- This instrument was developed for the National Long-Term Care Channeling Demonstration. This project was conducted by Mathematica Policy Research, Inc. under contract #HHS-100-80-0157 and Temple University under contract #HHS-100-80-0133 for the Department of Health and Human Services (HHS) Office of Social Services Policy (now Office of Disability, Aging and Long-Term Care Policy), as well as additional funding from the HHS Health Care Financing Administration (now Centers for Medicare and Medicaid Services) and HHS Administration on Aging. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm 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: webmaster.DALTCP@hhs.gov. 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. |
OMB APPROVAL NO: 0990-0074
EXPIRES: 9/30/84
MPR #743
NATIONAL LONG TERM CARE DEMONSTRATION
CLINICAL ASSESSMENT AND RESEARCH BASELINE INSTRUMENT
COMMUNITY VERSION
This report is authorized by law (Older Americans Act, Section 421; Social Security Act, Sections 1110, 1115, 1875 and 1881; and Public Health Service Act, Sections 1526 and 1533d). While you are not required to respond, your cooperation is needed to make the results of the survey comprehensive, accurate and timely.
| CLINICAL NOTES FROM THE SCREEN |
Mathematica Policy Research
January 11, 1982
This questionnaire was prepared for the Department of Health and Human Services under Contract No. HHS-100-80-0157.
| SAMPLE MEMBER ID. NUMBER |_____|_____| - |_____|_____|_____|_____|_____| - |_____| | ||
| SUBSAMPLE STATUS | YES | NO |
| CAREGIVER | 01 | 02 |
| PROVIDER | 01 | 02 |
| VALIDATION | 01 | 02 |
| COMPLETE INFORMED CONSENT FORMS |
First, I'd like to find out a little about you and your living situation.
You may have recently answered a few questions similar to the ones I am going to ask now. It is important that I ask them again so that we will have the same information on everyone.
A1. Are you married, widowed, divorced or separated, or have you never been married?
MARRIED . . . . . 01
WIDOWED . . . . . 02
DIVORCED . . . . . 03
SEPARATED . . . . . 04
NEVER MARRIED . . . . . 05 (A3)
NOT ANSWERED . . . . . -1 (A3)
A2. Were you MARITAL STATUS FROM A1 within the past year?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
A3. DOES SAMPLE MEMBER LIVE IN GROUP QUARTERS? IF PROXY, ASK: Does SAMPLE MEMBER live in a group home, like a boarding home, or a LOCAL TERMS FOR HOMES PROVIDING SUPPORTIVE SERVICES AND PERSONAL CARE?
YES . . . . . 01 (A8)
NO . . . . . 02
NOT ANSWERED . . . . . -1
A4. Do you live alone?
YES, ALONE . . . . . 01 (A8)
NO, WITH OTHERS . . . . . 02
NOT ANSWERED . . . . . -1
NAMES OF HOUSEHOLD MEMBERS
a. _________________________
b. _________________________
c. _________________________
d. _________________________
e. _________________________
f. _________________________
g. _________________________
h. _________________________
i. _________________________
j. _________________________
| COMMENTS ABOUT HOUSEHOLD COMPOSITION |
A5. Please tell me the names of everyone who usually lives with you. RECORD NAMES ON FACING PAGE. COUNT HOUSEHOLD MEMBERS OF USUAL HOME.
A6. How old is NAME? A7. How is NAME related to you? Spouse Child Grandchild Sibling Parent| Other
RelativeNon-
RelativeNA a. |_____|_____| 01 02 03 04 05 06 07 -1 b. |_____|_____| 01 02 03 04 05 06 07 -1 c. |_____|_____| 01 02 03 04 05 06 07 -1 d. |_____|_____| 01 02 03 04 05 06 07 -1 e. |_____|_____| 01 02 03 04 05 06 07 -1 f. |_____|_____| 01 02 03 04 05 06 07 -1 g. |_____|_____| 01 02 03 04 05 06 07 -1 h. |_____|_____| 01 02 03 04 05 06 07 -1 i. |_____|_____| 01 02 03 04 05 06 07 -1 j. |_____|_____| 01 02 03 04 05 06 07 -1
A8. Do you have any children (who do not live with you)? INCLUDE ONLY LIVING CHILDREN.
