES
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did any specialists outside the office
(02) NO
of [(US5A PROVIDER NAME)/the doctors or other health professionals at (US3A
(-8) DON'T KNOW
PROVIDER NAME)] prescribe medicine for [you/(SP)]?
(-9) REFUSED
SHOW CARD US4
In general, how often [does (US5A PROVIDER NAME)/do the doctors or other health
professionals at (US3A PROVIDER NAME)] talk with [you/(SP)] about the medicines
prescribed by these specialists?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
The next four questions ask about care [you/(SP)] received from the specialist [you/(SP)] saw
1. [PROVIDER 1]
most often in the last 12 months outside the office of [(US5A PROVIDER NAME)/the
2. [PROVIDER 2]
doctors or other health professionals at (US3A PROVIDER NAME)].
(01) continuous answer
First, what is the name of the specialist [you/(SP)] saw most often since (TODAY'S MONTH
(-8) Don't Know
AND YEAR-12 MONTHS)?
(-9) Refused
[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE
DIRECTORY, APPOINTMENT CARD, ETC., FOR COMPLETE INFORMATION.]
Is [(US37E1 PROVIDER NAME)/the specialist you saw most often since (TODAY'S
MONTH AND YEAR-12 MONTHS)] a male or female?
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE
PROVNUM>02
(01) MALE
(02) FEMALE
(-8) DON’T KNOW
(-9) REFUSED
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
SHOW CARD US5
[IF NEEDED: This question is about the last twelve months, that is since (TODAY'S
MONTH AND YEAR - 12 MONTHS).]
(01) YES, DEFINITELY
The next questions ask about care [you/(SP)] received from the specialist [you/(SP)] saw most (02) YES, SOMEWHAT
often in the last twelve months outside the [office of (US5A PROVIDER NAME)/the doctors (03) NO
or other health professionals at (US3A PROVIDER NAME)].
(-8) Don't Know
(-9) Refused
When [you see/(SP) sees/(SP) sees] [(US37E1-SPCLNAME)/this specialist], does [he/she/he
or she] seem to know enough information about [your/(SP)'s] medical history?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
SHOW CARD US4
When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], how often [do you/does
(SP)] have to repeat information that [you/(SP)] [have/has] already given to [(US5A
PROVIDER NAME)/the doctors or other health professionals at (US3A PROVIDER
NAME)]?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
SHOW CARD US4
(01) NEVER
The next questions ask about care [you/(SP)] received from the specialist [you/(SP)] saw most
(02) SOMETIMES
often since (TODAY'S MONTH AND YEAR-12 MONTHS) outside the [office of (US5A
(03) USUALLY
PROVIDER NAME)/the doctors or other health professionals at (US3A PROVIDER
(04) ALWAYS
NAME)].
(-8) Don't Know
(-9) Refused
When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], how often does [he/she/he
or she] seem to know [your/(SP)'s] important test results from other providers?
(01) YES
After [your/(SP)'s] most recent hospital stay, did [(US5A PROVIDER NAME)/the medical
(02) NO
providers at (US3A PROVIDER NAME)] contact [you/(SP)] to see how [you were/(SP) was]
(-8) DON'T KNOW
doing?
(-9) REFUSED
(01) YES
(02) NO
After [your/(SP)'S] most recent hospital stay, [were you/was (SP)] prescribed any medicines?
(-8) DON'T KNOW
(-9) REFUSED
After (your/(SP)'s)] most recent hospital stay, did [(US5A PROVIDER NAME)/the medical
providers at (US3A PROVIDER NAME)] contact [you/SP] to check if [you were/(SP) was]
able to follow instructions about any medicines [you were/(SP) was] prescribed?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
After (your/(SP)'s] most recent hospital stay, (were you/was (SP)] given instructions about
caring for [yourself/themself] at home?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
SHOW CARD US5
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
After [your/(SP)'s] most recent hospital stay, were the instructions [you were/(SP) was] given
(03) NO
easy to understand?
(-8) DON'T KNOW
(-9) REFUSED
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
SHOW CARD US7
(00) 0 HARD TO MANAGE
(01) 1
People sometimes need to manage their medical care by making appointments with multiple
(02) 2
providers, following their instructions, and taking medicines as prescribed.
(03) 3
(04) 4
Using any number from 0 to 10, where 0 is hard and 10 is easy, what number would you use
(05) 5
to rate how easy it was for [you/(SP)] to manage [your/(SP)'s] medical care since (TODAY'S
(06) 6
MONTH AND YEAR-12 MONTHS)?
(07) 7
(08) 8
[IN SITUATIONS WHERE A PROXY OR SOMEONE ELSE MANAGES THE
(09) 9
RESPONDENT’S MEDICAL CARE FOR OR WITH THEM, ANSWER BASED ON
(10) 10 EASY TO MANAGE
THEIR EXPERIENCE.]
Since (TODAY'S MONTH AND YEAR-12 MONTHS), when getting care for a medical
problem, was there ever a time when test results, medical records, or reasons for referrals
were not available at the time of [your/(SP)’s] scheduled doctor or other health professional
appointment?
(01) YES
(02) NO
(03) NOT APPLICABLE
(04) NOT SURE
(-9) Refused
The next few questions will help us understand how [(US5A PROVIDER NAME)/the doctors
or other health professionals at (US3A PROVIDER NAME)] use(s) a computer during
(01) YES
[your/(SP)'s] office visit. Please answer the following questions based on where [you go/(SP)
(02) NO
goes] for medical care most of the time.
(-8) Don't Know
(-9) Refused
[Does (US5A PROVIDER NAME)/Do the providers at (US3A PROVIDER NAME)] use a
computer during [your/(SP)'s] office visit?
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
Many health care providers are beginning to use electronic or computer-based medical records
instead of using paper-based records. When [you visit/(SP) visits] [(US5A PROVIDER
NAME)/the doctors or other health professionals at (US3A PROVIDER NAME)] [does he or
she/do they] generally enter [your/(SP)'s] health information into a computer while [you
are/(SP) is] present?
