Survey Text

2021 2014 2007 2000
2020 2013 2006 1999
2019 2012 2005 1998
2018 2011 2004 1997
2017 2010 2003 1996
2016 2009 2002
2015 2008 2001
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2021

No questionnaire text is available for this sample.


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2020

No questionnaire text is available for this sample.


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2019

No questionnaire text is available for this sample.


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2018
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

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2017
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2016
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

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2015
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2014
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2013
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2012
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2011
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2010
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2009
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2008
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2007
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2006
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2005
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2004
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2003
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2002
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2001
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2000
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
1999
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
1998
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
1997
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
1996
Survey form view entire document:  text  image
EV04
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EV] [STR-DT] [END-DT]
IF DATES KNOWN, ENTER ALL EVENT DATES FOR THIS PERSON-PROVIDER PAIR WITH THE EVENT TYPE (EV).
IF DATES NOT KNOWN, ASK: When (were/was) (PERSON) admitted to and discharged from (PROVIDER)? Please tell me the dates of all stays between (START DATE) and (END DATE).
IF NECESSARY, PROBE: On what date did (PERSON) enter (PROVIDER)? On what date did (PERSON) leave (PROVIDER)?

IF STILL IN (PROVIDER), ENTER 95 IN MONTH FOR DISCHARGE DATE.
PROBE: Any other stays?
TO ADD, PRESS CTRL/A. TO DELETE, PRESS CTRL/D.
TO LEAVE, PRESS ESC.
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
[Enter Month,Day,Year-2] - [Enter Month,Day,Year-2] .....
----------------------------------------------------
ROSTER DEFINITION: THIS ITEM USES PERSON'S- MEDICAL-EVENTS-ROSTER TO COLLECT ALL EVENTS (DATE RANGES) THAT ARE EVENT TYPE HS OR EVENT TYPE IC, DEPENDING ON THE TYPE OF EVENT BEING ASKED ABOUT.
----------------------------------------------------
----------------------------------------------------
PERSON'S EVENT ROSTER BEHAVIOR SPECIFICATIONS:

1. THIS ROSTER WILL APPEAR BLANK WHEN DISPLAYED.
INTERVIEWER CAN ADD ANY NUMBER OF EVENTS AT THE ROSTER QUESTIONS (I.E., NO LIMIT TO THE NUMBER OF EVENTS).
2. INTERVIEWER CAN DELETE AN EVENT THAT WAS ENTERED ON THE SCREEN WHERE DELETE IS USED.
THAT IS, AS LONG AS THE INTERVIEWER HAS NOT LEFT THE SCREEN, SHE SHOULD BE ABLE TO DELETE AN EVENT ENTERED IN ERROR.
----------------------------------------------------
----------------------------------------------------
REF AND DK ARE ALLOWED IN THE DAY AND YEAR FIELDS BUT ARE DISALLOWED IN THE MONTH FIELD.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------