Form CMS-10792 OECD PaRIS Patient Questionnaire

Attach2_PaRIS_Specifications

OECD PaRIS Patient Questionnaire
VERSION FOR ONLINE SCRIPTING
DRAFT
THIS VERSION HAS BEEN UPDATED POST ROUND 2 COG TESTING – DECEMBER 2021

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Attach2_PaRIS_Specifications
ASK ALL
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LANGUAGE
PLEASE SELECT THE LANGUAGE IN WHICH YOU WOULD LIKE TO CONDUCT THE INTERVIEW.
1

ENGLISH

2

SPANISH

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INTRO
This survey is being carried out by the Centers for Medicare and Medicaid Services in collaboration
with the Organisation for Economic Cooperation and Development (OECD). The United States is
taking part in an international survey to improve health services locally and nationally. The survey
asks questions about your experience of care and treatment by your health providers. In addition,
there are some questions about you and your health. Your answers are important and will help
policy makers and health care providers to improve healthcare based on patients’ needs.
Some of these questions may sound similar to questions you already answered during your regular
MCBS interview. We need to ask them again so that everyone around the world is asked the exact
same questions.

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ATDOOR (SINGLE)
All survey information will be kept private to the extent permitted by law, as prescribed by the
Privacy Act of 1974.
Medicare benefits will not be affected in any way by survey responses or participation.
Do you agree to take part in the survey?
1

YES

2

NO

ASK IF ATDOOR=YES
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SPVERNAM (SINGLE)
VERIFY THE SP’S NAME. IS THE SP’S NAME CORRECT AND COMPLETE?
FIRST NAME: [FIRST_NAME]
MIDDLE INITIAL: [MIDDLE_NAME]
LAST NAME: [LAST_NAME]
1

YES

2

NO

ASK IF SPVERNAM=1
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SPCORNAM (OPEN)
MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
FIRST NAME:
MIDDLE INITIAL:
LAST NAME:
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SPSTATUS (SINGLE)
PLEASE INDICATE THE RESPONDENT’S CURRENT STATUS. IF THE CASE IS A PROXY INTERVIEW AND
YOU HAVEN’T TALKED ABOUT THE RESPONDENT’S VITAL STATUS, PROBE AT THIS TIME ABOUT
WHETHER THE RESPONDENT IS ALIVE OR DECEASED AND WHERE THE RESPONDENT IS LOCATED.
WHEN WE REFER TO INSTITUTIONALIZED, WE ARE REFERRING TO THE MCBS DEFINITION OF A
FACILITY. PLEASE REMEMBER THAT HOSPITALS AND HOSPICE CARE ARE NOT FACILITIES UNDER
THE MCBS DEFINITION SO RESPONDENTS IN HOSPITALS AND HOSPICE CARE SHOULD NOT BE
CONSIDERED TO BE INSTITUTIONALIZED BELOW.
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FOR THE FULL MCBS DEFINITION OF A FACILITY, SEE THE “MCBS FACILITY DEFINITION” REFERENCE
CARD.
IS THE RESPONDENT CURRENTLY:
1

ALIVE AND NOT INSTITUTIONALIZED

2

ALIVE AND INSTITUTIONALIZED

3

DECEASED – DIED IN COMMUNITY

4

DECEASED – DIED IN INSTITUTION/FACILITY

ASK IF SPSTATUS=1
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PARIS_SCREEN (SINGLE)
Since (MONTH YEAR), have (you/SP) seen a healthcare professional? Healthcare professionals
include doctors, nurses, and other health professionals.
1
2
-8
-9

YES
NO
DON’T KNOW
REFUSED

ASK IF SPSTATUS=2, 3, 4 OR PARIS_SCREEN=2, -8, -9
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INTHANK (TEXT)
THIS CASE IS NOT ELIGIBLE FOR THE PARIS SURVEY.
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SPPROXIN (SINGLE)
WILL THIS INTERVIEW BE CONDUCTED WITH THE SAMPLE PERSON OR WITH A PROXY?
1

SAMPLE PERSON

2

PROXY

ASK IF SPPROXIN=2
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ROSTREL (SINGLE)
WHAT IS THE RELATIONSHIP TO THE SAMPLE PERSON?
02

SPOUSE

56

PARTNER

58

CHILD

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59

GRANDCHILD

60

PARENT

61

SIBLING

91

OTHER

-8

DON'T KNOW

-9

REFUSED

ASK IF SPPROXIN=2
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PROXYWHY (SINGLE)
WHAT IS THE MAIN REASON THAT A PROXY RESPONDENT IS NECESSARY?
1

SP NOT CAPABLE PHYSICALLY/SICK/BLIND/CAN’T
SPEAK/HEAR

2

SP NOT CAPABLE MENTALLY/POOR
MEMORY/PSYCHIATRIC DISORDER

3

SP UNABLE TO PROVIDE INFORMATION
REGARDING MEDICAL RECORDS

4

SP IN HOSPITAL

5

LANGUAGE PROBLEM

8

SP NOT AVAILABLE THIS ROUND

9

AUTHORIZED PROXY MUST ANSWER QUESTIONS
FOR SP

91

OTHER

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Your health
The first few questions are about your health.
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Q_GLOBAL (LOOP)
GLOBAL01

SHOWCARD PR1

GLOBAL02

In general, would you say your health is excellent, very good, good, fair, or
poor?
SHOWCARD PR1

GLOBAL03

In general, would you say your quality of life is excellent, very good, good,
fair, or poor?
SHOWCARD PR1
In general, how would you rate your physical health?

GLOBAL04

IF NEEDED: Would you rate it excellent, very good, good, fair, or poor?
SHOWCARD PR1
In general, how would you rate your mental health, including your mood
and your ability to think?

GLOBAL05

IF NEEDED: Would you rate it excellent, very good, good, fair, or poor?
SHOWCARD PR1
In general, how would you rate your satisfaction with your social activities
and relationships?

GLOBAL9R

IF NEEDED: Would you rate it excellent, very good, good, fair, or poor?
SHOWCARD PR1
In general, please rate how well you carry out your usual social activities
and roles. (This includes activities at home, at work and in your
community, and responsibilities as a parent, child, spouse, employee,
friend, etc.)
IF NEEDED: Would you rate it excellent, very good, good, fair, or poor?