(01) YES
(02) NO
[IF SUPPORT STAFF (NURSES, MEDICAL ASSISTANTS) ENTER INFORMATION
INTO THE ELECTRONIC HEALTH RECORD DURING THEIR VISIT, SELECT “YES” (-8) Don't Know
AT THIS QUESTION.]
(-9) Refused
[EXPLAIN IF NECESSARY: An “electronic health record” is an electronic version of a
patient’s medical history maintained by a provider over time. It automates the way in which
doctors can access patient health information. "Health Information" includes information such
as symptoms, vital signs, test results, or prescribed medicines.]
(01) YES
Is the examination room set up so that [(US5A PROVIDER NAME)/the doctors or other
(02) NO
health professionals at (US3A PROVIDER NAME)] can easily show [you/(SP)] information
(-8) Don't Know
on the computer screen?
(-9) Refused
[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A
PROVIDER NAME)] use the computer to show [you your/(SP) their] health information
during [your/(SP)'s] visit, such as trends in blood pressure reading, height, weight and body
mass index, previous lab results, x-rays/images, immunizations or medications?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A
PROVIDER NAME)] use the computer to show [you/(SP)] recommendations for preventive
health screenings or other medical services?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A
PROVIDER NAME)] read back to [you/(SP)] information that [you have/(SP) has] given
during [your/(SP)'s] visit that is being put into [your/(SP)'s] medical record?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Does (US5A PROVIDER NAME)/Do the doctors or other health professionals at (US3A
PROVIDER NAME)] send [you/(SP)] health information electronically, such as information
about [your/(SP)'s] medications, exercise plans, dietary advice, etc.?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
[Does (US5A PROVIDER NAME)'s/Do the doctors or other health professionals at (US3A
PROVIDER NAME)'s] office give [you/(SP)] access through [your/(SP)'s] own computer or
smart phone to parts or all of [your/(SP)'s] electronic medical record (such as a list of
[your/(SP)'s] medications, lab results, x-ray reports, office notes) through a “patient portal” or
other electronic system?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
SHOW CARD US6
Now I am going to read some statements people have made about how their provider uses a
computer. Think about the care [you receive/(SP) receives] from (US5A PROVIDER
NAME/US3A PROVIDER NAME). For each statement, please tell me whether you strongly
agree, agree, disagree, or strongly disagree.
(US5A PROVIDER NAME)'s/The doctors or other health professionals at (US3A
PROVIDER NAME) use of the computer during [my/(SP)'s] visit is helpful to [me/(SP)].
SHOW CARD US6
(US5A PROVIDER NAME)'s/The doctors or other health professionals at (US3A
PROVIDER NAME) use of the computer during [my/(SP)'s] visit distracts [him/her/them]
from paying attention to [me/(SP)].
SHOW CARD US6
[(US5A PROVIDER NAME)'s/The doctors or other health professionals at (US3A
PROVIDER NAME)] use of the computer during [my/(SP)'s] visit distracts [me/(SP)] from
paying attention to the clinician.
SHOW CARD US8
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
(01) STRONGLY AGREE
(02) AGREE
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
(01) Much more than it should be
For the next statement, please tell me if it's much more than it should be, somewhat more than (02) Somewhat more than it should be
it should be, about what it should be, somewhat less than it should be, much less than it
(03) About what it should be
should be, or no opinion?
(04) Somewhat less than it should be
(05) Much less than it should be
The amount of time during the visit that (US5A PROVIDER NAME)/the doctors or other
(06) No opinion
health professionals at (US3A PROVIDER NAME) spend(s) on the computer seems:
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Revision: Usual Source of Care
Section
USQ:
Winter Round
Effect on
Annual
Burden
N/A
Question Text
Response Options
Why is [your/(SP’s)] usual source of health care no longer available?
(01) PREVIOUS DOCTOR RETIRED
(02) PREVIOUS DOCTOR DIED
(03) PREVIOUS DOCTOR MOVED
(04) SP MOVED
(05) PREVIOUS DR/PLACE TOO FAR AWAY
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
Is your [your/(SP)'s] provider a physician or medical doctor (MD), doctor of osteopathy
(DO), physician's assistant (PA), or nurse practicioner?
[Does [your/(SP)'s] provider/Do the providers at [your/(SP)'s] usual source of care] speak
[LANGUAGE SPOKEN AT HOME/[your/(SP)'s] preferred language]?
(01) PHYSICIAN/MEDICAL DOCTOR (MD)
(02) DOCTOR OF OSTEOPATHY (DO)
(03) PHYSICIAN'S ASSISTANT (PA)
(04) NURSE PRACTITIONER
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
[Have you/Has (SP)] ever had a problem understanding a medical situation because it was not (02) NO
explained in [LANGUAGE SPOKEN AT HOME/[your/(SP)'s] preferred language]?
(-8) DON’T KNOW
(-9) REFUSED
About how long does it usually take for [you/(SP)] to get to [[your/their] provider's
office/[your/their] usual source of care]?
Who usually goes with [you/(SP)]?
[PROBE: Is that person a spouse, a child, an other family member, a friend, a home health
aide or home care worker, or a homemaker or house cleaner?]
What are the reasons [this person accompanies you/this person accompanies (SP)]?
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.
(01) HOURS ONLY
(02) MINUTES ONLY
(03) HOURS AND MINUTES
(-8) DON'T KNOW
(-9) REFUSED
(01) SPOUSE
(02) CHILD
(03) OTHER FAMILY MEMBER
(04) FRIEND
(05) HOME HEALTH AIDE/HOME CARE WORKER
(06) HOMEMAKER/HOUSE CLEANER
(-8) Don't Know
(-9) Refused
(01) WRITES DOWN WHAT DOCTOR
SAYS/RECORDS INSTRUCTIONS/TAKES
NOTES/REMEMBERS
(02) GIVES INFORMATION/EXPLAINS SP'S
MEDICAL CONDITION OR NEEDS TO THE
DOCTOR
(03) EXPLAINS DOCTOR’S INSTRUCTIONS TO SP
(04) ASKS QUESTIONS
(05) TRANSLATES LANGUAGE
(06) SCHEDULES APPOINTMENTS
(07) NOTHING/KEEPS SP COMPANY/SITS WITH
SP/MORAL SUPPORT
(08) TRANSPORTATION
(09) SP NEEDS PHYSICAL ASSISTANCE
(91) OTHER
(-8) DON'T KNOW
[Have you/Has (SP)] seen [[your/their] provider/[your/their] usual source of care] in the last
12 months?
