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
AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3 [AC06]
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2017
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor?s office, clinic, health center, or other place that [you/[PERSON]] usually [go/goes] if [you/he/she] [are/is] sick or [need/needs] advice about [your/his/her] health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3 [AC06]
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2016
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that [you/[PERSON]] usually [go/goes] if [you/he/she] [are/is] sick or [need/needs] advice about [your/his/her] health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3 [AC06]
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2015
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that [you/[PERSON]] usually [go/goes] if [you/he/she] [are/is] sick or [need/needs] advice about [your/his/her] health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3 [AC06]
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2014
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that [you/[PERSON]] usually [go/goes] if [you/he/she] [are/is] sick or [need/needs] advice about [your/his/her] health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3 [AC06]
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2013
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PV01
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV]
[[What is the name of the person or place that provided health care to [you/[PERSON]]?]]
INTERVIEWER: IS THE PROVIDER [ASSOCIATED WITH THIS EVENT] A PERSON OR A FACILITY (INCLUDING GROUP PRACTICES AND HMOs)?
[IF FACILITY NAMED, PROBE: If [you/[PERSON]] usually [see/sees] a particular person at this place, please give me the name of that person first.]
PERSON ................................. 1
FACILITY ............................... 2 [BOX_01]
HELP AVAILABLE FOR DEFINITION OF PERSON/FACILITY.
----------------------------------------------------
DISPLAY '[What is ... [you/[PERSON]]?]' AND 'ASSOCIATED WITH THIS EVENT' IF THE PROVIDER ROSTER (PV) SECTION WAS NOT CALLED FROM THE ACCESS TO CARE (AC) SECTION. IF THE PV SECTION WAS CALLED FROM THE AC SECTION, USE A NULL DISPLAY.

DISPLAY 'IF FACILITY NAMED, PROBE: ... person first.' IF THE PV SECTION WAS CALLED FROM THE AC SECTION. IF THE PV SECTION WAS NOT CALLED FROM THE AC SECTION, USE A NULL DISPLAY.
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----------------------------------------------------
IF CODED '1' (PERSON), SET PROVIDER TYPE TO 'PERSON-TYPE-PROVIDER'.
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----------------------------------------------------
IF CODED '2' (FACILITY), SET PROVIDER TYPE TO 'FACILITY-PROVIDER'.
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----------------------------------------------------
IF NO PERSON-PROVIDERS ON RU-MEDICAL-PROVIDERS- ROSTER AND PV01 IS CODED '1', THEN CREATE A NEW PROV RECORD.
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----------------------------------------------------
IF CODED '1' (PERSON) AND NO PROVIDERS THAT ARE TYPE 'PERSON-PROVIDER' ON RU-MEDICAL-PROVIDERS- ROSTER, GO TO PV04
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----------------------------------------------------
IF CODED '1' (PERSON) AND AT LEAST ONE PROVIDER THAT IS TYPE 'PERSON-PROVIDER' ON RU-MEDICAL- PROVIDERS-ROSTER, CONTINUE WITH PV02
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----------------------------------------------------
HARD CHECK: IF EVENT TYPE IS HS, ER, OP, OR IC, PV01 CANNOT BE CODED '1' (PERSON). IF PV01 IS CODED '1' (PERSON) FOR AN HS, ER, OP, OR IC EVENT,THE ERROR HANDLER WILL FORCE THE INTERVIEWER TO RECTIFY THE DATA.
----------------------------------------------------

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2012
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that [you/[PERSON]] usually [go/goes] if [you/he/she] [are/is] sick or [need/needs] advice about [your/his/her] health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3 [AC06]
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2011
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3 [AC06]
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2010
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3 [AC06]
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2009
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3 [AC06]
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2008
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3 [AC06]
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
HELP AVAILABLE FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2007
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AC05
===

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
PRESS F1 FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2006
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
PRESS F1 FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2005
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor?s office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)?s health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
PRESS F1 FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2004
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
PRESS F1 FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2003
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2002
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Is there a particular doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health?
YES ..................................... 1 [AC09]
NO ...................................... 2 [AC07]
MORE THAN ONE PLACE ..................... 3
REF ..................................... -7 [END_LP01]
DK ...................................... -8 [END_LP01]
[Code One]
PRESS F1 FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2001
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Please give me the name of the medical person, doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health.
PRESS ENTER TO CONTINUE.
PRESS F1 FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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2000
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Please give me the name of the medical person, doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health.
PRESS ENTER TO CONTINUE.
PRESS F1 FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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1999
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Please give me the name of the medical person, doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health.
PRESS ENTER TO CONTINUE.
PRESS F1 FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.