YES
How many? . . . . . |_____|_____|
NO . . . . . 00 (A10)
NOT ANSWERED . . . . . -1 (A10)
A9. (Do any of these children/Does this child) live within one-half hour travel time of you? IF PLACE NMES GIVEN, PROBE FOR TRAVEL TIME.
YES
NO . . . . . 00
NOT ANSWERED . . . . . -1
A10. Could you please tell me the name, address, and phone number of someone we might contact in case we have trouble getting in touch with you? RECORD NAME, ADDRESS, AND TELEPHONE NUMBER ON CONTACT SHEET IN QUESTION 15.
| NOTES ON RACIAL/ETHNIC BACKGROUND |
| NOTES ON PROBLEMS WITH ENGLISH/LITERACY |
A11. CODE WITHOUT ASKING IF BIRTHDATE PRECODED ONTO CONTACT SHEET (QUESTION 6) FROM SCREEN. What is your birthdate? PROBE: How old are you?
MONTH |_____|_____| DAY |_____|_____| YEAR |_____|_____|
NOT ANSWERED . . . . . -1
A12. What is the highest grade or year you finished in school? IF UNGRADED OR FOREIGN SCHOOL, PROBE: About what grade would that be equal to (in this country)?
NO SCHOOLING . . . . . 00
ELEMENTARY (01-08) . . . . . [_____]_____]
HIGH SCHOOL (09-12) . . . . . [_____]_____]
COLLEGE/GRADUATE (13-18+) . . . . . [_____]_____]
NOT ANSWERED . . . . . -1
A13. ASK IF NOT OBVIOUS,
What is your racial or ethnic background? PROBE: Are you of Spanish origin? READ CATEGORIES IF NECESSARY.
AMERICAN INDIAN OR ALASKAN NATIVE . . . . . 01
ASIAN OR PACIFIC ISLANDER . . . . . 02
BLACK, NOT OF HISPANIC ORIGIN . . . . . 03
HISPANIC . . . . . 04
WHITE, NOT OF HISPANIC ORIGIN . . . . . 05
NOT ANSWERED . . . . . -1
A14. CHECKPOINT A
DOES SAMPLE MEMBER SEEM VERY CONFUSED, DISORIENTED, ANXIOUS, OR EXHAUSTED?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -4
| NOTES ON SOURCES OF MEDICAL CARE |
B. PHYSICAL HEALTH
The next questions are about your physical health.
B1. How would you rate your overall health at the present time -- would you say
excellent, . . . . . 01
good, . . . . . 02
fair, . . . . . 03
or poor? . . . . . 04
NOT ANSWERED . . . . . -1
B2. Do you have a regular source of medical care, like a family doctor or a clinic?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
| NOTES ON HEALTH CONDITIONS |
| NOTES ON MEDICINES | |||
| MEDICINE | FREQUENCY | DOSAGE | DOCTOR |
B3. Now I am going to read you a list of health conditions and illnesses. Please tell me if you have any of them at the present time.
IF YES B4. Are you currently being treated for this condition? YES NO NA YES NO NA a. First, do you have anemia (tired blood, iron-poor blood)? 01 02 -1 01 02 -1 b. High blood pressure? 01 02 -1 01 02 -1 c. Angina or heart trouble,for example, heart attacks? 01 02 -1 01 02 -1 d. Effects of a stroke? 01 02 -1 01 02 -1 e. Diabetes? 01 02 -1 01 02 -1 f. Arthritis or pain in your joints? 01 02 -1 01 02 -1 g. Cancer, leukemia, or a tumor? 01 02 -1 01 02 -1 h. Nerve or muscle problems like neuralgia, Parkinson's disease, or seizures? 01 02 -1 01 02 -1 i. Respiratory problems like asthma, emphysema, or bronchitis? 01 02 -1 01 02 -1 j. Skin problems like a rash, eczema, or bed sores? 01 02 -1 01 02 -1 k. Broken or dislocated bones? 01 02 -1 01 02 -1 l. Paralysis? 01 02 -1 01 02 -1 m. Do you have any (other) health conditions or illnesses we haven't talked about? (SPECIFY) 01 02 - 01 02 -1 PROBE: Anything else? _________________________ 01 02 -1 01 02 -1
B5. I would like some information about the medicines you take regularly now. Let's start with your prescriptions. (May I see them?)