(01) YES
(02) NO
[IF NEEDED: This question is referring to the care provider [you/(SP)] usually saw in the last
(-8) DON’T KNOW
12 months.]
(-9) REFUSED
INCLUDE TELEMEDICINE VISITS.
SHOW CARD US4
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [[your/(SP)'s]
provider/the medical providers at [your/(SP)'s] usual source of care] ask about things in
[your/(SP)'s] work or life at home that affect [your/their] health?
SHOW CARD US4
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [[your/(SP)'s]
provider/the medical providers at [your/(SP)'s] usual source of care] explain things in a way
that was easy [for (SP)] to understand?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
SHOW CARD US4
Since (TODAY'S MONTH AND YEAR-12 MONTHS), how often did [[your/(SP)'s]
provider/the medical providers at [your/(SP)'s] usual source of care] listen carefully to
[you/(SP)]?
SHOW CARD US5
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [[your/(SP)'s] provider/the
medical providers at [your/(SP)'s] usual source of care]] talk with [you/(SP)] about setting
goals for [your/their] health?
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
Response Options
(01) NEVER
(02) SOMETIMES
(03) USUALLY
(04) ALWAYS
(-8) Don't Know
(-9) Refused
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
(03) NO
(-8) DON'T KNOW
(-9) REFUSED
SHOW CARD US1
Specialists are doctors or other health professionals who specialize in one area of health care. (01) YES
This card lists some examples of specialists.
(02) NO
(-8) DON'T KNOW
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] receive care from
(-9) REFUSED
any specialists outside the office of [[your/(SP)'s] provider/the doctors or other health
professionals at [your/(SP)'s] usual source of care]]?
(01) NEVER
(02) SOMETIMES
(03) USUALLY
In general, how often [does [your/(SP)'s] provider/do the doctors or other health professionals
(04) ALWAYS
at [your/(SP)'s] usual source of care] seem informed and up-to-date about the care [you
(-8) Don't Know
get/(SP) gets] from specialists?
(-9) Refused
SHOW CARD US4
SHOW CARD US5
(01) YES, DEFINITELY
After [your/(SP)'s] most recent hospital stay, did [[your/(SP)'s] provider/the medical providers (02) YES, SOMEWHAT
at [your/(SP)'s] usual source of care] seem to know the important information about this
(03) NO
hospital stay?
(-8) DON'T KNOW
(-9) REFUSED
[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] need help from
[anyone in [your/their] provider's office/the doctors or other health professionals at
[your/their] usual source of care] to manage [your/their] care among these different providers
and services?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
SHOW CARD US5
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [you/(SP)] get the help
(03) NO
[you/they] needed from [[your/their] provider's office/the doctors or other health professionals
(-8) DON'T KNOW
at [your/their] usual source of care] to manage [your/their] care among these different
(-9) REFUSED
providers and services?
Deletion: Physical Measures Collection
PXQ: Summer
Round
Decrease of
IS THIS INTERVIEW BEING CONDUCTED IN-PERSON OR OVER THE PHONE?
1 minute
(01) IN-PERSON
(02) PHONE
IF R IS IN A WHEELCHAIR OR CANNOT STAND, SELECT "R CANNOT
PARTICIPATE" WITHOUT READING TEXT BELOW.
Now I am going to ask you to do a few simple activities. Researchers are
interested in how performance on these activities relates to some of the other factors I
have asked you about in the interview.
(01) CONTINUE
(02) R CANNOT PARTICIPATE (IN WHEELCHAIR,
I will ask you to do these activities: height and weight measurements, a balance test, a walking CAN’T STAND)
test, a standing test, and a grip strength test.
(03) R NOT SELECTED FOR PXQ
My primary concern is for your safety, so I will ask you if you feel it would be safe for
you to complete each activity. I will describe these measurements and ask if you would feel
comfortable and safe completing each of the measurements. We will then complete the
measurements one after the other.
Let's start by measuring your height.
I will ask you to stand up straight against the wall with your feet together. Then, I will mark
your height on the wall using a sticky note and ask you to step away. I will then measure from
the sticky note to the floor.
(01) CONTINUE
(02) R CANNOT OR WILL NOT PARTICIPATE
Is there any reason why you feel you cannot participate?
[IF R REFUSES TO ATTEMPT THE MEASURE, SELECT R CANNOT OR WILL NOT
PARTICIPATE]
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
RECORD HEIGHT TO THE NEAREST HALF-INCH.
[HEIGHT MUST BE RECORDED IN INCHES]
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED.
[IF THE RESPONDENT REFUSED TO ATTEMPT THE MEASURE, SELECT
"REFUSED."]
WHAT IS THE PRIMARY REASON THE RESPONDENT CANNOT OR WILL NOT
PARTICIPATE IN THIS MEASURE?
Response Options
(01) continuous answer
(996) TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE
MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R FELT UNSAFE DUE TO
COVID-19
(07) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) Continuous answer
Now, we will measure your weight.
I will ask you to stand on the scale and stand still. Once I have recorded the weight, I will ask
you to step off of the scale.
Is there any reason why you feel you cannot participate?
(01) CONTINUE
(02) R CANNOT OR WILL NOT PARTICIPATE
[IF R REFUSES TO ATTEMPT THE MEASURE, SELECT R CANNOT OR WILL NOT
PARTICIPATE]
RECORD WEIGHT TO THE NEAREST TENTH OF A POUND
(01) continuous answer
(02) R OVER SCALE MAXIMUM
(996) TEST COULD NOT BE COMPLETED
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED.
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE
MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R FELT UNSAFE DUE TO
COVID-19
(07) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
WHAT IS THE PRIMARY REASON THE RESPONDENT CANNOT OR WILLNOT
PARTICIPATE IN THIS MEASURE?