Responses (SINGLE)
1

EXCELLENT

2

VERY GOOD

3

GOOD
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4

FAIR

5

POOR

-8

DON’T KNOW

-9

REFUSED

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Q_GLOBAL06 (SINGLE)
To what extent are you able to carry out your everyday physical activities such as walking,
climbing stairs, carrying groceries, or moving a chair? Would you say complete, mostly,
moderately, a little, or not at all?
1

COMPLETELY

2

MOSTLY

3

MODERATELY

4

A LITTLE

5

NOT AT ALL

-8

DON’T KNOW

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REFUSED

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SYMPINTRO
The next few questions are about any specific symptoms you may have recently experienced. For
each statement, please tell me if you have had this experience not at all, a little bit, somewhat,
quite a bit, or very much.
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Q_PROMISDYSCB001 (SINGLE)
SHOWCARD PR2
In the past 7 days, I have been short of breath
IF NEEDED: Would you say not at all, a little bit, somewhat, quite a bit, or very much?
1

NOT AT ALL

2

A LITTLE BIT

3

SOMEWHAT

4

QUITE A BIT

5

VERY MUCH

-8

DON’T KNOW

-9

REFUSED
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Q_PROMISLEEP44 (SINGLE)
SHOWCARD PR2
In the past 7 days, I had a problem with my sleep
IF NEEDED: Would you say not at all, a little bit, somewhat, quite a bit, or very much?
1

NOT AT ALL

2

A LITTLE BIT

3

SOMEWHAT

4

QUITE A BIT

5

VERY MUCH

-8

DON’T KNOW

-9

REFUSED

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Q_GLOBAL08R (SINGLE)
In the past 7 days, how would you rate your fatigue on average?
IF NEEDED: Would you say not at all, a little bit, somewhat, quite a bit, or very much?
1

NONE

2

MILD

3

MODERATE

4

SEVERE

5

VERY SEVERE

-8

DON’T KNOW

-9

REFUSED

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Q_PROMISPAIN (SINGLE)
SHOWCARD PR2
In the past 7 days, how much did pain interfere with your day to day activities? Would you say not
at all, a little bit, somewhat, quite a bit, or very much?
1

NOT AT ALL

2

A LITTLE BIT

3

SOMEWHAT

4

QUITE A BIT

5

VERY MUCH
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-8

DON’T KNOW

-9

REFUSED

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Q_GLOBAL07R (SINGLE)
In the past 7 days, how would you rate your pain on average on a scale of 0 being no pain to 10
being worst imaginable?
0-No pain
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2
3
4
5
6
7
8
9
10-Worst imaginable pain
-8

DON’T KNOW

-9

REFUSED

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Q_ GLOBAL10R (SINGLE)
SHOWCARD PR3
In the past 7 days, how often have you been bothered by emotional problems such as feeling
anxious, depressed or irritable? Would you say never, rarely, sometimes, often, or always?
1

NEVER

2

RARELY

3

SOMETIMES

4

OFTEN

5

ALWAYS

-8

DON’T KNOW

-9

REFUSED

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SHOWCARD PR4
(REPEAT ON EACH SCREEN) For the next few questions, please think about how you have been
feeling over the last two weeks. For each one, would you say all of the time, most of the time,
more than half of the time, less than half of the time, some of the time, or at no time?

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QWHO5 (LOOP)
QWHO5_A

I have felt cheerful and in good spirits

QWHO5_B

I have felt calm and relaxed

QWHO5_C

I have felt active and vigorous

QWHO5_D My daily life has been filled with things that interest me
QWHO5_E

I woke up feeling fresh and rested

Responses (SINGLE)
1

ALL OF THE TIME

2

MOST OF THE TIME

3

MORE THAN HALF OF THE TIME

4

LESS THAN HALF OF THE TIME

5

SOME OF THE TIME

6

AT NO TIME

-8

DON’T KNOW

-9

REFUSED

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Managing your health and health care
The next few questions ask about your recent physical activity, diet and use of tobacco and alcohol
and the support you may have received from healthcare professionals such as doctors, nurses, and
other healthcare professionals.
ASK ALL
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Q_EXERCISE (SINGLE)
In the past week, on how many days did you do at least 30 minutes of either vigorous or moderate
activity (such as running, swimming, riding a bike, brisk walking, or dancing)? Vigorous physical
activities typically make you breathe much harder than normal, whereas moderate activities make
you breathe somewhat harder than normal. Would you say every day, 5 to 6 days, 3 to 4 days, 1 to
2 days, none, or are you not sure?
1

EVERY DAY

2

5 TO 6 DAYS

3

3 TO 4 DAYS

4

1 TO 2 DAYS

5

NONE, DID NOT DO ANY VIGOROUS OR MODERATE ACTIVITY IN THE
PAST WEEK

6

NOT SURE

-9

REFUSED
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Q_ADVPHYSACT (SINGLE)
In the past 12 months, has any healthcare professional talked with you about your physical
activity?
IF NEEDED: Healthcare professionals include doctors, nurses, and other health professionals.
1
2
3
-9

YES
NO
NOT SURE
REFUSED

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Q_EHISFR (SINGLE)
SHOWCARD PR5
How often do you eat fruit (including fresh, frozen, canned or dried and excluding juice squeezed
from fresh fruit or made from concentrate)? Would you say once or more a day, 4 to 6 times a
week, 1 to 3 times a week, less than once a week, or never?
1

ONCE OR MORE A DAY

2

4 TO 6 TIMES A WEEK

3

1 TO 3 TIMES A WEEK

4

LESS THAN ONCE A WEEK

5

NEVER

-8

DON’T KNOW

-9

REFUSED

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Q_EHISVG (SINGLE)
SHOWCARD PR5
How often do you eat vegetables or salad (including fresh, frozen or canned and excluding
potatoes and fresh juice or juice made from concentrate)? Would you say once or more a day, 4 to
6 times a week, 1 to 3 times a week, less than once a week, or never?
1

ONCE OR MORE A DAY

2

4 TO 6 TIMES A WEEK

3

1 TO 3 TIMES A WEEK

4

LESS THAN ONCE A WEEK

5

NEVER
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-8

DON’T KNOW

-9

REFUSED

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Q_ ADVDIET (SINGLE)
In the past 12 months, has any healthcare professional talked with you about healthy eating?
IF NEEDED: Healthcare professionals include doctors, nurses, and other health professionals.
1
2
3
-9

YES
NO
NOT SURE
REFUSED

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Q_EHISSK01 (SINGLE)
Do you smoke tobacco products (excluding electronic cigarettes or similar
electronic devices) at all nowadays?
IF YES: Do you smoke daily or occasionally?
1
2
3
-8
-9

YES, DAILY
YES, OCCASIONALLY
NOT AT ALL
DON’T KNOW
REFUSED

ASK IF Q_EHISSK01 = 3
NEW PAGE
Q_EHISSK04 (SINGLE)
Have you ever smoked tobacco products (excluding electronic cigarettes or similar
electronic devices) daily, or almost daily, for at least one year?
1
2
-8
-9

YES
NO
DON’T KNOW
REFUSED

ASK IF Q_EHISSK01 = 1 or 2
NEW PAGE
Q_CWF2014IHP (SINGLE)
In the past 12 months, has any healthcare professional talked with you about the health risks of
smoking or using tobacco and ways to quit?
IF NEEDED: Healthcare professionals include doctors, nurses, and other health professionals.
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1
2
3
-9

YES
NO
NOT SURE
REFUSED

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Q_EHIS (SINGLE)
SHOWCARD PR6
In the past 12 months, how often have you had an alcoholic drink of any kind ? Would you say
every day, 5-6 days a week, 3-4 days a week, 1-2 days a week, 2-3 days in a month, once a month,
less than once a month, not in the past 12 months because you no longer drink, or never?
IF NEEDED: Alcoholic drinks include beer, wine, wine coolers, cider, spirits, cocktails, liquor, or
homemade alcohol.
1
2
3
4
5
6
7
8
9
-8
-9