AFTER PRESCRIPTIONS NOTED, Are there any other medicines you keep in a special place, for example in the refrigerator, or any special medicines like eyedrops, suppositories or injections?
AFTER ANY SPECIAL MEDICINES NOTED, Are there any non-prescription medicines you take regularly like vitamines, aspirin, or laxatives?
RECORD MEDICINES ON OPPOSITE PAGE
NUMBER OF MEDICINES |_____|_____| REGULARLY = ON A ROUTINE BASIS AT THE PRESENT TIME.
| Are you frequently in pain? |
| NOTES ON DIET AND NUTRITION |
B6. DOES SAMPLE MEMBER HAVE ANY HEALTH CONDITIONS OR ILLNESSES IN B3?
YES . . . . . 01
NO . . . . . 02 (B9)
NOT ANSWERED . . . . . -1 (B9)
B7. Thinking about the (health condion(s)/illness(es)) you have now, did (it/any of these) first become a problem within the past year?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
B8. Did (it/any) become much worse
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
B9. Often what you eat is important to your health. Could you please tell me what you ate yesterday? PROBE: It may help to shart with what you ate for breakfast. READ CATEGORIES IF NECESSARY. CIRCLE ALL THAT APPLY.
DAIRY PRODUCTS, SUCH AS MILK, CHEESE, OR YOGURT . . . . . 01
"PROTEIN FOODS", SUCH AS MEAT, POULTRY, FISH, EGGS, OR DRIED BEANS . . . . . 02
FRUITS OR VEGETABLES-EITHER RAW, COOKED OR CANNED . . . . . 03
FOODS MADE FROM GRAINS, SUCH AS BREAD, CEREAL, NOODLES, OR RICE . . . . . 04
DID NOT EAT YESTERDAY . . . . . 05
DOES NOT EAT AT ALL (IV TUBES) . . . . . 06
NOT ANSWERED . . . . . -1
B10. Are you on a special diet?
YES . . . . . 01
NO . . . . . 02 (B12)
NOT ANSWERED . . . . . -1 (B12)
B11. Did a doctor prescribe it? INCLUDE DIETS "PRESCRIBED" BY DIETICIANS UNDER DOCTORS' ORDERS.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
| NOTES ON SPECIAL EQUIPMENT |
B12. CODE WITHOUT ASKING IF KNOWN. Do you smoke?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
B13. Now, I'd like to talk about special equipment you may use.
CODE WITHOUT ASKING IF KNOWN. Do you use any of the following special equipment or aids regularly now? REGULARLY = ON A RECURRING BASIS, DURING THE PAST WEEK.
YES NO NOT ANSWERED a. Dentures? 01 02 -1 b. A cane? 01 02 -1 c. A walker? 01 02 -1 d. A wheelchair? 01 02 -1 e. A leg brace? 01 02 -1 f. A back brace? 01 02 -1 g. A pacemaker (for your heart)? 01 02 -1 h. A hearing aid? 01 02 -1 i. Glasses or contact lenses? 01 02 -1 j. Any other special equipment that I haven't mentioned? (SPECIFY) _________________________ 01 02 -1
MEDICAL TREATMENTS AT HOME
| NOTES ON HELP AND HELP NEEDED |
| NOTES ON VISION PROBLEMS (GLASSES, CATARACTS, GLAUCOMA, NIGHTVISION, AND SO ON) |
| NOTES ON HEARING PROBLEMS, BY OBSERVATION OR PROBE (HEARING AID, NEED FOR RAISED VOLUME, AND SO ON) |
B14. Do you regularly have any medical treatments at home like injections, therapies, oxygen or changing of bandages? REGULARLY = ON A ROUTINE BASIS OF AT LEAST ONCE A WEEK, AT THE PRESENT TIME.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
B15. Do you feel that you are getting enough help to carry out these treatments at home or do you need more help with them?