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1998
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Please give me the name of the medical person, doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health.
PRESS ENTER TO CONTINUE.
PRESS F1 FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.
AC06
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......]
ASK IF NOT OBVIOUS.
[Is (PROVIDER)/Does (PROVIDER) work at] a clinic in a hospital, a hospital outpatient department, an emergency room at a hospital, or some other kind of place?
HOSPITAL CLINIC OR OUTPATIENT DEPARTMENT ............................ 1
HOSPITAL EMERGENCY ROOM ................. 2 [BOX_03]
OTHER KIND OF PLACE ..................... 3 [BOX_03]
REF ..................................... -7 [BOX_03]
DK ...................................... -8 [BOX_03]
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
DISPLAY 'Is (PROVIDER)' IF USC PROVIDER IS FLAGGED AS 'FACILITY-TYPE-PROVIDER'. DISPLAY 'Does (PROVIDER) work at' IF USC PROVIDER IS FLAGGED AS 'PERSON-IN-FACILITY-PROVIDER'.
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----------------------------------------------------
IF CODED '2' (HOSPITAL EMERGENCY ROOM), FLAG THIS USC PROVIDER AS 'HOSPITAL BASED'.
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----------------------------------------------------
NOTE: FOR QUESTIONS AC06 - AC12, THE CONTEXT HEADER WILL DISPLAY THE PERSON-PROVIDER NAME IF THE USC PROVIDER BEING ASKED ABOUT IS FLAGGED AS 'PERSON-TYPE-PROVIDER' OR 'PERSON-IN-FACILITY- PROVIDER'. IF THE USC PROVIDER BEING ASKED ABOUT IS FLAGGED AS 'FACILITY-TYPE-PROVIDER', THE CONTEXT HEADER WILL DISPLAY THE FACILITY-PROVIDER NAME.
----------------------------------------------------
AC07
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......]
Is this clinic or outpatient department owned and operated by the hospital or is this a private doctor's office located at the hospital?
OWNED AND OPERATED BY HOSPITAL .......... 1
PRIVATE DOCTOR'S OFFICE ................. 2
REF ..................................... -7
DK ...................................... -8
[Code One]
----------------------------------------------------
IF CODED '1' (OWNED AND OPERATED BY HOSPITAL) OR '-8' (DON'T KNOW), FLAG THIS USC PROVIDER AS 'HOSPITAL BASED'.
----------------------------------------------------

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1997
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AC06
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......]
ASK IF NOT OBVIOUS.
[Is (PROVIDER)/Does (PROVIDER) work at] a clinic in a hospital, a hospital outpatient department, an emergency room at a hospital, or some other kind of place?
HOSPITAL CLINIC OR OUTPATIENT DEPARTMENT ............................ 1
HOSPITAL EMERGENCY ROOM ................. 2 [BOX_03]
OTHER KIND OF PLACE ..................... 3 [BOX_03]
REF ..................................... -7 [BOX_03]
DK ...................................... -8 [BOX_03]
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
DISPLAY 'Is (PROVIDER)' IF USC PROVIDER IS FLAGGED AS 'FACILITY-TYPE-PROVIDER'. DISPLAY 'Does (PROVIDER) work at' IF USC PROVIDER IS FLAGGED AS 'PERSON-IN-FACILITY-PROVIDER'.
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (HOSPITAL EMERGENCY ROOM), FLAG THIS USC PROVIDER AS 'HOSPITAL BASED'.
----------------------------------------------------
----------------------------------------------------
NOTE: FOR QUESTIONS AC06 - AC12, THE CONTEXT HEADER WILL DISPLAY THE PERSON-PROVIDER NAME IF THE USC PROVIDER BEING ASKED ABOUT IS FLAGGED AS 'PERSON-TYPE-PROVIDER' OR 'PERSON-IN-FACILITY- PROVIDER'. IF THE USC PROVIDER BEING ASKED ABOUT IS FLAGGED AS 'FACILITY-TYPE-PROVIDER', THE CONTEXT HEADER WILL DISPLAY THE FACILITY-PROVIDER NAME.
----------------------------------------------------
AC07
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......]
Is this clinic or outpatient department owned and operated by the hospital or is this a private doctor's office located at the hospital?
OWNED AND OPERATED BY HOSPITAL .......... 1
PRIVATE DOCTOR'S OFFICE ................. 2
REF ..................................... -7
DK ...................................... -8
[Code One]
----------------------------------------------------
IF CODED '1' (OWNED AND OPERATED BY HOSPITAL) OR '-8' (DON'T KNOW), FLAG THIS USC PROVIDER AS 'HOSPITAL BASED'.
----------------------------------------------------
EM35OV2
=======

