Section 15, Part A - Medical and Health Expenditures - Screening Questions for Payments
Section 15, Part A collects out-of-pocket medical payments, including payments for medical services,
prescription drug purchases, and rentals or purchases of medical supplies and equipment. IMPORTANT: The Census Bureau
does not release to the Bureau of Labor Statistics any confidential information such as names and
addresses. This information is only used during the course of the interview.
Now I am going to ask some questions about medical payments and reimbursements.
I will begin with your payments.
By payments I mean any co-pays and out-of-pocket expenses. Include all payments, even those for
persons who are outside of your household.
Since the first of the reference month, have you or any members of your household made any
payments for the following?
* Read each item on list
- Eye examinations, treatment, or surgery
- Purchase of eye glasses or contact lenses
- Dental care
- Hospital room or hospital services
- Services by medical professionals other than physicians
- Physician services
- Continue list
For definitions Information Booklet »
Have you or any members of your household made any payments for
* Read each item on list
- Lab tests or x-rays
- Care in convalescent or nursing homes
- Care for invalids, convalescents,handicapped, or elderly persons in the home
- Adult day care centers
- Other medical care and services
- Hearing aids
- Prescription drugs
- Purchase or rental of supportive or rehabilitative equipment
- Purchase or rental of medical or surgical equipment for general use
- None/No More
For definitions Information Booklet »
* Ask if not apparent
Describe the care/service/item.[enter text] _______________
* Ask if not apparent
Describe the care/service/item.[enter text] _______________
* Ask if not apparent
Was this a purchase or rental?
* Ask if not apparent
Was/were the care/service/item for a member of your household or someone outside of your
household?
In what month was(were) the payment(s) made?
[enter text] _____________
* Enter 13 for same amount each month of the reference period
What was the total amount paid in the above month?/
What is your monthly expense?
[enter value] _____________
* Enter 'C' for a combined expense
What is the "care/service/item"combined with?
* Enter all that apply
Did you or any members of your household make any other payments for
the "care/service/item"?
End of Section 15A
Go to Section 15 Part B - Screening Questions for Reimbursements »
Go to CE CAPI Survey Instrument Home Page »
Last Modified Date: April 7,2016
United States Department of Labor