EVERY DAY ALMOST
5-6 DAYS A WEEK
3-4 DAYS A WEEK
1-2 DAYS A WEEK
2-3 DAYS IN A MONTH
ONCE A MONTH
LESS THAN ONCE A MONTH
NOT IN THE PAST 12 MONTHS, AS I NO LONGER DRINK ALCOHOL
NEVER, OR ONLY A FEW SIPS OR TRIES, IN MY WHOLE LIFE
DON’T KNOW
REFUSED

ASK IF Q_EHIS = 2 TO 7
NEW PAGE
Q_CWF2017IHP (SINGLE)
In the past 12 months, has any healthcare professional talked with you about alcohol use?
IF NEEDED: Healthcare professionals include doctors, nurses, and other health professionals.
1
2
3
-9

YES
NO
NOT SURE
REFUSED

ASK ALL
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Q_PN (show on separate screens)
(Put this text on separate screen). The next few questions are about how you and the healthcare
professionals that you usually see support your health and health care. As a reminder, healthcare
professionals include doctors, nurses, and other health professionals.

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For each statement, please tell me if you strongly disagree, disagree, neither agree nor disagree,
agree, or strongly agree.
PN1
SHOWCARD PR7
I rely on healthcare professionals to tell me everything I need to know to manage my
health

PN2

IF NEEDED: Do you strongly disagree, disagree, neither agree nor disagree, agree, or
strongly agree?
SHOWCARD PR7
Most health issues are too complex for me to understand

PN3

IF NEEDED: Do you strongly disagree, disagree, neither agree nor disagree, agree, or
strongly agree?
SHOWCARD PR7
I actively try to prevent diseases and illnesses

PN4

IF NEEDED: Do you strongly disagree, disagree, neither agree nor disagree, agree, or
strongly agree?
SHOWCARD PR7
I leave it to healthcare professionals to make the right decisions about my health

PN5

IF NEEDED: Do you strongly disagree, disagree, neither agree nor disagree, agree, or
strongly agree?
SHOWCARD PR7
It is important to me to be informed about health issues

PN6

IF NEEDED: Do you strongly disagree, disagree, neither agree nor disagree, agree, or
strongly agree?
SHOWCARD PR7
I need to know about health issues so I can keep myself and my family healthy

PN7

IF NEEDED: Do you strongly disagree, disagree, neither agree nor disagree, agree, or
strongly agree?
SHOWCARD PR7
I have difficulty understanding a lot of the health information that I read

PN8

IF NEEDED: Do you strongly disagree, disagree, neither agree nor disagree, agree, or
strongly agree?
SHOWCARD PR7
My healthcare professionals and I work together to manage my health
IF NEEDED: Do you strongly disagree, disagree, neither agree nor disagree, agree, or
strongly agree?
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IF NEEDED: Healthcare professionals include doctors, nurses, and other health
professionals.
SHOWCARD PR7

PN9

When I read or hear something that is relevant to my health care, I bring it up with my
healthcare professionals
IF NEEDED: Do you strongly disagree, disagree, neither agree nor disagree, agree, or
strongly agree?
IF NEEDED: Healthcare professionals include doctors, nurses, and other health
professionals.
SHOWCARD PR7

PN10

I try to understand my personal health risks
IF NEEDED: Do you strongly disagree, disagree, neither agree nor disagree, agree, or
strongly agree?
PREOS2m SHOWCARD PR7
When I think something is wrong with my health care, I raise my concerns with my
healthcare professionals
IF NEEDED: Do you strongly disagree, disagree, neither agree nor disagree, agree, or
strongly agree?
IF NEEDED: Health professionals include doctors, nurses, and other health
professionals.
Responses (SINGLE)
1
2
3
4
5
-8
-9

STRONGLY DISAGREE
DISAGREE
NEITHER AGREE NOR DISAGREE
AGREE
STRONGLY AGREE
DON’T KNOW
REFUSED

ASK ALL
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Q_CONFIDENT (LOOP)
P3CEQ10

MPBSPAINSTRC

SHOWCARD PR9
How confident are you that you can manage your own health and
wellbeing? Would you say very confident, confident, somewhat
confident, or not confident at all?
SHOWCARD PR9

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How confident are you that you can follow instructions from
healthcare professionals about how you should care for yourself at
home? Would you say very confident, confident, somewhat
confident, or not confident at all?

MPBSPAMEDREC

MPBSPANECESS

MPBSPASIDEFX

eHEALS

IF NEEDED: Healthcare professionals include doctors, nurses, and
other health professionals.
SHOWCARD PR9
How confident are you that you can follow instructions from
healthcare professionals about how to change your habits or
lifestyle? Would you say very confident, confident, somewhat
confident, or not confident at all?
IF NEEDED: Healthcare professionals include doctors, nurses, and
other health professionals.
SHOWCARD PR9
How confident are you that you can identify when it is necessary for
you to get medical care? Would you say very confident, confident,
somewhat confident, or not confident at all?
SHOWCARD PR9
How confident are you that you can identify when you are having
side effects from your medications? Would you say very confident,
confident, somewhat confident, not confident at all, or does not
apply?
SHOWCARD PR9
How confident are you in using information from the Internet to
make health decisions? Would you say very confident, confident,
somewhat confident, not confident at all, or does not apply?

Responses (SINGLE)
1
2
3
4
5
-8
-9

VERY CONFIDENT
CONFIDENT
SOMEWHAT CONFIDENT
NOT CONFIDENT AT ALL
DOES NOT APPLY (MPBSPASIDEFX AND eHEALS
ONLY)
DON’T KNOW
REFUSED

ASK ALL
NEW PAGE
EXPINTRO

Your experience of health care
The following questions are about the care you are receiving from primary care services for your
health and wellbeing. Primary care services are usually the first point of contact with the health
care system for a wide range of new and long-term health problems.
ASK ALL
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NEW PAGE
Q_CWF1130 (SINGLE)
Is there one single professional you usually go to for most of your health problems?
IF YES: Is this a doctor or another healthcare professional?
1
2
3
4
-9

YES, A DOCTOR
YES, ANOTHER HEALTHCARE PROFESSIONAL
NO, THERE IS NO SINGLE HEALTHCARE PROFESSIONAL I USUALLY GO FOR MOST OF
MY HEALTH PROBLEMS
NOT SURE
REFUSED

ASK IF Q_CWF1130 = 1
NEW PAGE
Q_ USUALDR1 (SINGLE)
Who is this doctor? A primary care doctor, a specialist doctor, or are you not sure?
1
2
3
-9

PRIMARY CARE DOCTOR
SPECIALIST DOCTOR
NOT SURE
REFUSED

ASK IF Q_CWF1130 = 1
NEW PAGE
Q_CWF1140 (SINGLE)
SHOWCARD PR10
How long have you been seeing this doctor? Would you say 1 year or less, more than 1 yar but no
more than 3 years, more than 3 years but no more than 5 years, more than 5 years but no more
than 10 years, 10 years or more, or not sure?
1
2
3
4
5
6
-9