(01) Continuous answer
Next I am going to ask you to do a few simple activities for me, starting with a balance
measure. Let me first demonstrate this measure. After I demonstrate the measure, please tell
me if you cannot do a particular movement or if you feel it would be unsafe to try and do it.
[IF R REFUSES TO ATTEMPT THE MEASURE, SELECT R CANNOT OR WILL NOT
PARTICIPATE]
(01) CONTINUE
(02) R CANNOT OR WILL NOT PARTICIPATE
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
SHOW CARD PX1
DEMONSTRATE FIRST POSITION WHILE EXPLAINING POSITION
STAND WITH FEET TOGETHER, SIDE-BY-SIDE FOR 10 SECONDS
TRY NOT TO MOVE YOUR FEET
TRY TO HOLD THIS POSITION UNTIL I TELL YOU TO STOP
ASK R TO STAND IN FIRST POSITION
ONCE R IS IN POSITION, SAY ‘BEGIN’ AND START TIMING
TIME THE FIRST POSITION
PUSH ‘START’ BUTTON WHEN YOU SAY ‘BEGIN’
PUSH ‘STOP/RESET’ BUTTON AND SAY ‘STOP’ AFTER 10 SECONDS, OR
PUSH ‘STOP/RESET’ BUTTON IF RESPONDENT STEPS OUT OF THE POSITION
BEFORE 10 SECONDS
(01) NUMBER OF SECONDS HELD: _____
[996] TEST COULD NOT BE COMPLETED
WHEN R IS IN FIRST POSITION:
Are you ready?
WHEN R IS READY, PUSH ‘START’ AND SAY:
Begin
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE
MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R FELT UNSAFE DUE TO
COVID-19
(07) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) [Continuous answer]
SHOW CARD PX2
DEMONSTRATE SECOND POSITION WHILE EXPLAINING POSITION
STAND WITH THE HEEL OF ONE FOOT TOUCHING THE SIDE OF THE BIG
TOE OF THE OTHER FOOT FOR 10 SECONDS
TRY NOT TO MOVE YOUR FEET
TRY TO HOLD THIS POSITION UNTIL I TELL YOU TO STOP
ASK R TO STAND IN SECOND POSITION
ONCE R IS IN POSITION, SAY ‘BEGIN’ AND START TIMING
TIME THE SECOND POSITION
PUSH ‘START’ BUTTON WHEN YOU SAY ‘BEGIN’
PUSH ‘STOP/RESET’ BUTTON AND SAY ‘STOP’ AFTER 10 SECONDS, OR
PUSH ‘STOP/RESET’ BUTTON IF RESPONDENT STEPS OUT OF THE POSITION
BEFORE 10 SECONDS
(01) NUMBER OF SECONDS HELD: _____
[996] TEST COULD NOT BE COMPLETED
WHEN R IS IN SECOND POSITION:
Are you ready?
WHEN R IS READY, PUSH ‘START’ AND SAY:
Begin
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE
MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R FELT UNSAFE DUE TO
COVID-19
(07) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) [Continuous answer]
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
SHOW CARD PX3
DEMONSTRATE THIRD POSITION WHILE EXPLAINING POSITION
STAND WITH THE HEEL OF ONE FOOT IN FRONT OF AND TOUCHING THE
TOES OF THE OTHER FOOT FOR 10 SECONDS
TRY NOT TO MOVE YOUR FEET
TRY TO HOLD THIS POSITION UNTIL I TELL YOU TO STOP
ASK R TO STAND IN THIRD POSITION
ONCE R IS IN POSITION, SAY ‘BEGIN’ AND START TIMING
TIME THE THIRD POSITION
PUSH ‘START’ BUTTON WHEN YOU SAY ‘BEGIN’
PUSH ‘STOP/RESET’ BUTTON AND SAY ‘STOP’ AFTER 10 SECONDS, OR
PUSH ‘STOP/RESET’ BUTTON IF RESPONDENT STEPS OUT OF THE POSITION
BEFORE 10 SECONDS
(01) NUMBER OF SECONDS HELD: _____
[996] TEST COULD NOT BE COMPLETED
WHEN R IS IN THIRD POSITION:
Are you ready?
WHEN R IS READY, PUSH ‘START’ AND SAY:
Begin
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE
MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R FELT UNSAFE DUE TO
COVID-19
(07) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) [Continuous answer]
Now I am going to observe how you normally walk. If you use a cane or other walking aid
and you feel you need it to walk a short distance, then you may use it. First, let me
demonstrate this measure.
After I demonstrate the measure, please tell me if you cannot do a particular movement or if
you feel it would be unsafe to try and do it.
(01) CONTINUE
(02) R CANNOT OR WILL NOT PARTICIPATE
[IF R REFUSES TO ATTEMPT THE MEASURE, SELECT R CANNOT OR WILL NOT
PARTICIPATE]
USE PRE-CUT STRING TO MEASURE DISTANCE ON THE FLOOR
DEMONSTRATE THE WALK WHILE PROVIDING INSTRUCTIONS
STAND WITH TOES TOUCHING THE BEGINNING OF THE STRING
START WALKING WHEN I SAY BEGIN
WALK AT YOUR USUAL PACE
WALK PAST THE END OF THE STRING BEFORE YOU STOP
ALLOW R TO USE HIS/HER WALKING AID (CANE OR WALKER)
ASK R TO STAND AT BEGINNING OF STRING
When I say “Begin” you may start walking.
PUSH ‘START’ AND SAY:
‘Begin’
PUSH ‘STOP/RESET’ WHEN ONE OF R’S FEET IS COMPLETELY ACROSS THE
OTHER END OF THE STRING
(01) ABLE TO DO (SPECIFY SECONDS): ______
[996] TEST COULD NOT BE COMPLETED
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE
MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R FELT UNSAFE DUE TO
COVID-19
(07) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) [Continuous answer]
ASK RESPONDENT TO REPEAT WALK, FROM THE END OF THE STRING BACK
TO THE BEGINNING OF THE STRING
When I say “Begin” you may start walking.
