Form CMS-10549.GenIC#3 CMS-10549.GenIC#3 Screening Instrument

Attachment C: Eligibility Screener

PARTICIPANT NUMERIC IDENTIFIER: ___________________________

1. BENEFICIARY SEX [CODE WITHOUT ASKING IF POSSIBLE.]

   1. MALE

   2. FEMALE

2. How old are you?

_______ years

3. Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease. I need to confirm, do you receive health insurance through Medicare?

   1. YES

   2. NO I am sorry, but only people who receive insurance through Medicare are eligible for this study.

READ IF NECESSARY: Do you have a Medicare card? Medicare Part A includes coverage for hospital stays and Part B includes coverage for doctor’s services. Part C, Medicare Advantage Plans, is offered through private insurance companies under contract with Medicare. Some people opt to add on Part D, which is prescription drug coverage.

4. I am going to read you a list of medical conditions. Has a doctor or other health professional ever told you that you have any of these conditions? For each condition, please respond yes or no.

INTERVIEWER: READ EACH CONDITION SLOWLY AND CIRCLE YES OR NO FOR EACH CONDITION.

Hypertension	YES / NO
Angina pectoris or coronary heart disease	YES / NO
Congestive heart failure	YES / NO
Stroke, a brain hemorrhage, or a cerebrovascular accident	YES / NO
High cholesterol	YES / NO
Any kind of cancer, malignancy, or tumor other than skin cancer	YES / NO
Rheumatoid arthritis	YES / NO
Osteoarthritis	YES / NO
Arthritis, other than rheumatoid or osteoarthritis	YES / NO
Alzheimer’s disease	YES / NO
Any type of dementia other than Alzheimer's disease	YES / NO
Depression	YES / NO
Osteoporosis	YES / NO
Emphysema, asthma, or COPD	YES / NO
Diabetes	YES / NO

IF RESPONDENT HAS NONE OF THE ABOVE CONDITIONS THANK THEM USING THIS SCRIPT:

Thank you for volunteering for this study. Unfortunately, you do not meet the criteria for this study. I appreciate the time you took to speak with me today.

5. What is the highest degree or level of school you have completed?

1. NO SCHOOLING COMPLETED

2. NURSERY SCHOOL TO 8TH GRADE

3. 9TH-12TH GRADE, NO DIPLOMA

4. HIGH SCHOOL GRADUATE (HIGH SCHOOL DIPLOMA OR THE EQUIVALENT)

5. VOCATIONAL/TECHNICAL/BUSINESS/TRADE SCHOOL CERTIFICATE OR DIPLOMA (BEYOND THE HIGH SCHOOL LEVEL)

6. SOME COLLEGE, BUT NO DEGREE

7. ASSOCIATE DEGREE

8. BACHELOR'S DEGREE

9. MASTER'S, PROFESSIONAL OR DOCTORATE DEGREE

6. Are you of Hispanic, Latino, or Spanish origin?

1. YES

2. NO

7. What is your race? [SELECT ONE OR MORE. READ RESPONSE OPTIONS IF NEEDED.]

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African American

   4. Native Hawaiian or Other Pacific Islander

   5. White

7. We would like to audio-record the interview so that we may review our conversation as we prepare a summary of our findings. Is this OK with you?

[INTERVIEWER: THIS QUESTION IS NOT ASKING FOR CONSENT. RESPONDENTS WILL BE ASKED AGAIN ABOUT RECORDING DURING THE CONSENT PROCESS. THEY WILL HAVE THE OPPORTUNITY TO REFUSE RECORDING AND STILL PARTICIPATE IN THE INTERVIEW. WE PREFER TO RECRUIT RESPONDENTS WHO ARE LIKELY TO CONSENT TO RECORDING.]

1. YES

2. NO

7. INTERVIEWER, CHECK THE RECRUITMENT SPREADSHEET TO DETERMINE IF THIS PERSON HAS A CONDITION NOT YET REPRESENTED OR UNDERREPRESENTED AMONG COMPLETED RESPONDENTS THUS FAR.

   1. IF YES, GO TO 10.

   2. IF NO, GO TO 11.

7. IF SCREENING OVER THE PHONE, CONFIRM CONTACT INFORMATION AND SCHEDULE APPOINTMENT:

Ok, let’s schedule an appointment to do the interview. What is a good public place we could meet with you to do the appointment? Some options are a library, community center, or coffee shop near your home. You could also come to our offices in downtown Chicago if you prefer.

[TAKE INFORMATION]

Thank you for volunteering to participate. We will see you [REPEAT DATE AND TIME OF APPOINTMENT] at [REPEAT AGREED UPON LOCATION]. Can I also confirm that [REPEAT PHONE NUMBER] is the best way to contact you if needed?

AFTER HANGING UP, ENTER THE INFORMATION FROM THIS SCREENER INTO THE RECRUITMENT SPREADSHEET ALONG WITH THE DATE, TIME, AND LOCATION OF THE APPOINTMENT.

IF SCREENING IN PERSON, SET UP FOR INTERVIEW:

Great, let’s set up over here and conduct the interview.

7. IF THERE IS TOO MUCH OVERLAP IN CONDITION(S) WITH OTHER RESPONDENTS:

Thank you for volunteering for this study. Unfortunately, you do not meet the criteria of this study at this time. I appreciate the time you took to speak with me today. If we have an opening for this study at a later date could I contact you?

[IF NEEDED: We need to talk to people who have a variety of health conditions. Right now we have enough people with (CONDITION), but I would be happy to put you on a wait list in case an interview slot opens up.]

INTERVIEWER: IF THEY WOULD LIKE TO BE ON THE WAITLIST, CONFIRM THEIR CONTACT INFORMATION.

Can I confirm that [REPEAT PHONE NUMBER] is the best way to contact you? We will be in touch if we have an opening.

AFTER HANGING UP, ADD THE RESPONDENT TO THE WAITLIST TAB IN THE RECRUITMENT SPREADSHEET.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1275 (expires 05/31/2021). The time required to complete this information collection is estimated to average 70 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure****  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact MCBS@cms.hhs.gov.