Data Cart

Your data extract

0 variables
0 samples
View Cart



hosp

[p. 54]

HOSPITAL PAGE

We are also collecting information on hospital and surgical costs. Before I ask the next questions, it would be helpful if you would get the hospital bills and any surgeon's bills for the hospital stay(s) you told me about for --,--, etc. (and the doctor's bill for -- delivery.)

1. Person number ____
Probe
I.C. or Dum.

You said that -- was in the hospital (nursing home) during the past year -
2. When did -- enter the hospital (nursing home) (the last time)?
USE YOUR CALENDAR
Make sure the YEAR is correct

Month __
Day __
Year 19__

3. What is the name and address of this hospital (nursing home)?

Name ____
Street ____
City (or county) ____
State ____

4. How many nights was -- in the hospital (nursing home)?

____

5a. How many of these -- nights were during the past 12 months?

____

b. How many of these -- nights were during the past 2 weeks?

____

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

[] Yes
[] No

If medical name unknown, enter an adequate description.
Show CAUSE, KIND, and PART OF BODY in same detail as required for the Condition page.
6. For what condition did -- enter the hospital (nursing home) -- do you know the medical name?

For delivery, ask:
Was this a normal delivery?
[] Yes (8)
[] No
What was the matter?

For newborn, ask: Was the baby normal at birth?
[] Yes (8)
[] No
What was the matter?

Condition ____
Cause ____
Kind ____
Part of body ____

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

1[] Yes
2[] No

If name of operation is not known, describe what was done.
8a. Were any operations performed on -- during this stay in the hospital (nursing home)?

[] Yes
0 [] No (Item T)

b. What was the name of the operation? If name of operation is not known, describe what was done. ________

c. Any other operations?

[] Yes (Describe) ________
[] No

ITEM T
Mark appropriate box(es):

1[] "Yes" in Q.5c (19)
[] "No" in Q.5c (Mark one box)
2[] Under 55 (12)
[] 55 and over (9a)
9a. When -- left (name of hospital/nursing home) did he return home or go to some other place?

3[] Home (10)
4[] Some other place (9b)

b. What kind of place did -- go to? (Specify)
Interviewer: If place in 9b is a hospital, nursing home, or similar place, was a Hospital page filled for that stay?

[] Hospital page filled (12)
[] Hospital page not filled (Fill hospital page for unreported stay after completing Q's 12-18 for this stay)

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

000[] None
XXI[] Still in bed
___ days

11. ALTOGETHER how many days was -- confirmed to the house after returning home from the hospital (nursing home)?

000[] None
XXI[] Still confined to home
___ days

Enter the person number and date of entry
12. Ask questions 13 through 18 for each completed hospitalization

Person No.____
Date of Entry
Month___
Day___
Year___

13. What was the total amount of the hospital bill for this stay?
Do not include any doctor's or surgeon's bills.
Mark one box

[] Estimate, bill received
[] Estimate, bill not received
[] From bill
Dollars____
Cents_____

14a. Did (will) health insurance pay any part of the hospital bill?

[] Yes
[] No (18a)

b. What is the name of the insurance plan?

Dollars ____
Cents ____

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

[] Yes (Reask 14b)
[] No

Ask for each health insurance plan named, then go to 15b.
d. What was (will be) the amount paid by (name of plan)?

Name of insurance plan____
Dollars ____
Cents ____

Enter total amount paid by health insurance in line A.
Enter any amount paid by Social Security Medicare in line B.
15a. Who paid (will pay) the hospital bill?

Source of payment
A. 1[] Health insurance (All plans excluding Medicare)
B. 2[] Social Security Medicare
C. 3[] Self and family in household
D. 4[] Other (Specify) ____

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

[] Yes (15c and reask 15b)
[] No (15d or Int. Check Item)

c. Who was this?

____

d. What was the amount paid by --?

Source of payment
A. 1[] Health insurance (All plans excluding Medicare)
Dollars ____
Cents ____

B. 2[] Social Security Medicare
Dollars ____
Cents ____

C. 3[] Self and family in household
Dollars ____
Cents ____

D. 4[] Other (Specify) ____
Dollars ____
Cents ____

INTERVIEWER CHECK ITEM

0[] No operation (19)
1[] Operation or delivery (16a)
16a. What was the amount of the surgeon's (doctor's) bill for this operation (delivery)?
Mark one box

[] Estimate, bill received
[] Estimate, bill not received
[] From bill
Dollars ___
Cents___

b. Is the $______ for the surgeon's (doctor's) bill included in the $______ amount you gave for the hospital bill?

1[] Yes ( In a footnote indicate the actual amount of the hospital bill after deducting the surgeon's (doctor's) bills; also indicate any changes in the amounts paid by health insurance or other sources if the entries in questions 14 and 15 include payments for expenses other than the hospital bill.) (17)
4[] No (17)

17a. Did (will) health insurance pay any part of the surgeon's (doctor's) bill?

[] Yes
[] No (18a)

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 surgeon's (doctor's) bill?

[] Yes (Reask 17b)
[] No

Ask for each health insurance plan named, then go to 18b.
d. What was (will be) the amount paid by (name of plan)?

Name of insurance plan____
Dollars ___
Cents___

Enter total amount paid by health insurance in line A
Enter any amount paid by Social Security Medicare in line B
18a. Who paid (will pay) the surgeon's (doctor's) bill?

Source of payment
A. 1[] Health insurance (All plans excluding Medicare)
B. 2[] Social Security Medicare
C. 3[] Self and family in household
D. 4[] Other (Specify) ____

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

[] Yes (18c and reask 18b)
[] No (18d or 19)

c. Who was this?

____

d. What was the amount paid by --?

Source of payment
A. 1[] Health insurance (All plans excluding Medicare)
Dollars ____
Cents ____

B. 2[] Social Security Medicare
Dollars ____
Cents ____

C. 3[] Self and family in household
Dollars ____
Cents ____

D. 4[] Other (Specify) ____
Dollars ____
Cents ____

19. NOTE: If the condition in Q.6 or 8 is on Card D, or there are "1" or more nights in Q.5b, a Condition page is required.
If there is no Condition page, fill one after completing all required Hospital pages.