PUSH ‘START/STOP’ AND SAY:
‘Begin’
(01) ABLE TO DO (SPECIFY SECONDS): ______
[996] TEST COULD NOT BE COMPLETED
PUSH ‘STOP/RESET’ WHEN ONE OF R’S FEET IS COMPLETELY ACROSS THE
OTHER END OF THE STRING
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE
MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R FELT UNSAFE DUE TO
COVID-19
(07) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) [Continuous answer]
RECORD YOUR OBSERVATIONS OF THE R'S MEASURE. CHECK ALL THAT
APPLY.
(01) R WALKED UNSTEADILY
(02) R LIMPED, SHUFFLED OR DRAGGED A LEG
(03) R USED A CANE
(04) R USED WALKER
(05) R STATED IT’S PAINFUL
(06) NOTHING APPLIES
Now I am going to ask you to stand up from a chair without using your arms. First, let me
demonstrate this measure. After I demonstrate the measure, please tell me if you cannot do
this movement or if you feel it would be unsafe to try.
[IF R REFUSES TO ATTEMPT THE MEASURE, SELECT R CANNOT OR WILL NOT
PARTICIPATE]
(01) CONTINUE
(02) R CANNOT OR WILL NOT PARTICIPATE
DEMONSTRATE CHAIR STAND WHILE PROVIDING INSTRUCTIONS
SIT IN CHAIR WITH YOUR FEET ON THE FLOOR. SIT SO THAT YOU CAN
PLACE THE WIDTH OF YOUR HANDS BETWEEN THE CHAIR AND YOUR KNEES.
(01) R STOOD WITHOUT USING ARMS
FOLD YOUR ARMS ACROSS YOUR CHEST
[996] TEST COULD NOT BE COMPLETED
STAND UP, KEEPING YOUR ARMS FOLDED ACROSS YOUR CHEST
When I say ‘Begin’ you may stand up straight from the chair.
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE
MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R FELT UNSAFE DUE TO
COVID-19
(07) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) [Continuous answer]
Now I'm going to ask you to stand up and sit down as quickly as you can five times, keeping
your arms folded across your chest. I'm going to demonstrate one for you.
(01) CONTINUE
DEMONSTRATE 1 CHAIR STAND WHILE PROVIDING INSTRUCTIONS
SIT IN CHAIR WITH YOUR FEET ON THE FLOOR
FOLD YOUR ARMS ACROSS YOUR CHEST
STAND UP AND SIT DOWN ONCE
TELL R TO REPEAT THAT 4 MORE TIMES
When I say “Begin” you may stand up.
PUSH ‘START’ AND SAY ‘Begin’
(01) TIME TO COMPLETE FIVE STANDS (SPECIFY
SECONDS): ______
[996] TEST COULD NOT BE COMPLETED
COUNT OUT LOUD AS RESPONDENT ARISES EACH TIME
PUSH ‘STOP/RESET’ WHEN R HAS COMPLETELY STOOD UP FROM THE CHAIR
FOR THE 5TH TIME
STOP THE EXERCISE EARLY IF R CANNOT RISE WITHOUT USING ARMS, R IS
TOO TIRED TO CONTINUE, OR R IS UNABLE TO COMPLETE AFTER 1 MINUTE
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE
MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R FELT UNSAFE DUE TO
COVID-19
(07) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) [Continuous answer]
IF R IS MISSING BOTH OF THEIR HANDS, SELECT "R CANNOT PARTICIPATE"
WITHOUT READING TEXT BELOW.
Now I would like to assess the strength of your hand in a gripping action.
(01) CONTINUE
(02) R CANNOT PARTICIPATE (MISSING BOTH
HANDS)
(01) R IS MISSING RIGHT HAND
IF R IS OBVIOUSLY MISSING ONE HAND, SELECT WHICH HAND IS MISSING. IF
(02) R IS MISSING LEFT HAND
R IS NOT OBVIOUSLY MISSING A HAND, SELECT "CONTINUE"
(03) CONTINUE
IF SP IS OBVIOUSLY MISSING A HAND OR ARM, SELECT THE REMAINING
HAND AND DO NOT ASK. OTHERWISE, ASK:
Which is your dominant hand?
[If Needed: Which hand do you use to hold a pencil?]
(01) Right
(02) Left
(03) Both hands equally dominant
(-8) DON'T KNOW
(-9) REFUSED
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
Now we will measure your grip strength
We will use this machine [SHOW DYNAMOMETER] to measure how strong your hands
are.
You will squeeze the handle 2 times [per hand], one practice and one test trial, while your arm (01) CONTINUE
is at your side and your elbow is bent like this [DEMONSTRATE 90 DEGREES].
The handle won’t move, but the machine will show how hard you squeezed. [PRESS RESET
AND TEST, THEN SQUEEZE TO DEMONSTRATE].
See? [SHOW RESPONDENT THE FORCE MEASUREMENT].
SHOW CARD PX4
Let’s practice with your RIGHT hand.
Is there any reason why you feel you cannot participate with your right hand? The items on
this card list some examples of reasons why you should not participate.
IF RESPONDENT HAS ANY OF THE CONDITIONS LISTED ON SHOWCARD PX4
FOR THEIR RIGHT HAND, SELECT CONTINUE WITHOUT COMPLETING THE
PRACTICE TRIAL
When I say ‘squeeze,’ I want you to squeeze the handle hard, but not as hard as you can.
(01) CONTINUE
[If Needed: We are starting with the right hand, even if you are not right handed.]
[SUPPORT DYNAMOMETER DURING PRACTICE]
Ready? 3-2-1-squeeze. [HOLD FOR 3-4 SECONDS]
Stop.
[PRESS RESET AND TEST ON DYNAMOMETER BEFORE CONTINUING]
SHOW CARD PX4
Let’s practice with your LEFT hand.
Is there any reason why you feel you cannot participate with your left hand? The items on this
card list some examples of reasons why you should not participate.
IF RESPONDENT HAS ANY OF THE CONDITIONS LISTED ON SHOWCARD PX4
FOR THEIR LEFT HAND, SELECT CONTINUE WITHOUT COMPLETING THE
PRACTICE TRIAL
(01) CONTINUE
When I say ‘squeeze,’ I want you to squeeze the handle hard, but not as hard as you can.
