Survey Text

2016 2010 2004 1998
2015 2009 2003 1997
2014 2008 2002 1996
2013 2007 2001
2012 2006 2000
2011 2005 1999
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
----------------------------------------------------

top
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
----------------------------------------------------