* Ask if not apparent
Describe the care/service/item.[enter text] _______________
* Ask if not apparent
Who was/were the "care/service/item" for?
* Enter name of person: [enter text] _____________
In what month was(were) the payment(s) made?
[enter text] _____________
* Enter 13 for a continuous expense
What was the total amount paid in the above month?/
Enter monthly amount if continuous. [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 CU 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: November 21, 2006