[SUPPORT DYNAMOMETER DURING PRACTICE.]
Ready? 3-2-1-squeeze. [HOLD FOR 3-4 SECONDS]
Stop.
[PRESS RESET AND TEST ON DYNAMOMETER BEFORE CONTINUING]
IF RESPONDENT HAS ANY OF THE CONDITIONS LISTED ON SHOWCARD PX4
FOR THEIR RIGHT HAND, SELECT "TEST COULD NOT BE COMPLETED"
WITHOUT CONDUCTING THE TEST
Now we’re going to test your RIGHT hand. When I say ‘squeeze,’ this time I want you to
squeeze the handle as hard as you can.
[SUPPORT DYNAMOMETER DURING TEST]
Ready? 3-2-1-squeeze! Harder, harder, harder! [HOLD FOR 3-4 SECONDS]
Stop.
[RECORD FORCE TO NEAREST TENTH OF A POUND]
[PRESS RESET AND TEST ON DYNAMOMETER]
(01) continuous answer
(996) TEST COULD NOT BE COMPLETED
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Response Options
REASON WHY CANNOT BE COMPLETED FOR RIGHT HAND
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE
MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R FELT UNSAFE DUE TO
COVID-19
(07) NOT ATTEMPTED, R MET EXCLUSION
CRITERIA ON SHOWCARD
(08) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) [Continuous answer]
IF RESPONDENT HAS ANY OF THE CONDITIONS LISTED ON SHOWCARD PX4
FOR THEIR LEFT HAND, SELECT "TEST COULD NOT BE COMPLETED"
WITHOUT CONDUCTING THE TEST AND TURN OFF THE DYNAMOMETER.
Now we’re going to test your LEFT hand. When I say ‘squeeze,’ this time I want you to
squeeze the handle as hard as you can.
[SUPPORT DYNAMOMETER DURING TEST]
(01) continuous answer
(996) TEST COULD NOT BE COMPLETED
Ready? 3-2-1-squeeze! Harder, harder, harder! [HOLD FOR 3-4 SECONDS]
Stop.
[RECORD FORCE TO NEAREST TENTH OF A POUND]
[TURN OFF THE DYNAMOMETER]
Deletion: Site Follow-Up Questions
IMQ: Winter and
Summer Rounds
REASON WHY CANNOT BE COMPLETED FOR LEFT HAND
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE
MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) NOT ATTEMPTED, R FELT UNSAFE DUE TO
COVID-19
(07) NOT ATTEMPTED, R MET EXCLUSION
CRITERIA ON SHOWCARD
(08) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) [Continuous answer]
Net decrease
of 0.5
Where did [you/(SP)] go for [your/(SP)'s] Shingles vaccine?
minutes
OTHER (SPECIFY)
(01) PHARMACY/DRUG STORE
(02) DOCTORS OFFICE OR GROUP PRACTICE
(03) CLINIC (MEDICAL
CLINIC/NEIGHBORHOOD/FAMILY HEALTH
CENTER/RURAL HEALTH CLINIC/COMPANY
CLINIC/WORKPLACE)
(04) HOSPITAL/WALK-IN URGENT CENTER
(05) VA FACILITY
(06) COMMUNITY SITE (HEALTH FAIR/SHOPPING
MALL/CHURCH/SCHOOL/LIBRARY)
(07) AT HOME
(08) SENIOR CENTER
(91) OTHER, SPECIFY
(-8) DON'T KNOW
(-9) REFUSED
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Where did [you/(SP)] go for [your/(SP)'s] pneumonia shot?
Response Options
(01) PHARMACY/DRUG STORE
(02) DOCTORS OFFICE OR GROUP PRACTICE
(03) CLINIC (MEDICAL
CLINIC/NEIGHBORHOOD/FAMILY HEALTH
CENTER/RURAL HEALTH CLINIC/COMPANY
CLINIC/WORKPLACE)
(04) HOSPITAL/WALK-IN URGENT CENTER
(05) VA FACILITY
(06) COMMUNITY SITE (HEALTH FAIR/SHOPPING
MALL/CHURCH/SCHOOL/LIBRARY)
(07) AT HOME
(08) SENIOR CENTER
(91) OTHER, SPECIFY
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
Where did [you/(SP)] go for [your/(SP)'s] RSV vaccine?
(01) PHARMACY/DRUG STORE
(02) DOCTORS OFFICE OR GROUP PRACTICE
(03) CLINIC (MEDICAL
CLINIC/NEIGHBORHOOD/FAMILY HEALTH
CENTER/RURAL HEALTH CLINIC/COMPANY
CLINIC/WORKPLACE)
(04) HOSPITAL/WALK-IN URGENT CENTER
(05) VA FACILITY
(06) COMMUNITY SITE (HEALTH FAIR/SHOPPING
MALL/CHURCH/SCHOOL/LIBRARY)
(07) AT HOME
(08) SENIOR CENTER
(91) OTHER, SPECIFY
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
Where did [you/(SP)] go for [your/(SP)'s] flu vaccine?
(01) PHARMACY/DRUG STORE
(02) DOCTORS OFFICE OR GROUP PRACTICE
(03) CLINIC (MEDICAL
CLINIC/NEIGHBORHOOD/FAMILY HEALTH
CENTER/RURAL HEALTH CLINIC/COMPANY
CLINIC/WORKPLACE)
(04) HOSPITAL/WALK-IN URGENT CENTER
(05) VA FACILITY
(06) COMMUNITY SITE (HEALTH FAIR/SHOPPING
MALL/CHURCH/SCHOOL/LIBRARY)
(07) AT HOME
(08) SENIOR CENTER
(91) OTHER, SPECIFY
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
Revision: Site Follow-Up Questions
IMQ: Winter and
Summer Rounds
What is the main reason didn't [you/(SP)] get a Shingles vaccine?
N/A
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.
