Case identification number
Relation to Main R
reason for proxy
month of death
year of death
main cause of death
ZY8 CAUSE OF DEATH CODED
how long ill
units of how long ill
any other illness at time of death
other illness at time of death
ZY12 CAUSE OF DEATH CODED
weeks hosp 12 mo prior to death
weeks nursing home 12 mo prior to death
add weeks required care 12 mo prior to death
who provided most care
where living just before death
since (date) live at son/daughter/relative
lived with whom
how long at son/daugher/relative
units at son/daughter/relative
receive pension other than ss at time of death
work for pay since (date)
year last worked for pay
hours per week last year working
any 3+ mo not work from (date) to date stopped
where R currently lives
month began living there
year began living there
how many people live there
how are they related - 1
how are they related - 2
how are they related - 3
how are they related - 4
how are they related - 5
how are they related - 6
how are they related - 7
how are they related - 8
most serious condition
CHRONIC HEALTH CONDITION 1 (ZY32T01)
CHRONIC HEALTH CONDITION 2 (ZY32T01)
next most serious condition
CHRONIC HEALTH CONDITION 1 (ZY32T02)
CHRONIC HEALTH CONDITION 2 (ZY32T02)
need assistance with bathing/showering
need assistance with dressing
need assistance with eating
need assistance with getting in/out bed/chair
need assistance with using toilet
how long needed assistance
unit of time needed assist
receive help past 12 mo from not living with
who provided most help
male or female
weeks help last 12 mo from this person
average hours helped per week
receive help past 12 mo from living with
receive pension other than ss
year last worked