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
PM12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [STR-DT] [END-DT]
What is the name of the (next) pharmacy that filled the prescription(s) for [you/[PERSON]]?
[1. Pharmacy] [STREET ADDRESS] [CITY]
[2. Pharmacy] [STREET ADDRESS] [CITY]
[3. Pharmacy] [STREET ADDRESS] [CITY]
REF ................................... -7
DK .................................... -8
----------------------------------------------------
DISPLAY 'ADD PHARMACY' AND ?DELETE PHARMACY? BUTTONS AS OPTIONS ON THIS SCREEN.
----------------------------------------------------
----------------------------------------------------
IF ?ADD PHARMACY? IS SELECTED, GO TO PM14 (NOTE THAT PM14 IS ACTUALLY A POPUP ON PM12).
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH PM13
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
Title: RU_PHAR_1
COL #1 HEADER: PHARMACY INSTRUCTIONS: DISPLAY PHARMACY NAME (PHAR.PHARNAME)
COL #2 HEADER: STREET ADDRESS INSTRUCTIONS: DISPLAY TRUNCATED STREET ADDRESS (PHAR.PHARADR1)
COL #3 HEADER: CITY INSTRUCTIONS: DISPLAY TRUNCATED CITY (PHAR.PHARCITY)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-PHARMACIES-ROSTER FOR SELECTION/ADDITION.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SELECT ONE ALLOWED. INTERVIEWER MUST SELECT ONE ONLY FROM THE LIST OF PROVIDERS OR MAY SELECT ?ADD PHARMACY?
2. ADD ALLOWED.
3. EDITS ARE NOT ALLOWED.
4. LIMITED DELETE ALLOWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
DISPLAY ALL; NO FILTER.
----------------------------------------------------
----------------------------------------------------
NOTE: THE VARIABLE PLNK.ACTIVE IS SET TO THE CURRENT RU LETTER AND ROUND NUMBER FOR THE SELECTED PHARMACY IF THE PLNK WAS CREATED IN A PRIOR ROUND. THIS VARIABLE IS USED IN THE CLOSING SECTION.
----------------------------------------------------

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2017
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PM12
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [STR-DT] [END-DT]
What is the name of the (next) pharmacy that filled the prescription(s) for [you/[PERSON]]?
[1. Pharmacy] [STREET ADDRESS] [CITY]
[2. Pharmacy] [STREET ADDRESS] [CITY]
[3. Pharmacy] [STREET ADDRESS] [CITY]
REF ................................... -7
DK .................................... -8
----------------------------------------------------
DISPLAY 'ADD PHARMACY' AND ?DELETE PHARMACY? BUTTONS AS OPTIONS ON THIS SCREEN.
----------------------------------------------------
----------------------------------------------------
IF ?ADD PHARMACY? IS SELECTED, GO TO PM14 (NOTE THAT PM14 IS ACTUALLY A POPUP ON PM12).
----------------------------------------------------
----------------------------------------------------
OTHERWISE, CONTINUE WITH PM13
----------------------------------------------------
----------------------------------------------------
ROSTER DETAILS:
Title: RU_PHAR_1
COL #1 HEADER: PHARMACY INSTRUCTIONS: DISPLAY PHARMACY NAME (PHAR.PHARNAME)
COL #2 HEADER: STREET ADDRESS INSTRUCTIONS: DISPLAY TRUNCATED STREET ADDRESS (PHAR.PHARADR1)
COL #3 HEADER: CITY INSTRUCTIONS: DISPLAY TRUNCATED CITY (PHAR.PHARCITY)
----------------------------------------------------
----------------------------------------------------
ROSTER DEFINITION:
THIS ITEM DISPLAYS THE RU-PHARMACIES-ROSTER FOR SELECTION/ADDITION.
----------------------------------------------------
----------------------------------------------------
ROSTER BEHAVIOR:
1. SELECT ONE ALLOWED. INTERVIEWER MUST SELECT ONE ONLY FROM THE LIST OF PROVIDERS OR MAY SELECT ?ADD PHARMACY?
2. ADD ALLOWED.
3. EDITS ARE NOT ALLOWED.
4. LIMITED DELETE ALLOWED.
----------------------------------------------------
----------------------------------------------------
ROSTER FILTER:
DISPLAY ALL; NO FILTER.
----------------------------------------------------
----------------------------------------------------
NOTE: THE VARIABLE PLNK.ACTIVE IS SET TO THE CURRENT RU LETTER AND ROUND NUMBER FOR THE SELECTED PHARMACY IF THE PLNK WAS CREATED IN A PRIOR ROUND. THIS VARIABLE IS USED IN THE CLOSING SECTION.
----------------------------------------------------

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2016
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Disability Days (DD) Section

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2015
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Disability Days (DD) Section

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2014
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Disability Days (DD) Section

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2013
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Disability Days (DD) Section

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2012
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Disability Days (DD) Section

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2011
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Disability Days (DD) Section

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2010
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Disability Days (DD) Section