(01) WORRIED ABOUT SIDE EFFECTS/ALLERGIC
TO INGREDIENTS IN VACCINE/MEDICAL
REASON FOR NOT GETTING VACCINE
(02) VACCINE IS NOT NEEDED OR NECESSARY
(03) FORGOT/TOO BUSY
(04) SHOT COULD BE PAINFUL/DON'T LIKE
NEEDLES
(05) COULDN'T AFFORD VACCINE/OTHER COSTRELATED CONCERNS
(06) INTEND TO GET VACCINE BUT HAVE NOT
YET GOTTEN IT
(07) PROVIDER DID NOT RECOMMEND VACCINE
(08) VACCINE NOT AVAILABLE/COULDN'T FIND
A PLACE OFFERING THE VACCINE
(09) DIFFICULTY MAKING AN
APPOINTMENT/TRANSPORTATION PROBLEMS
(10) DISEASE IS NOT SERIOUS
(11) DOESN'T TRUST THE GOVERNMENT
(-8) DON'T KNOW
(-9) REFUSED
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
What is the main reason didn't [you/(SP)] get a pneumonia shot?
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.
What is the main reason didn't [you/(SP)] get an RSV vaccine?
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.
What is the main reason didn't [you/(SP)] get a seasonal flu vaccine since July 1st?
The next questions are about coronavirus or COVID-19 vaccination. [Have you/Has (SP)]
had at least one dose of a COVID-19 vaccine?
Deletion: COVID-19
IMQ: Winter and Decrease of
IF NEEDED: Please include booster shots.
Summer Rounds 1 minute
IF NEEDED: This question is asking for the total number of COVID-19 vaccine doses that
[you have/(SP) has] received since the vaccine first became available in December 2020.
Response Options
(01) WORRIED ABOUT SIDE EFFECTS/ALLERGIC
TO INGREDIENTS IN VACCINE/MEDICAL
REASON FOR NOT GETTING VACCINE
(02) VACCINE IS NOT NEEDED OR NECESSARY
(03) FORGOT/TOO BUSY
(04) SHOT COULD BE PAINFUL/DON'T LIKE
NEEDLES
(05) COULDN'T AFFORD VACCINE/OTHER COSTRELATED CONCERNS
(06) INTEND TO GET VACCINE BUT HAVE NOT
YET GOTTEN IT
(07) PROVIDER DID NOT RECOMMEND VACCINE
(08) VACCINE NOT AVAILABLE/COULDN'T FIND
A PLACE OFFERING THE VACCINE
(09) DIFFICULTY MAKING AN
APPOINTMENT/TRANSPORTATION PROBLEMS
(10) DISEASE IS NOT SERIOUS
(11) DOESN'T TRUST THE GOVERNMENT
(-8) DON'T KNOW
(-9) REFUSED
(01) WORRIED ABOUT SIDE EFFECTS/ALLERGIC
TO INGREDIENTS IN VACCINE/MEDICAL
REASON FOR NOT GETTING VACCINE
(02) VACCINE IS NOT NEEDED OR NECESSARY
(03) FORGOT/TOO BUSY
(04) SHOT COULD BE PAINFUL/DON'T LIKE
NEEDLES
(05) COULDN'T AFFORD VACCINE/OTHER COSTRELATED CONCERNS
(06) INTEND TO GET VACCINE BUT HAVE NOT
YET GOTTEN IT
(07) PROVIDER DID NOT RECOMMEND VACCINE
(08) VACCINE NOT AVAILABLE/COULDN'T FIND
A PLACE OFFERING THE VACCINE
(09) DIFFICULTY MAKING AN
APPOINTMENT/TRANSPORTATION PROBLEMS
(10) DISEASE IS NOT SERIOUS
(11) DOESN'T TRUST THE GOVERNMENT
(-8) DON'T KNOW
(-9) REFUSED
(01) WORRIED ABOUT SIDE EFFECTS/ALLERGIC
TO INGREDIENTS IN VACCINE/MEDICAL
REASON FOR NOT GETTING VACCINE
(02) VACCINE IS NOT NEEDED OR NECESSARY
(03) FORGOT/TOO BUSY
(04) SHOT COULD BE PAINFUL/DON'T LIKE
NEEDLES
(05) COULDN'T AFFORD VACCINE/OTHER COSTRELATED CONCERNS
(06) INTEND TO GET VACCINE BUT HAVE NOT
YET GOTTEN IT
(07) PROVIDER DID NOT RECOMMEND VACCINE
(08) VACCINE NOT AVAILABLE/COULDN'T FIND
A PLACE OFFERING THE VACCINE
(09) DIFFICULTY MAKING AN
APPOINTMENT/TRANSPORTATION PROBLEMS
(10) DISEASE IS NOT SERIOUS
(11) DOESN'T TRUST THE GOVERNMENT
(91) OTHER
(-8) DON’T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
Since December 2020, how many COVID-19 vaccinations [have you/has (SP)] received in
total?
IF NEEDED: Please include booster shots and any additional doses.
IF NEEDED: This question is asking for the total number of COVID-19 vaccine doses that
[you have/(SP) has] received since the vaccine first became available in December 2020.
In [PREVIOUS YEAR], did [you/(SP)] receive at least one dose of the COVID-19 vaccine?
IF NEEDED: Please include booster shots.
Response Options
(01) 1 VACCINATION
(02) 2 VACCINATIONS
(03) 3 VACCINATIONS
(04) 4 OR MORE VACCINATIONS
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) NOT YET ELIGIBLE TO RECEIVE COVID-19
BOOSTER DOSE
(02) PLANS TO GET A BOOSTER AND IS
Why did [you/(SP)] not get a COVID-19 vaccine [in [PREVIOUS YEAR]]?
ELIGIBLE, BUT HASN'T YET
(03) THINKS THEY HAVE ENOUGH IMMUNITY TO
[PROBE: Any other reason?]
COVID-19 FROM PRIOR DOSES OF THE VACCINE
(04) NOT WORRIED ABOUT GETTING COVID-19
DO NOT READ ALOUD. CODE BASED ON WHAT THE RESPONDENT SAYS.
(10) DOCTOR HAS NOT RECOMMENDED IT
(05) ALREADY HAD COVID-19
CHECK ALL THAT APPLY.
