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hosp_personapproach

[p.66]


HOSPITAL

Person 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 during the past 2 weeks?

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 _________

Ask for all conditions except deliveries and births
6. Was this the first time--was hospitalized for....?

1[] Yes
2[] No

If name of operation is not known, describe what was done.
7a. Were any operations preformed on -- during this stay at the (hospital/nursing home)?

[] Yes
2[] No- go to 8

b. What was the name of the operation?

Operation ________

c. Any other operations?

[] Yes-describe __________
[] 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.
8. What is the name and address of the (hospital/nursing home)?

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

Ask questions 9-18 for all completed hospitalizations- mark one box

[] Yes in Q4c- go to item 18
[] No in Q4c- ask Q9

9. What was the total amount of the hospital (nursing home)bill for this stay? Do not include any doctor's or surgeon's bills.
Hospital bill

Dollars ____
Cents ____

10a. Did (will) health insurance pay any part of the hospital bill?

[] Yes -ask b
[] No -go to 11

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

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
11a. Who paid (will pay) the (remainder of the) hospital bill?

A1[] Health insurance-all plans excl. Medicare
B2[] Social Security medicare
C3[] Self and family
D4[] 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?

A1[] Health insurance-all plans excl. Medicare
B2[] Social Security medicare
C3[] Self and family
D4[] Other (specify) ________

d. What was the amount paid by--?

Dollars ____
Cents ____

Interviewer: After totaling all sources of payment for the hospital bill. Check 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

[p.67]

12a. What was the amount of the doctor's and surgeon's bill for this stay?
Doctor/surgeon

Dollars ________
Cents ________

b. In the $ --for the doctor's and surgeon's bill included in the $--amount you gave me for the hospital bill?

1[] Yes (in a footnote, indicate the actual amount of the hospital bill,after deducting the doctor's and surgeon's bills, also indicate any changes in the amounts paid by health insurance or other sources if the entries in Qs. 10 and 11 include payments for expenses other than the hospital bill)
2[] No- go to 13

13a. Did (will) health insurance pay any part of the doctor's and surgeon's bill?

[] Yes
[] No-go to 14

b. What is the name of the insurance plan?

Name of insurance plan ________

c. Did (will) any other health insurance plan pay part of the doctor's and surgeon's bill?

[] Yes (reask b)
[] No (ask d)

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

Dollars ____
Cents____

Enter total amount paid by health insurance in line A.Enter any amount paid by Social Security Medicare in line B.
14a. Who paid (will pay) the (remainder of the) doctor's and surgeon's bill?

A1[] health insurance-all plans excl. Medicare
B2[] Social Security medicare
C3[] Self and family
D4[] Other -specify ________

b. Did any other person or agency pay any other part of the doctor's and surgeon's bill?

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

c. Who was this?

A1[] health insurance-all plans excl. Medicare
B2[] Social Security medicare
C3[] Self and family
D4[] Other -specify ________

d. What was the amount paid by --?

Dollars ____
City ____

Interviewer: After totaling all sources of payment for the doctor's and surgeon's bill, check one of the following boxes.

[] Total amount paid (to be paid) agrees with amount of doctor's bill- go to Q15.
[] Total amount paid (to be paid) does not agree with amount of the doctor's bill-Resolve difference with respondent

15a. When --left (name of hospital/nursing home) did he return home or go some other place?

[] Home -go to 16
[] Some other place-ask 15b

b. What kind of place did --go to? Specify ________
Interview: if the place in 15b is a hospital, nursing home, or similar place, was a hospital page filled for that stay?

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

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

000[] None
XXX[] Still in bed
Days ______

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

000[] None
XXX[] Still fined to house
Days ____

18. Note to interviewer:
If the condition in Q.5 or 7 is listed in item AA on the condition page or any part of this hospitalization was during the past 2 weeks 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.