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2009
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Disability Days (DD) Section

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2008
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Disability Days (DD) Section

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2007
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Disability Days (DD) Section

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2006
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Disability Days (DD) Section

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2005
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Disability Days (DD) Section

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2004
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PM11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF PRESCRIPTION MEDICINE.] [STR-DT] [END-DT]
In what year did (PERSON) first use (MEDICINE)?
[Enter Year-4] ........................
HAS NOT YET TAKEN/USED ................ XX
REF ................................... -7
DK .................................... -8
----------------------------------------------------
IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV1
----------------------------------------------------
----------------------------------------------------
IF YEAR IS REFERENCE YEAR MINUS 1, GO TO PM11OV2
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO PM10
----------------------------------------------------

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2003
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PM11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF PRESCRIPTION MEDICINE.] [STR-DT] [END-DT]
In what year did (PERSON) first use (MEDICINE)?
[Enter Year-4] ........................
HAS NOT YET TAKEN/USED ................ XX
REF ................................... -7
DK .................................... -8
----------------------------------------------------
IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV1
----------------------------------------------------
----------------------------------------------------
IF YEAR IS REFERENCE YEAR MINUS 1, GO TO PM11OV2
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO PM10
----------------------------------------------------

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2002
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PM11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF PRESCRIPTION MEDICINE.] [STR-DT] [END-DT]
In what year did (PERSON) first use (MEDICINE)?
[Enter Year-4] ........................
HAS NOT YET TAKEN/USED ................ XX
REF ................................... -7
DK .................................... -8
----------------------------------------------------
IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV1
----------------------------------------------------
----------------------------------------------------
IF YEAR IS REFERENCE YEAR MINUS 1, GO TO PM11OV2
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO PM10
----------------------------------------------------

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2001
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PM11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF PRESCRIPTION MEDICINE.] [STR-DT] [END-DT]
In what year did (PERSON) first use (MEDICINE)?
[Enter Year-2] ........................
HAS NOT YET TAKEN/USED ................ 99
REF ................................... -7
DK .................................... -8
----------------------------------------------------
IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV1
----------------------------------------------------
----------------------------------------------------
IF YEAR IS REFERENCE YEAR MINUS 1, GO TO PM11OV2
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_02
----------------------------------------------------

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2000
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PM11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF PRESCRIPTION MEDICINE.] [STR-DT] [END-DT]
In what year did (PERSON) first use (MEDICINE)?
[Enter Year-2] ........................
HAS NOT YET TAKEN/USED ................ 99
REF ................................... -7
DK .................................... -8
----------------------------------------------------
IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV1
----------------------------------------------------
----------------------------------------------------
IF YEAR IS REFERENCE YEAR MINUS 1, GO TO PM11OV2
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_02
----------------------------------------------------

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1999
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PM11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF PRESCRIPTION MEDICINE.] [STR-DT] [END-DT]
In what year did (PERSON) first use (MEDICINE)?
[Enter Year-2] ........................
HAS NOT YET TAKEN/USED ................ 99
REF ................................... -7
DK .................................... -8
----------------------------------------------------
IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV1
----------------------------------------------------
----------------------------------------------------
IF YEAR IS REFERENCE YEAR MINUS 1, GO TO PM11OV2
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_02
----------------------------------------------------

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1998
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PM11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF PRESCRIPTION MEDICINE.] [STR-DT] [END-DT]
In what year did (PERSON) first use (MEDICINE)?
[Enter Year-2] ........................
HAS NOT YET TAKEN/USED ................ 99
REF ................................... -7
DK .................................... -8
----------------------------------------------------
IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV1
----------------------------------------------------
----------------------------------------------------
IF YEAR IS REFERENCE YEAR MINUS 1, GO TO PM11OV2
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_02
----------------------------------------------------

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1997
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PM11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF PRESCRIPTION MEDICINE.] [STR-DT] [END-DT]
In what year did (PERSON) first use (MEDICINE)?
[Enter Year-2] ........................
HAS NOT YET TAKEN/USED ................ 99
REF ................................... -7
DK .................................... -8
----------------------------------------------------
IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV1
----------------------------------------------------
----------------------------------------------------
IF YEAR IS REFERENCE YEAR MINUS 1, GO TO PM11OV2
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_02
----------------------------------------------------

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1996
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PM11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF PRESCRIPTION MEDICINE.] [STR-DT] [END-DT]
In what year did (PERSON) first use (MEDICINE)?
[Enter Year-2] ........................
HAS NOT YET TAKEN/USED ................ 99
REF ................................... -7
DK .................................... -8
----------------------------------------------------
IF YEAR IS REFERENCE YEAR, CONTINUE WITH PM11OV1
----------------------------------------------------
----------------------------------------------------
IF YEAR IS REFERENCE YEAR MINUS 1, GO TO PM11OV2
----------------------------------------------------
----------------------------------------------------
OTHERWISE, GO TO BOX_02
----------------------------------------------------