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All Respondents Questionnaire

This instrument was developed for the National Board and Care Survey project. This project was conducted by the Bureau of the Census under contract for the Department of Health and Human Services (HHS) Office of Disability, Aging and Long-Term Care Policy. For additional information about this subject, you can visit the DALTCP home page at or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: The DALTCP Project Officer was Robert Clark.

NOTE: This is a recreation of this form. See the PDF version for a scanned version of the actual form.





STATE: _________________________
AGENCY: _________________________
CONTACT: _________________________  
POSITION: _________________________
DATE: _________________________
INTERVIEWER: _________________________  


START TIME: _________________________    


Hello, my name is _________________________ with the Research Triangle Institute in North Carolina. We are conducting a study of state involvement in the regulation of board and care facilities for the American Association of Retired Persons (AARP). The purpose of the study is to describe various aspects of each state's board and care environment. We are talking with several people within every state who have experience with a specific aspect of board and care, for instance you have been identified as one of the people within your state with experience in the _________________________ of board and care homes. The information which we collect will be used to develop state profiles of board and care involvement, as well as to provide a summary of board and care activities across the U.S. WE WILL PROVIDE AARP WITH A DATABASE CONTAINING INFORMATION ON ALL RESPONSES, AS WELL AS, A LIST OF CONTACT NAMES.



1. How is your agency primarily involved with board and care homes? (IF MORE THAN ONE AREA OF INVOLVEMENT IS GIVEN, TRY TO DETERMINE WHAT THE MAJOR INVOLVEMENT IS.)

_____ Licensure (USE QUESTIONNAIRE 2)
_____ Monitoring/Inspection (USE QUESTIONNAIRE 2, PART 2)
_____ Enforcement (USE QUESTIONNAIRE 2)
_____ Payment/Reimbursement (USE QUESTIONNAIRE 3)
_____ Case Management (USE QUESTIONNAIRE 4)
_____ Placement and referral (USE QUESTIONNAIRE 4)


_____ County Dept. of Social Services/Welfare (USE QUESTIONNAIRE 4)
_____ Local Ombudsman (USE QUESTIONNAIRE 5)

2. Does your agency license, monitor or provide funding for facilities serving a primarily elderly population (elderly meaning persons over 60 years old)?

_____ Yes
_____ No

3. Does your agency provide services to a primarily elderly population?

_____ Yes
_____ No


ENDING TIME: _________________________