ENOUGH HELP/NO HELP NEEDED . . . . . 01
NEED MORE HELP . . . . . 02
NOT ANSWERED . . . . . -1
B16. CODE WITHOUT ASKING IF KNOWN. (With your glasses or lenses) can you see well enough to read the labels on your medicine bottles or see the numbers on a telephone? IF FOREIGN, PROBE: Could you read a SM'S NATIVE LANGUAGE newspaper?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
B17. CAN THE SAMPLE MEMBER HEAR WELL ENOUGH TO UNDERSTAND NORMAL CONVERSATION (WITH A HEARING AID IF USUALLY WORN)?
ASK OF A PROXY RESPONDENT.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
B18. IS THE RESPONDENT A SAMPLE MEMBER OF A PROXY?
SAMPLE MEMBER . . . . . 01
PROXY . . . . . 02 (C1)
| NOTES ON COGNITIVE FUNCTIONING |
| DO NOT ASK OF A PROXY RESPONDENT |
B19. Sometimes when people get older, they have trouble remembering things. If you do not know the answers to some of the next questions, that's okay. It's very normal. If you do know the answers, the questions may seem obvious.
CORRECT INCORRECT/
NOT ANSWEREDa. What is the date today? _________________________ 01 02 b. What day of the week is it? _________________________ 01 02 c. What is the name of this place? PROBE: This neighborhood? This apartment (house/project)? _________________________
HOME, PLACE NAME ARE TYPICAL OF CORRECT RESPONSES.01 02 d. What is your telephone number? IF SAMPLE MEMBER DOES NOT HAVE A PHONE, What is your street address? _________________________ 01 02 e. How old are you? _________________________ 01 02 f. When were you born? MO:__________ DAY: _____ YR: __________
CHECK CONTACT SHEET QUESTOIN 6. IF NOT ON CONTACT SHEET, CHECK A11.01 02 g. What is the name of the President of the United States? _________________________ 02 h. Who was President before this one? _________________________ 01 02 i. What was your mother's maiden name? _________________________
ACCEPT ANY SURNAME OTHER THAN SM'S.01 02 j. Subtract 3 from 20 and keep subtracting 3 from each new number you get, all the way down. PROBE: Can you subtract 3 from that? _________________________
17, 14, 11, 8, 5, 201 02 Thank you. That's all of those questions.
|_____|_____| NUMBER CORRECT
B20. DID YOU USE CHECKPOINT A TO SKIP TO B19 (SEE A14)?
YES . . . . . 01
NO . . . . . 02
B21. CHECKPOINT B
DOES SAMPLE MEMBER SEEM VERY CONFUSED, DISORIENTED, ANXIOUS, OR EXHAUSTED?
YES . . . . . 01
NO . . . . . 02
| REASON(S) FOR HOSPITALIZATION(S) |
C. MEDICAL CARE UTILIZATION
C1. The next questions are about your use of medical services.
Since DATE 6 MONTHS AGO, how many times were you admitted to any kind of hospital? TRANSFER BETWEEN HOSPITALS = MULTIPLE ADMISSIONS.
