hosp

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1. Person number ________

Enter month, day, year; if the exact date is not known, obtain the best estimate. Use your calender.
You said that --was in the (hospital/nursing home) during the past year:
2. When did -- enter the (hospital/nursing home) (the last time)?

Do not include any nights in interview week. If the exact number is not known, accept the best estimate.
3. How many nights was --in the (hospital/nursing home)?

Complete question 4 from entries in questions 2 and 3; if not clear ask the questions.
4a. How many of these -- nights were in the past 12 months?

Do not include any nights in interview week.
b. How many of these -- nights were last week or the week before?

Use your calender.
c. Was -- still in the (hospital/nursing home) last Sunday night for this hospitalization (stay)?

If medical name not known, enter an adequate description. Entry must show cause, kind, and part of body in same detail as required for the condition page.
5. For what condition did -- enter the (hospital/nursing home)-do you know the medical name?
For delivery ask: wasthis a normal delivery?
For newborn ask: was the baby normal at birth?
If "No" ask what was the matter?
Record in condition box.

If name of operations is not known, describe what was done.
6a. Were any operations performed on -- during this stay at the (hospital/nursing home)?

b. What was the name of the operation?

c. Any other operations?

Enter the full name of the hospital or nursing home; the street or highway on which it is located and the city and state; if the city is not known, enter the county.
What is the name and address of the (hospital/nuring home)?

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Ask if "No" marked in question 4c.
8. What was the total amount of the (hospital/nursing home) bill for this stay?
Do not include doctor's or surgeons' bills.

9a. Did (will) health insurance pay any part of this bill?

b. What is the name of the insurance plan?

c. Did (will) any other health insurance plan pay part of this (hospital/nursing home) bill?
If "Yes" reask 9b.

For each health insurance plan named ask:
d. What was (will-be) the amount paid by (name of place)?

Enter total amount paid by health insurance in Line A.
Enter any amount paid by social security medicare in line B.

10a. Who paid (will pay) the (remainder of the) hospital bill? Mark each category mentioned.

b. Did any other person or agency pay any other part of the hospital bill?

c. Who was this? Mark each category mentioned.

d. What was the amount paid by --?
Enter amount paid opposite appropriate category.
Total of above- include amount paid by health insurance.

Interviewer:
Add amounts entered (include any amount paid by health insurance) and enter in total box, then mark one of the following boxes.

Ask question 11-13 if person is 55 years old or over. Mark one circle

11a. When -- left (name of hospital/nursing home). did he return home or go some other place?

b. What kind of place did-- go to?

Interviewer:
If the place in 11b is a hospital, nursing home or a similar place, was a hospital page filled for that stay? Mark one box.

12. After leaving the (hospital/nuring home) how many days did -- have to remain in bed all or most of the day? Mark entry.

13. (Altogether) how many days was -- confined to the house after returning home from the (hospital/nursing home)? Mark entry.

14. Note to interviewer
If the condition in question 5 or 6 is on card A (A-1, A-2) or B (B-1, B-2) or there is "1" or more nights in question 4b, the condition must have a completed condition page. If the condition does not have a conditions page, fill one after completing all required hospital pages

CARD A.
A-1:
Now I'm going to read a list of conditions -Please tell me if you, your--etc have had any of these conditions during the past 12 months?

CARD B.
B-1:
Have you, your-- etc ever had any of these conditions?