1 YEAR OR LESS
MORE THAN 1 YEAR BUT NO MORE THAN 3
YEARS
MORE THAN 3 YEARS BUT NO MORE THAN 5
YEARS
MORE THAN 5 YEARS BUT NO MORE THAN 10
YEARS
10 YEARS OR MORE
NOT SURE
REFUSED

ASK IF Q_CWF1130 = 1
NEW PAGE
Q_ USUALDR2 (SINGLE)

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SHOWCARD PR11
How often have you seen this doctor in the past 12 months? This could be in person, on the
phone, by video call or online messaging. Would you say not at all, once, 2-4 times, 5 or more
times, or not sure?
1
2
3
4
5
-9

NOT AT ALL/NOT IN THE PAST 12 MONTHS
ONCE
2-4 TIMES
5 TIMES OR MORE
NOT SURE
REFUSED

ASK IF Q_CWF1130 = 2
NEW PAGE
Q_ USUALDR3 (SINGLE)
Who is this healthcare professional? Are they a primary care nurse, a specialist nurse, another
professional, or are you not sure?
1
2
3
4
-9

A PRIMARY CARE NURSE
A SPECIALIST NURSE
ANOTHER PROFESSIONAL
NOT SURE
REFUSED

ASK IF USUALDR3 = 1-3
NEW PAGE
Q_ USUALDR4 (SINGLE)
SHOWCARD PR10
How long have you been seeing this healthcare professional? Would you say 1 year or less, more
than 1 year but no more than 3 years, more than 3 years but no more than 5 years, more than 5
years but no more than 10 years, 10 years or more, or not sure?
1
2
3
4
5
6
-9

1 YEAR OR LESS
MORE THAN 1 YEAR BUT NO MORE THAN 3 YEARS
MORE THAN 3 YEARS BUT NO MORE THAN 5 YEARS
MORE THAN 5 YEARS BUT NO MORE THAN 10 YEARS
10 YEARS OR MORE
NOT SURE
REFUSED

ASK IF USUALDR3 = 1-3
NEW PAGE
Q_ USUALDR5 (SINGLE)
How often have you seen this healthcare professional in the past 12 months? This could be in
person, on the phone, by video call or online messaging. Would you say not in the past 12 months,
once, 2-4 times, 5 times or more, or not sure?
1

NOT IN THE PAST 12 MONTHS
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2
3
4
5
-9

ONCE
2-4 TIMES
5 TIMES OR MORE
NOT SURE
REFUSED

ASK ALL
NEW PAGE
Q_CHRONCOND (LOOP)
Have you ever been told by a doctor that you have any of the following health conditions?
1
2
3
4
5
6
7
8
9
10
11
12
13

High blood pressure
Cardiovascular or heart condition (e.g., high cholesterol, high triglycerides or heart
failure)
Diabetes (type 1 or 2)
Arthritis or ongoing problem with back or joints
Breathing condition (e.g., asthma or COPD)
Alzheimer’s disease or other cause of dementia
Ongoing depression, anxiety or other mental health condition (e.g., bipolar disorder
or schizophrenia)
Neurological condition (e.g., epilepsy or migraine)
Chronic kidney disease
Chronic liver disease
Cancer (diagnosis or treatment in the last 5 years)
Other chronic conditions
I have never been told by a doctor that I have any of these problems

Responses (SINGLE)
1
2
-8
-9

YES
NO
DON’T KNOW
REFUSED

ASK IF Q_CHRONCOND = 12
NEW PAGE
Q_ CHRONCONDOS (OPEN)
What other chronic conditions have you been told by a doctor you have?
ASK IF Q_CHRONCOND = 1 TO 12
NEW PAGE
The next few questions are about the care you may have received for these health conditions.
Q_P3CEQ6 (SINGLE)

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Do you have a single professional who takes responsibility for coordinating your care across the
services that you use?
IF NEEDED: Healthcare professionals include doctors, nurses, and other health professionals.
IF NEEDED: A professional may coordinate your care by being the first point of contact with the
health care system.
1
2
3
-9

YES
NO
NOT SURE
REFUSED

ASK IF Q_CHRONCOND = 1 TO 12 AND Q_P3CEQ6 = 1
NEW PAGE
Q_ P3CEQ5m1 (SINGLE)
Is this the same professional that you see for most of your health problems?
1
2
3
-8

YES
NO
NOT SURE
REFUSED

ASK IF Q_CHRONCOND = 1 TO 12 AND Q_P3CEQ6 = 1 AND Q_P3CEQ5m1 = 2 OR 3
NEW PAGE
Q_P3CEQ5m2 (SINGLE)
SHOWCARD PR12
Who is this professional? Are they a primary care doctor, specialist, primary care nurse, hospital
nurse, some other professional or not sure?
1
2
3
4
5
6
7
8
-9

A PRIMARY CARE DOCTOR -FAMILY DOCTOR- GENERAL
PRACTITIONER
A SPECIALIST DOCTOR
A PRIMARY CARE NURSE
A HOSPITAL NURSE
OTHER DOCTOR
OTHER NURSE
OTHER HEALTHCARE PROFESSIONAL
NOT SURE
REFUSED

ASK IF Q_CHRONCOND = 1 TO 12
NEW PAGE
Q_P3CEQ5 (SINGLE)
SHOWCARD PR8
Is your health care organized in a way that works for you? Would you say not at all, to some
extent, more often than not, always, or not sure?

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1
2
3
4
5
-9

NOT AT ALL
TO SOME EXTENT
MORE OFTEN THAN NOT
ALWAYS
NOT SURE
REFUSED

ASK IF Q_CHRONCOND = 1 TO 12
NEW PAGE
Q_ROUTINEF (SINGLE)
Are you offered regular follow-up for your health condition(s)? If you have more than one
condition, please answer about the condition that you are seen for most regularly.
1
2
3
-9

YES
NO
NOT SURE
REFUSED

ASK IF Q_ ROUTINEF = 1
NEW PAGE
Q_ROUTINEF2 (SINGLE)
How often are you offered regular follow-up visits for any of your health problems? Would you say
every 3 months or more often, every 6 months, every 12 months, over longer periods of time, or
not sure?
IF NEEDED: If you have more than one condition, please answer about the condition that you are
seen for most regularly.
1
2
3
4
5
-9

YES, ABOUT EVERY 3 MONTHS OR MORE OFTEN
YES, ABOUT EVERY 6 MONTHS
YES, ABOUT EVERY 12 MONTHS
YES, OVER LONGER PERIODS OF TIME
NOT SURE
REFUSED

ASK IF Q_CHRONCOND = 1 TO 12
NEW PAGE
Q_P3CE (LOOP)
P3CEQ1

SHOWCARD PR8
Do you discuss with the healthcare professionals involved in your care what is
most important for you in managing your own health and wellbeing? Would you
say not at all, to some extent, more often than not, always, or not relevant?

