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Condition approach

1. Person number ________

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

Month ________
Day ________
Year ________ (make sure the year is correct)

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)?

Total nights in hospital/nursing home ________

Complete question 4 from entries in questions 2 and 3 if not clear, ask the questions.
Do not include any nights in interview week
4a. How many of these --nights were during the past 12 months?

Nights past 12 months ____

b. How many of these --nights were last week or the week before?

Nights past 2 weeks ____

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

1[] Yes
2[] No

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.
5a. For what condition did --enter the (hospital/nursing home) do you know the medical name?
For deliver ask: was this a normal deliver? If No ask:What was the matter? Record in condition box.
For newborn ask: was the baby normal at birth? If No ask:What was the matter? Record in condition box.

Condition ________
Cause ________
Kind ________
Part of body _________

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)?

[] Yes
[] No-go to 7

b. What was the name of the operation?

Operation ________

c. Any other operations?

[] Yes -describe above
[] No

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.
7. What is the name and address of the (hospital/nursing home)?

Name of hospital ________
Street ________
City (or county) ________
State ________


Ask questions 8-10 for all completed hospitalizations- mark one circle

[] Yes in Q4c- go to item 14
[] No in Q4c- ask 8-10

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 any doctor's or surgeon's bills.

Dollars ____
Cents ____

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

[] Yes
[] No -go to 10

b. What is the name of the insurance plan?

Name of insurance plan ______

c. Did (will) any other health insurance plan pay part of his hospital (nursing home) bill?

[] Yes -reask b
[] No- go to d

If "Yes" reask 9b
For each health insurance plan named, ask:
d. What was (will be) the amount paid by (name of plan)? ________

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.

A[] Health insurance-all plans excl. Medicare
B[] Social Security medicare
C[] Self and family
D[] Relative not in household
E[] Friend
F[] Kerr Mills or other Fed. Plans
G[] Armed Forces Medicare
H[] State or local Welfare agency
I[] Other (specify) ________

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

[] Yes -ask c
[] No- go to d

c. Who was this? Mark each category mentioned

A1[] Health insurance-all plans excl. Medicare
B2[] Social Security medicare
C3[] Self and family
D[] Relative not in household
E[] Friend
F[] Kerr Mills or other Fed. Plans
G[] Armed Forces Medicare
H[] State or Local Welfare Agency
I[] Other specify

d. What was the amount paid by--? Enter amount paid opposite appropriate category.

Dollars ____
Cents ____

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

[] Total amount paid (to be paid) agrees with amount of the hospital bill- go to Q.12
[] Total amount paid (to be paid) does not agree with amount of the hospital bill- resolve difference with respondent

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

[] Under 55- go to 14
[] 55 or over-ask 11a

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

[] Home - go to question 12
[] Some other place- ask question 11b

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

Specify ________

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.

[] Hospital page filled- stop
[] Hospital page not filled-fill hosp. page for unreported stay

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

[survey choices not clear]

[] Still in bed- go to 14
[] None
[] DK

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

[] Still confined in house
[] None
[] DK

14. Note to interviewer:
If the condition in question 5 or 6 in 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 condition page, fill one after completing all required hospital pages