Page 194 - QAP Manual 2020

NCI™ ADULT IN-PERSON SURVEY (IPS) 2020-21

BI-72 If this person required in-patient hospitalization due to COVID-19, where did this person go
after leaving the hospital?

□ 98. Did not require in-patient hospitalization due to COVID-19
□ 1. Returned to the home where they lived prior to hospitalization
□ 2. Their family home [Note: If they lived in the family home prior to hospitalization, please
choose option 1.]
□ 3. A different group home/provider operated residential setting than where they lived prior to
hospitalization
□ 4. A nursing home [Note: If they lived in a nursing home prior to hospitalization, please choose
option 1.]
□ 5. A rehabilitation facility
□ 6. Other _(please add specifics)______________________
□ 99. Don’t know

BI-73 What was the source(s) for the Background Information for this survey? Check ALL THAT
APPLY.
□ 1. Case Management/Service Coordinator Records
□ 2. Service Provider Records

□ 3. Regional Center Database
□ 4. Medi-Cal Agency Database
□ 5. Individual being surveyed/family member
□ 6. Other:__________________________________________________________________

• END OF BACKGROUND INFORMATION SECTION •

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