P3CEQ2

IF NEEDED: Healthcare professionals include doctors, nurses, and other health
professionals.
SHOWCARD PR8
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Attach2_PaRIS_Specifications

P3CEQ3

Are you involved as much as you want to be in decisions about your care? Would
you say not at all, to some extent, more often than not, always, or not relevant?
SHOWCARD PR8
Are you considered as a ‘whole person’ rather than just a disease/condition in
relation to your care? Would you say not at all, to some extent, more often than
not, always, or not relevant?

Responses (SINGLE)
1
2
3
4
5
-9

NOT AT ALL
TO SOME EXTENT
MORE OFTEN THAN
NOT
ALWAYS
NOT RELEVANT
REFUSED

ASK IF Q_CHRONCOND = 1 TO 12
NEW PAGE
Sometimes health professionals support patients in defining health goals. These are things that
are important to you and you want help in achieving, doing more of, or simply keep doing (such as
physical activity, minimising the need for medicines, coping better with your health condition(s) or
understanding better your condition(s)).
ASK ALL
NEW PAGE
Q_PCMH4 (SINGLE)
SHOWCARD PR13
How often does someone at your primary care provider’s office talk to you about specific goals for
your health? Would you say always, often, sometimes, rarely, never, or not sure?
1
2
3
4
5
6
-9

ALWAYS
OFTEN
SOMETIMES
RARELY
NEVER
NOT SURE
REFUSED

ASK ALL
NEW PAGE
The next few questions are about care plans. This is a written agreement between you and your
healthcare professionals detailing the type of care you receive over an extended period of time
and how this care will be given, also including what you will do yourself. Not everybody has a care
plan.
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Attach2_PaRIS_Specifications
ASK IF Q_CHRONCOND = 1 TO 12
NEW PAGE
Q_P3CEQ7a
Do you have a care plan that takes into account all your health and wellbeing needs?
1
2
3
-9

YES
NO
NOT SURE
REFUSED

ASK IF Q_CHRONCOND = 1 TO 12 AND Q_P3CEQ7a = 1
NEW PAGE
Q_P3CEQ7b (SINGLE)
Is this care plan (or plan of care) available to you?
1
2
3
-9

YES
NO
NOT SURE
REFUSED

ASK IF Q_CHRONCOND = 1 TO 12 AND Q_P3CEQ7a = 1
NEW PAGE
P3CEQ7c (SINGLE)
SHOWCARD PR8
To what extent have you found your care plan (or plan of care) useful for you to manage your
health and wellbeing? Would you say not at all, to some extent, more often than not, always, or
not sure?
1
NOT AT ALL
2
TO SOME EXTENT
3
MORE OFTEN THAN NOT
4
ALWAYS
5
NOT SURE
-9
REFUSED

ASK IF Q_CHRONCOND = 1 TO 12 AND Q_P3CEQ7a = 1
NEW PAGE
Q_P3CEQ7d (SINGLE)
SHOWCARD PR8
To what extent do all the professionals involved in your care appear to be following the same care
plan?
IF NEEDED: Would you say not at all, to some extent, more often than not, always, or not sure?
IF NEEDED: Healthcare professionals include doctors, nurses, and other health professionals.
1
NOT AT ALL
2
TO SOME EXTENT
3
MORE OFTEN THAN NOT
23

Attach2_PaRIS_Specifications
4
5
-9

ALWAYS
NOT SURE
REFUSED

ASK IF Q_CHRONCOND = 1 TO 12
NEW PAGE
Q_P3CEQ8 (SINGLE)
Do you have enough support from your healthcare professionals to help you to manage your own
health and wellbeing? Would you say you do not need support, have had no support, sometimes
have enough support, often have enough support, always have enough support, not relevant, or
not sure?
IF NEEDED: Healthcare professionals include doctors, nurses, and other health professionals.
1
I DO NOT NEED SUPPORT
2
I HAVE HAD NO SUPPORT
3
I SOMETIMES HAVE ENOUGH SUPPORT
4
I OFTEN HAVE ENOUGH SUPPORT
5
I ALWAYS HAVE ENOUGH SUPPORT
6
NOT RELEVANT
7
NOT SURE
-9
REFUSED
ASK IF Q_CHRONCOND = 1 TO 12
NEW PAGE
P3CEQ9 (SINGLE)
To what extent do you receive useful information at the time you need it to help you manage your
health and wellbeing? Would you say you do not receive any information, you sometimes receive
enough information, you often receive enough information, you always receive enough
information, you receive too much information, not relevant or not sure?
1
I DO NOT RECEIVE ANY INFORMATION
2
I SOMETIMES RECEIVE ENOUGH INFORMATION
3
I OFTEN RECEIVE ENOUGH INFORMATION
4
I ALWAYS RECEIVE ENOUGH INFORMATION
5
I RECEIVE TOO MUCH INFORMATION
6
NOT RELEVANT
7
NOT SURE
-9
REFUSED
ASK IF Q_CHRONCOND = 1 TO 12
NEW PAGE
Q_P3CEQ11b (SINGLE)
Do your healthcare professionals involve your family, friends and/or caregivers much as you want
them to be in decisions about your care? Would you say not at all, to some extent, more often
than not, always, you do not want them to be involved, they do not want to be involved or not
applicable?
1
NOT AT ALL
2
TO SOME EXTENT
24

Attach2_PaRIS_Specifications
3
4
5
6
7
-9

MORE OFTEN THAN NOT
ALWAYS
I DO NOT WANT MY FAMILY, FRIENDS OR
CAREGIVERS TO BE INVOLVED
MY FAMILY, FRIENDS OR CAREGIVERS DO NOT
WANT TO BE INVOLVED
NOT APPLICABLE
REFUSED

ASK IF Q_CHRONCOND = 1 TO 12
NEW PAGE
Q_MEDCWF1605 (SINGLE)
How many different medications as prescribed by a doctor or a nurse are you taking on a regular
or ongoing basis? Would you say no medication, 1-4 different medications, 5-9 medications, 10-15
medications, or 16 or more medications?
1
NO MEDICATION
2
1-4 DIFFERENT MEDICATIONS
3
5-9 MEDICATIONS
4
10-15 MEDICATIONS
5
16 OR MORE MEDICATIONS
-8
DON’T KNOW
-9
REFUSED
ASK IF Q_CHRONCOND = 1 TO 12 AND Q_MEDCWF1605 = 2 TO 5
NEW PAGE
Q_MEDCWF71110 (SINGLE)
In the past 12 months, has a healthcare professional reviewed with you all medications you take?
IF NEEDED: Healthcare professionals include doctors, nurses, and other health professionals.
1
YES
2
NO
3
NOT SURE
4
I AM NOT TAKING ANY MEDICATION
-8
DON’T KNOW
-9
REFUSED
ASK ALL
NEW PAGE
The next few questions are about your experience with your primary care provider’s office in the
last 12 months.
ASK ALL
Q_ P3CEQ4 (SINGLE)
SHOWCARD PR15
Were there times when you had to repeat information that should have been in your medical
records? Would you say yes, definitely; yes, to some extent; no, not really; no, definitely not; or
not sure?
25