[Enter Month-2] ........................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
EDIT: COMPLETE DATE AT EM35 MUST BE = OR ) COMPLETE DATE AT EM34
----------------------------------------------------
----------------------------------------------------
EDIT/RANGE CHECK:

ENTRIES FOR MONTH AND DAY FIELDS MUST CORRESPOND TO CALENDAR MONTHS AND DAYS. THAT IS,
- IF MONTH, ALLOWABLE VALUES = 01 - 12.
- IF DAY:
- ALLOWABLE VALUES = 01 - 31 IF MONTH CODED '01', '03', '05', '07', '08', '10', '12';
- ALLOWABLE VALUES = 01 - 30 IF MONTH CODED '04', '06', '09', '11';
- ALLOWABLE VALUES = 01 - 29 IF MONTH CODED '02' AND YEAR IS 1996 (LEAP YEAR);
- ALLOWABLE VALUES = 01 - 28 IF MONTH CODED '02' AND YEAR IS NOT 1996 (I.E., NOT LEAP YEAR).

MISSING VALUES = -7 AND -8 ALLOWED FOR MONTH AND DAY FIELDS.
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EDIT: JOB END DATE MUST BE = OR ) THE PERSON'S DATE OF BIRTH + 12 YEARS AND ( OR = THE REFERENCE PERIOD END DATE FOR THIS PERSON. IF A DATE OF BIRTH IS NOT AVAILABLE, THEN JOB END DATE MUST BE ( OR = THE REFERENCE PERIOD END DATE FOR THIS PERSON.
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1996
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AC05
====

[PERSON'S FIRST MIDDLE AND LAST NAME]
Please give me the name of the medical person, doctor's office, clinic, health center, or other place that (PERSON) usually (go/goes) if (PERSON) (are/is) sick or (need/needs) advice about (PERSON)'s health.
PRESS ENTER TO CONTINUE.
PRESS F1 FOR DEFINITION OF USUAL SOURCE OF HEALTH CARE.
AC06
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......]
ASK IF NOT OBVIOUS.
[Is (PROVIDER)/Does (PROVIDER) work at] a clinic in a hospital, a hospital outpatient department, an emergency room at a hospital, or some other kind of place?
HOSPITAL CLINIC OR OUTPATIENT DEPARTMENT ............................ 1
HOSPITAL EMERGENCY ROOM ................. 2 [BOX_03]
OTHER KIND OF PLACE ..................... 3 [BOX_03]
REF ..................................... -7 [BOX_03]
DK ...................................... -8 [BOX_03]
[Code One]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
DISPLAY 'Is (PROVIDER)' IF USC PROVIDER IS FLAGGED AS 'FACILITY-TYPE-PROVIDER'. DISPLAY 'Does (PROVIDER) work at' IF USC PROVIDER IS FLAGGED AS 'PERSON-IN-FACILITY-PROVIDER'.
----------------------------------------------------
----------------------------------------------------
IF CODED '2' (HOSPITAL EMERGENCY ROOM), FLAG THIS USC PROVIDER AS 'HOSPITAL BASED'.
----------------------------------------------------
----------------------------------------------------
NOTE: FOR QUESTIONS AC06 - AC12, THE CONTEXT HEADER WILL DISPLAY THE PERSON-PROVIDER NAME IF THE USC PROVIDER BEING ASKED ABOUT IS FLAGGED AS 'PERSON-TYPE-PROVIDER' OR 'PERSON-IN-FACILITY- PROVIDER'. IF THE USC PROVIDER BEING ASKED ABOUT IS FLAGGED AS 'FACILITY-TYPE-PROVIDER', THE CONTEXT HEADER WILL DISPLAY THE FACILITY-PROVIDER NAME.
----------------------------------------------------
AC07
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......]
Is this clinic or outpatient department owned and operated by the hospital or is this a private doctor's office located at the hospital?
OWNED AND OPERATED BY HOSPITAL .......... 1
PRIVATE DOCTOR'S OFFICE ................. 2
REF ..................................... -7
DK ...................................... -8
[Code One]
----------------------------------------------------
IF CODED '1' (OWNED AND OPERATED BY HOSPITAL) OR '-8' (DON'T KNOW), FLAG THIS USC PROVIDER AS 'HOSPITAL BASED'.
----------------------------------------------------