(07) NOT REQUIRED TO GET A COVID-19
BOOSTER (BY WORK OR SCHOOL)
IF R IS NOT ELIGIBLE FOR THEIR NEXT DOSE, SELECT "NOT YET ELIGIBLE TO (08) EXPERIENCED SIDE EFFECTS FROM
RECEIVE COVID-19 BOOSTER DOSE."
PREVIOUS DOSE(S) OF THE COVID-19 VACCINE
(91) OTHER
(-8) DON’T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
In [PREVIOUS YEAR], [were you/was (SP)] tested at least one time to see whether [you
were/(SP) was] infected with COVID-19?
[IF NEEDED: For example, the test can be done by swabbing the nose or mouth. Some tests
can be done by yourself or by someone else at home, and some tests are done by a health
professional.]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS EVER
BEEN INFECTED WITH COVID-19.
What kind of test(s) did [you/(SP)] take? A nasal or throat swab or saliva test that was
collected or read by a health care professional, an at-home test that was read by
[yourself/(SP)] or a non-health care professional, or a blood test to look for COVID-19
antibodies?
SELECT ALL THAT APPLY
(01) NASAL OR THROAT SWAB OR SALIVA TEST
THAT WAS COLLECTED OR READ BY A HEALTH
CARE PROFESSIONAL
(02) AT-HOME TEST THAT WAS READ BY
[YOURSELF/(SP)] OR A NON-HEALTH CARE
PROFESSIONAL
(03) BLOOD TEST TO LOOK FOR COVID-19
ANTIBODIES
(-8) DON'T KNOW
(-9) REFUSED
Did the test(s) find that [you/(SP)] had COVID-19?
[IF NEEDED: If [you/(SP)] had more than one test in [PREVIOUS YEAR] to see whether
[you were/(SP) was] infected with COVID-19, answer yes if any of them were positive.]
INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS EVER
BEEN INFECTED WITH COVID-19.
In [PREVIOUS YEAR], did [you/(SP)] seek medical care for COVID-19?
(01) YES
(02) NO
(-8) DON’T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
MCBS Community Deletions and Revisions
Community Interview Deletions and
Revisions
Section
Effect on
Annual
Burden
Question Text
In [PREVIOUS YEAR], how often did [you/(SP)] wear a facemask when out in public?
Would you say none of the time, some of the time, most of the time, or all of the time?
The next questions are about coronavirus or COVID-19 vaccination.
Revision: COVID-19
IMQ: Winter and
Summer Rounds
N/A
Since July 1st, (ROUND YEAR MINUS 1), [have you/has (SP)] had a COVID-19
vaccination?
IF NEEDED: Please include booster shots.
What is the main reason [you/(SP)] did not get a COVID-19 vaccine [in [PREVIOUS
YEAR]]?
[PROBE: Any other reason?]
IF R IS NOT ELIGIBLE FOR THEIR NEXT DOSE, SELECT "NOT ELIGIBLE FOR
NEXT DOSE YET."
Response Options
(01) NONE OF THE TIME
(02) SOME OF THE TIME
(03) MOST OF THE TIME
(04) ALL OF THE TIME
(05) NOT APPLICABLE- R DOES NOT GET OUT
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) WORRIED ABOUT SIDE EFFECTS/ALLERGIC
TO INGREDIENTS IN VACCINE/MEDICAL
REASON FOR NOT GETTING VACCINE
(02) VACCINE IS NOT NEEDED OR NECESSARY
(03) FORGOT/TOO BUSY
(04) SHOT COULD BE PAINFUL/DON'T LIKE
NEEDLES
(05) COULDN'T AFFORD VACCINE/OTHER COSTRELATED CONCERNS
(06) INTEND TO GET VACCINE BUT HAVE NOT
YET GOTTEN IT
(07) PROVIDER DID NOT RECOMMEND VACCINE
(08) VACCINE NOT AVAILABLE/COULDN'T FIND
A PLACE OFFERING THE VACCINE
(09) DIFFICULTY MAKING AN
APPOINTMENT/TRANSPORTATION PROBLEMS
(10) DISEASE IS NOT SERIOUS
(11) DOESN'T TRUST THE GOVERNMENT
(91) OTHER
(-8) DON’T KNOW
(-9) REFUSED
MCBS Facility Deletions and Revisions
MCBS Revision to Current Clearance
Proposed Changes to Facility Interviews and Effect on Burden
Facility Interview Deletions and
Revisions
Section
Deletion: Immunization COVID-19
CV: Winter
Round
Effect on
Annual
Burden
Question Text
Decrease of I am now going to ask you some questions about COVID-19 vaccinations (SP) may have
0.25 minutes received.
Has (SP) received at least one dose of a COVID-19 vaccine?
[IF NEEDED: Please include booster shots.]
[IF NEEDED: This question is asking for the total number of COVID-19 vaccine doses that
(SP) has received since the vaccine first became available in December 2020. ]
How many COVID-19 vaccinations has (SP) received in total?
[IF NEEDED: Please include booster shots and any additional doses.]
[IF NEEDED: This question is asking for the total number of COVID-19 vaccine doses that
(SP) has received since the vaccine first became available in December 2020. ]
In (PREVIOUS YEAR), has (SP) received at least one dose of the COVID-19 vaccine?
[IF NEEDED: Please include booster shots.]
Revision: Immunization COVID-19
HS: Fall round
N/A
COVID-19 VACCINE
[3.0, O0250]
Is (SP's) COVID vaccination up to date?
Response Options
(01) CONTINUE
(00) NO
(01) YES
(-8) DON'T KNOW
(-9) REFUSED
(01) ONE VACCINATION
(02) TWO VACCINATIONS
(03) THREE VACCINATIONS
(04) FOUR OR MORE VACCINATIONS
(-8) DON'T KNOW
(-9) REFUSED
(00) NO
(01) YES
(-8) DON'T KNOW
(-9) REFUSED
(00) NO
(01) YES
(-8) DON'T KNOW
(-9) REFUSED
| File Type | application/pdf |
| Author | NORC |
| File Modified | 2025-09-29 |
| File Created | 2025-09-29 |