Attach2_PaRIS_Specifications
1
2
3
4
5
-9

YES, DEFINITELY
YES, TO SOME EXTENT
NO, NOT REALLY
NO, DEFINITELY NOT
NOT SURE
REFUSED

ASK ALL
NEW PAGE
Q_PREOS3 (SINGLE)
SHOWCARD PR13
Sometimes patients experience an event or circumstance that could have resulted, or did result, in
unnecessary harm to themselves, such as not getting an appointment when needed; receiving a
wrong or delayed diagnosis or treatment; or experiencing problems with communications
between healthcare professionals.
How often do you believe you had any such event or circumstance with your primary care
provider’s office?
1
2
3
4
5
98
-8
-9

ALWAYS
OFTEN
SOMETIMES
RARELY
NEVER
NOT APPLICABLE
DON’T KNOW
REFUSED

ASK ALL
NEW PAGE
Q_PREOS1 (SINGLE)
SHOWCARD PR13
How often did you feel that the healthcare professionals at your primary care provider’s office
encouraged you to talk about any concerns about your healthcare?
IF NEEDED: Would you say always, often, sometimes, rarely, never, or not applicable?
IF NEEDED: Healthcare professionals include doctors, nurses, and other health professionals.
1
ALWAYS
2
OFTEN
3
SOMETIMES
4
RARELY
5
NEVER
98
NOT APPLICABLE
-8
DON’T KNOW
-9
REFUSED
26

Attach2_PaRIS_Specifications

ASK ALL
NEW PAGE
Q_OECDACC3 (SINGLE)
SHOWCARD PR13
How often did you have a health problem but did not seek care because of difficulties in travelling
to your primary care provider’s office?
IF NEEDED: Would you say always, often, sometimes, rarely, never, or not applicable?
1
ALWAYS
2
OFTEN
3
SOMETIMES
4
RARELY
5
NEVER
98
NOT APPLICABLE
-8
DON’T KNOW
-9
REFUSED
ASK ALL
NEW PAGE
Q_ OECDACC46 (SINGLE)
SHOWCARD PR13
How often did you have a health problem but did not seek care, or did take a prescription
medicine because of the cost?
IF NEEDED: Would you say always, often, sometimes, rarely, never, or not applicable?
1
ALWAYS
2
OFTEN
3
SOMETIMES
4
RARELY
5
NEVER
98
NOT APPLICABLE
-8
DON’T KNOW
-9
REFUSED
ASK ALL
NEW PAGE
The next questions are about the online services that your primary care provider’s office may offer
to patients like you, such as a website, smartphone app or video consultations.
ASK ALL
NEW PAGE
Q_GPPS4 (SINGLE)
How easy is it for you to use your primary care provider’s website to look for information or access
services? Would you say very easy, fairly easy, not very easy, not at all easy, you haven’t tried,
your provider doesn’t have one, or not sure?
27

Attach2_PaRIS_Specifications
1
2
3
4
5
6
7

VERY EASY
FAIRLY EASY
NOT VERY EASY
NOT AT ALL EASY
I HAVEN’T TRIED
MY PRIMARY CARE PROVIDER DOES NOT
HAVE A WEBSITE
NOT SURE

ASK ALL
NEW PAGE
Q_GPPS5 (MULTI)
As far as you know, which of the following online services does your primary care provider’s office
offer? Booking appointments online, ordering repeat prescriptions online, accessing medical
records online, video consultations, none of these, or you don’t know?
SELECT ALL
1
BOOKING APPOINTMENTS ONLINE
2
ORDERING REPEAT PRESCRIPTIONS ONLINE
3
ACCESSING MY MEDICAL RECORDS ONLINE
4
VIDEO CONSULTATIONS
5
NONE OF THESE
99
DON’T KNOW
-9
REFUSED
ASK ALL
NEW PAGE
Q_GPPS6 (MULTIPLE)
Which of the following online services offered by your primary care provider’s office have you
used? Booking appointments online, ordering repeat prescriptions online, accessing your medical
records online, video consultations, or none of these?
SELECT ALL
1
BOOKING APPOINTMENTS ONLINE
2
ORDERING REPEAT PRESCRIPTIONS ONLINE
3
ACCESSING MY MEDICAL RECORDS ONLINE
4
VIDEO CONSULTATIONS
5
NONE OF THESE
-8
DON’T KNOW
-9
REFUSED
ASK ALL
NEW PAGE
Q_CWF119 (SINGLE)
SHOWCARD PR1
When taking all things into consideration in relation to the care you have received, overall, how do
you rate the medical care that you have received in the past 12 months from your primary care
provider’s office? Would you say excellent, very good, good, fair, poor, you haven’t received
medical care in the last 12 months, or not sure?
28

Attach2_PaRIS_Specifications
1

EXCELLENT

2

VERY GOOD

3

GOOD

4

FAIR

5

POOR

6

HAVE NOT RECEIVED MEDICAL
CARE IN THE LAST 12 MONTHS

7

NOT SURE

-8

DON’T KNOW

-9

REFUSED

ASK ALL
NEW PAGE

Other health services
The next few questions are about other health services you have used in the last 12 months.
ASK ALL
NEW PAGE
Q_ EMERG (SINGLE)
In the last 12 months, have you been to a hospital emergency department for your own medical
care?
IF NEEDED: How many times? Once, twice, or 3 or more times?
1
NO
2
YES, ONCE
3
YES, TWICE
4
YES, 3 OR MORE TIMES
5
NOT SURE
-8
DON’T KNOW
-9
REFUSED
ASK ALL
NEW PAGE
Q_CWF2016HOSP (SINGLE)
In the last 12 months, have you been in a hospital for one night or longer?
IF NEEDED: How many times? Once, twice, or 3 or more times?
1
NO
2
YES, ONCE
3
YES, TWICE
4
YES, 3 OR MORE TIMES
5
NOT SURE
-8
DON’T KNOW
29

Attach2_PaRIS_Specifications
-9

REFUSED

ASK ALL
NEW PAGE

Your last consultation (SHOW ON SCREEN FOR ALL QS UP TO Q_OECDEXP5)

