Survey Text

2019
2018
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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
AC310 (AC1195)
BLAISE NAME: AffrdCarePM
Question Text:
In the last 12 months, was there any time when [[you/[PERSON]]/anyone in the household] needed prescription medicines, but did not get it because [[you/he/she]/they] couldn?t afford it?
Responses:

 

YES 1
NO 2 BOX_110 (AC1215)
REFUSED RF BOX_110 (AC1215)
DON'T KNOW DK BOX_110 (AC1215)
Programmer Instructions: 
If coded ?1? (YES) and a MULTI-PERSON RU, continue with AC320.
If coded ?1? (YES) and a SINGLE-PERSON RU, automatically code person at AC320 and go to BOX_110.
Display Instructions: 
Display ?[you/[PERSON]]? if SINGLE-PERSON RU. Otherwise, display ?anyone in the household?.
AC320 (AC1196)
BLAISE NAME: AffrdWhoPM
Question Text:
Who was that?
PROBE: Did anyone else need prescription medicines but did not get it because they couldn?t afford it?
ENTER ALL THAT APPLY.
Responses: 
>[FIRST NAME [MIDDLE NAME] LAST NAME]1 1
[FIRST NAME [MIDDLE NAME] LAST NAME]2 2
[FIRST NAME [MIDDLE NAME] LAST NAME]3 3
[FIRST NAME [MIDDLE NAME] LAST NAME]4 4
[FIRST NAME [MIDDLE NAME] LAST NAME]N 5
Programmer Instructions: 
Go to BOX_110.
Display Instructions: 
Roster 2 - no add/edit/delete
Roster definition:
This item displays RU members roster for selection. Display RU member?s first, middle, and last name (Person.FullName).
Roster filter:
No filter; display all.