The next questions are about the last time that you had a visit with a primary care doctor, nurse or
other healthcare professional to get care for yourself (this may have been with your main
healthcare professional or another healthcare professional and includes consultations over the
phone or in a doctor’s office, a clinic, or the outpatient department of a hospital). Do not include
care you received when you stayed overnight in a hospital, accident and emergency care, or dental
care visits.
ASK ALL
NEW PAGE
Q_PURPOS (SINGLE)
What was the main purpose of this visit? Would you say first contact for a new problem, follow-up
for a new problem, routine care for a long-term problem, non-routine care for long-term problem,
general preventive care, or not sure?
1
FIRST CONTACT FOR A NEW PROBLEM
2
FOLLOW-UP FOR A NEW PROBLEM
3
ROUTINE CARE FOR A LONG-TERM PROBLEM
4
NON-ROUTINE CARE FOR A LONG-TERM
PROBLEM
5
GENERAL PREVENTIVE CARE
6
NOT SURE
-9
REFUSED
ASK ALL
NEW PAGE
Q_OECDACC7a (SINGLE)
Who did you have this last visit with? If you saw more than one professional, please select the one
you spent most time with on the day. A primary care doctor, another specialist doctor, a nurse, an
allied healthcare professional such as a physiotherapist, dietician or podiatrist, another healthcare
professional, or not sure?
1
A PRIMARY CARE DOCTOR
2
ANOTHER SPECIALIST DOCTOR
3
A NURSE
4
AN ALLIED HEALTHCARE PROFESSIONAL,
SUCH AS A PHYSIOTHERAPIST,
DIETICIAN/DIETICIAN NUTRITIONIST, OR
PODIATRIST
5
ANOTHER HEALTHCARE PROFESSIONAL
6
NOT SURE
-9
REFUSED

ASK ALL
30

Attach2_PaRIS_Specifications
NEW PAGE
Q_OECDACC7b (SINGLE)
Where was this professional working? A primary care provider’s office, an outpatient department
of a hospital, other, not sure, or not applicable?
1
A PRIMARY CARE PROVIDER’S OFFICE
2
AN OUTPATIENT DEPARTMENT OF A
HOSPITAL
3
OTHER
4
NOT SURE
5
NOT APPLICABLE
-9
REFUSED
ASK ALL
NEW PAGE
Q_OECDACC7c (MULTI)
Which of the following best describes the type of care you received? Face-to-face visit in a
professional’s office, telephone visit, video visit, home visit, other or not sure?
SELECT ALL
1
FACE-TO-FACE VISIT IN HEALTH PROFESSIONAL’S OFFICE
2
TELEPHONE VISIT
3
VIDEO VISIT
4
HOME VISIT
5
OTHER
6
NOT SURE
-9
REFUSED
ASK ALL
NEW PAGE
GPPSACCESS (SINGLE)
SHOWCARD PR14
How long after initially trying to book the appointment did the appointment take place? On the
same day, next day, a few days and up to a week later, more than a week and up to one month
later, more than one month later or you can’t remember?
1
ON THE SAME DAY
2
ON THE NEXT DAY
3
A FEW DAYS AND UP TO A WEEK LATER
4
MORE THAN A WEEK AND UP TO ONE
MONTH LATER
5
MORE THAN ONE MONTH LATER
6
CAN’T REMEMBER
-9
REFUSED
ASK ALL
NEW PAGE
Q_OECDACC9 (SINGLE)
Was the time you waited a problem for you?
1

YES
31

Attach2_PaRIS_Specifications
2
3
-9

NO
NOT SURE
REFUSED

ASK ALL
NEW PAGE
Q_OECDACC8 (SINGLE)
SHOWCARD PR15
Did this healthcare professional spend enough time with you? Would you say yes, definitely; yes,
to some extent; no, not really; no, definitely not; or not sure?
1
YES, DEFINITELY
2

YES, TO SOME EXTENT

3

NO, NOT REALLY

4

NO, DEFINITELY NOT

5

NOT SURE

-9

REFUSED

ASK ALL
NEW PAGE
Q_OECDEXP2 (SINGLE)
SHOWCARD PR15
Did this healthcare professional explain things in a way that was easy to understand?
IF NEEDED: Would you say yes, definitely; yes, to some extent; no, not really; no, definitely not; or
not sure?
1
YES, DEFINITELY
2

YES, TO SOME EXTENT

3

NO, NOT REALLY

4

NO, DEFINITELY NOT

5

NOT SURE

-9

REFUSED

ASK ALL
NEW PAGE
Q_OECDEXP3 (SINGLE)
SHOWCARD PR15
Did this healthcare professional give you an opportunity to ask questions or raise concerns about
recommended treatment?
IF NEEDED: Would you say yes, definitely; yes, to some extent; no, not really; no, definitely not; or
not sure?
1
YES, DEFINITELY
2

YES, TO SOME EXTENT
32

Attach2_PaRIS_Specifications
3

NO, NOT REALLY

4

NO, DEFINITELY NOT

5

NOT SURE

-9

REFUSED

ASK ALL
NEW PAGE
Q_GPPSTRUST (SINGLE)
SHOWCARD PR8
Did you have confidence and trust in the healthcare professional you saw or spoke to?
IF NEEDED: Would you say yes, definitely; yes, to some extent; no, not really; no, definitely not; or
not sure?
1
NOT AT ALL
2

TO SOME EXTENT

3

MORE OFTEN THAN NOT

4

ALWAYS

5

NOT SURE

-9

REFUSED

ASK ALL
NEW PAGE
Q_OECDEXP5 (SINGLE)
SHOWCARD PR1
Overall, how would you rate the quality of this visit? Would you say excellent, very good, good,
fair, poor, or not sure?
1
EXCELLENT
2

VERY GOOD

3

GOOD

4

FAIR

5

POOR

6

NOT SURE

-9

REFUSED

ASK ALL
NEW PAGE
The next questions are about your experience of care in relation to the COVID-19/coronavirus
pandemic.
Q_COVID1 (SINGLE)
In the last 12 months, has a healthcare professional or laboratory result confirmed to you that you
have had COVID-19?
33

Attach2_PaRIS_Specifications

1
2
3
-9

YES
NO
NOT SURE
REFUSED

ASK ALL
NEW PAGE
Q_HSE2018m (SINGLE)
In the last 12 months, have you received at least one vaccination for COVID-19?
1
5
6
-9

YES
NO
NOT SURE
REFUSED

ASK ALL
NEW PAGE
Q_GPPSCV2a (MULTIPLE)
In the last 12 months, have you avoided making an appointment at your primary care provider’s
office for any reasons?
1
6
7
8
-9

YES
I DIDN´T NEED AN APPOINTMENT
NO
NOT SURE
REFUSED

ASK IF Q_GPPSCV2a=1
NEW PAGE
Q_GPPSCV2b (MULTIPLE)
Why did you avoid making an appointment? Would you say this was because you didn’t have
time, you were worried about the risk of catching COVID-19, you were worried about the burden
to the health care system, you found it too difficult, another reason, or not sure?
IF NEEDED: Any other reason?
SELECT ALL
1
I DID NOT HAVE TIME
2
I WAS WORRIED ABOUT THE RISK OF
CATCHING COVID-19
3
I WAS WORRIED ABOUT THE BURDEN TO
THE HEALTH SYSTEM
4
I FOUND IT TOO DIFFICULT
5
FOR ANOTHER REASON
8
Not sure
-9
REFUSED

34

Attach2_PaRIS_Specifications
ASK ALL
NEW PAGE
Q_COVID2 (SINGLE)
SHOWCARD PR12
In the last 12 months, how often have you been concerned that you may not be receiving the care
you needed because services were focusing on the response to the COVID-19 pandemic? Would
you say always, often, sometimes, rarely, never, or not applicable?
1
ALWAYS
2
OFTEN
3
SOMETIMES
4
RARELY
5
NEVER
98
NOT APPLICABLE
-9
REFUSED

ASK ALL
NEW PAGE

About yourself
Finally, we would like to ask you some information about yourself. It is important to collect this
information to understand whether there are any differences in the quality of services
experienced by different groups of people.
ASK ALL
NEW PAGE
Q_ISCED (SINGLE)
What is the highest educational level that you have attained?
1
2
3
4
5
6
7
8
9
10
11
12
13

GRADE 4 OR LESS
GRADE 5 TO 8
GRADE 9 TO 11
GRADE 12 (NO DIPLOMA)
REGULAR HIGH SCHOOL DIPLOMA
GED OR ALTERNATIVE CREDENTIAL
SOME COLLEGE CREDIT, BUT LESS THAN 1 YEAR
1 OR MORE YEARS OF COLLEGE CREDIT, NO
DEGREE
ASSOCIATE’S DEGREE (AA, AS, ETC)
BACHELOR’S DEGREE (BA, BS, ETC.)
MASTER’S DEGREE (MA, MS, MBA, ETC.)
PROFESSIONAL DEGREE (MD, DDS, JD, ETC.)
DOCTORATE DEGREE (PhD, EdD, ETC.)

ASK ALL
NEW PAGE
Q_SEX/GENDER (SINGLE, OPEN)
Are you…?
35

Attach2_PaRIS_Specifications

1
2
3
97

FEMALE
MALE
OTHER
PREFER NOT TO SAY

ASK ALL
NEW PAGE
Q_OECDLGBTI (SINGLE)
This question is about your sexual orientation. Do you identify as: heterosexual or straight, gay or
lesbian, bisexual, something else, or would you prefer not to say?
IF NEEDED: Heterosexual or straight means being attracted to the opposite sex. Gay or Lesbian
means being attracted to the same sex. Bisexual means being attracted to both sexes.
1
2
3
4
97

HETEROSEXUAL OR STRAIGHT
GAY OR LESBIAN
BISEXUAL
SOMETHING ELSE
PREFER NOT TO SAY

ASK ALL
NEW PAGE
Q_OECDLIT5a (SINGLE)
Which of these terms best describes your current work situation? Self-employed, in paid
employment, looking for work, looking after the home, unable to work due to sickness or illhealth, retired, not working and not looking for work, other, or don’t know?
1
2
3
4
5
6
8
10
99

SELF-EMPLOYED [WORK FOR
YOURSELF]
IN PAID EMPLOYMENT [WORK FOR
SOMEONE ELSE]
LOOKING FOR WORK
LOOKING AFTER THE HOME
UNABLE TO WORK DUE TO SICKNESS
OR ILL-HEALTH
RETIRED
NOT WORKING AND NOT LOOKING
FOR WORK
OTHER
DON’T KNOW

ASK ALL
NEW PAGE
Q_OECDLIT7 (SINGLE)
Which of these categories does your total income before taxes usually fall into? Include income
from jobs, Social Security, Railroad Retirement, other retirement income, and the other sources of
income.

36

Attach2_PaRIS_Specifications
IF NEEDED: Please provide your total income after taxes during the past 12 months. Include
income from jobs, Social Security, Railroad Retirement, other retirement income, and any other
sources of income.
1
2
3
99
97

UP TO $50,640 A YEAR
BETWEEN $50,640 AND $84,401 A
YEAR
$84,401OR MORE A YEAR
DON’T KNOW
PREFER NOT TO SAY

ASK ALL
NEW PAGE
Q_MONMED (SINGLE)
In the past 12 months, did you have problems paying or were unable to pay any medical bills?
1
2
98

YES
NO
NOT APPLICABLE

ASK ALL
NEW PAGE
Q_MON (Show on different screens)
SHOWCARD PR13
How often in the past 12 months would you say you were worried or stressed about the following
things? Would you say always, often, sometimes, rarely, or never?
MONMEAL Having enough money to buy healthy meals?
MONRENT Having enough money to pay your rent or mortgage?
MONBILLS Having enough money to pay for other monthly bills, like
electricity, heat, and your telephone?
Responses (SINGLE)
1
2
3
4
5
-8
-9

ALWAYS
OFTEN
SOMETIMES
RARELY
NEVER
DON’T KNOW
REFUSED

ASK ALL
NEW PAGE
MEDHIMS6
Were you born in the United States of America? (SINGLE, OPEN)
1

YES
37

Attach2_PaRIS_Specifications
2
-8
-9

NO
DON’T KNOW
REFUSED

ASK IF MEDHIMS6=2
NEW PAGE
MEDHIMS6_OS (OPEN)
What country were you born in?
1
-8
-9

OPEN TEXT
DON’T KNOW
REFUSED

ASK ALL
NEW PAGE
MEDHIMS7
Are you a citizen of the United States of America? (SINGLE, OPEN)
1
2
-8
-9

YES
NO
DON’T KNOW
REFUSED

ASK IF MEDHIMS7=2
NEW PAGE
MEDHIMS7_OS (OPEN)
What country are you a citizen of?
1
-8
-9

OPEN TEXT
DON’T KNOW
REFUSED

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Q_AREA
Which of these best describes the type of area in which you live? City, town or suburb, rural area,
or are you not sure?
1
2
3
4
-9

CITY
TOWN OR SUBURB
RURAL AREA
DON’T KNOW
REFUSED

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Attach2_PaRIS_Specifications
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WHODIS (Show on different screens)
Should you need help, how easy is it for you to get help from the following people? Would you say
very easy, easy, neither easy nor difficult, difficult, very difficult, or not applicable?
WHODIS1

A close family member (including your
partner)?

WHODIS2

Friends, neighbors and co-workers?

Responses (SINGLE)
1
VERY EASY
2
EASY
3
NEITHER EASY NOR DIFFICULT
4
DIFFICULT
5
VERY DIFFICULT
6
NOT APPLICABLE
-8
DON’T KNOW
-9
REFUSED

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WHOWB11 (SINGLE)
Do you need physical care or support, such as help with eating, dressing, bathing, moving around
the house or assistance outside the house such as for using transportation?
1
2
-8
-9

YES
NO
DON’T KNOW
REFUSED

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Q_WHOWB11 (SINGLE)
Do you need emotional care or support, such as comfort, advice or counseling?
1
2
-8
-9

Yes
No
DON’T KNOW
REFUSED

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Q_WHOWB12 (SINGLE)
Do you need support for health care, such as administering medicines, changing bandages or
arranging for appointments with primary care providers?
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Attach2_PaRIS_Specifications

1
2
-8
-9

Yes
No
DON’T KNOW
REFUSED

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Q_AGSCTRUST
SHOWCARD PR7
How strongly do you agree or disagree that the health care system can be trusted? Would you say
strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?
1
2
3
4
5
-8
-9

STRONGLY DISAGREE
DISAGREE
NEITHER AGREE NOR DISAGREE
AGREE
STRONGLY AGREE
DON’T KNOW
REFUSED

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END
Thank you for your time and participation in this survey.

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