ADMISSION . . . . . |_____|_____|
NONE . . . . . 00 (C5)
NOT ANSWERED . . . . . -1 (C5)
C2. (Starting with the most recent time,) could you please tell me which hospital(s) you were in since DATE 6 MONTHS AGO?
a. MOST RECENT STAY _________________________|_____|_____|_____|
NOT ANSWERED . . . . . -1b. NEXT MOST RECENT _________________________|_____|_____|_____|
NOT ANSWERED . . . . . -1c. NEXT MOST RECENT _________________________|_____|_____|_____|
NOT ANSWERED . . . . . -1d. NEXT MOST RECENT _________________________|_____|_____|_____|
NOT ANSWERED . . . . . -1e. NEXT MOST RECENT _________________________|_____|_____|_____|
NOT ANSWERED . . . . . -1
C3. Were you in the hospital since DATE 2 MONTHS AGO? PROBE: Did you stay overnight?
YES . . . . . 01
NO . . . . . 02 (C5)
NOT ANSWERED . . . . . -1 (C5)
C4. Altogether, how many days were you in the hospital since DATE 2 MONTHS AGO? PROBE: Counting all hospital stays since DATE 2 MONTHS AGO? IF "A WEEK," PROBE FOR FULL WEEK OF 7 DAYS.
HOSPITAL DAYS . . . . . |_____|_____|
NOT ANSWERED . . . . . -1
| REASON(S) FOR NURSING HOME STAY(S) |
C5. Since DATE 6 MONTHS AGO, were you a resident in a nursing home, convalescent home or similar place?
YES . . . . . 01
NO . . . . . 02 (C10)
NOT ANSWERED . . . . . -1 (C10)
C6. Did you have any other admissions to a nursing home since DATE 6 MONTHS AGO?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
C7. Could you please tell me which nursing home(s) you were in since DATE 6 MONTHS AGO? PROBE: Any other times, since DATE 6 MONTHS AGO?
a. MOST RECENT STAY _________________________|_____|_____|_____|
NOT ANSWERED . . . . . -1b. NEXT MOST RECENT _________________________|_____|_____|_____|
NOT ANSWERED . . . . . -1c. NEXT MOST RECENT _________________________|_____|_____|_____|
NOT ANSWERED . . . . . -1
C8. Were you in a nursing home since DATE 2 MONTHS AGO? PROBE: Were you a resident in a nursing home?
YES . . . . . 01
NO . . . . . 02 (C10)
NOT ANSWERED . . . . . -1 (C10)
C9. Altogether, how many days were you in a nursing home since DATE 2 MONTHS AGO?
NURSING HOME DAYS . . . . . |_____|_____|
NOT ANSWERED . . . . . -1
C10. The next question is about doctors you may have seen since DATE 2 MONTHS AGO (outside of the (hospital/nursing home) stay(s) you just told me about).
Since DATE 2 MONTHS AGO, how many times have you seen a medical doctor in an office, clinic, or at home? Please include hospital outpatient clinics and emergency rooms. IF MENTIONS NUMBER OF VISITS TO CLINIC, PROBE: On how many of those visits did you see a doctor?
DOCTOR VISITS . . . . . |_____|_____|
NONE . . . . . 00
NOT ANSWERED . . . . . -1
C11. Since DATE 2 MONTHS AGO, how many days did you stay in bed most or all of the day (either at home or in the (hospital/nursing home))?
DAYS . . . . . |_____|_____|
NONE . . . . . 00
NOT ANSWERED . . . . . -1
EATING
| NOTES ON HELP AND HELP NEEDED |
D. PHYSICAL ACTIVITIES OF DAILY LIVING
EATING
D1. The next questions are about taking care of yourself.
First I'd like to ask you about help with eating.
During the past week, did someone usually help you eat or stay in the room in case you needed help eating? DO NOT INCLUDE HELP WITH CUTTING MEAT OR BUTTERING BREAD. USUALLY = HALF THE TIME OR MORE DURING THE PAST WEEK.
YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HAS HELPED . . . . . 02 (D3)
IV, TUBES . . . . . 03 (D4)
NOT ANSWERED . . . . . -1 (D3)
D2. Did someone usually feed you? PROBE: For most of the meal?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
D3. Do you feel that you need (help/more help) with eating?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
BED AND CHAIR TRANSFER
D4. During the past week, did someone usually help you get out of bed or a chair or stay in the room in case you needed help? IF HELP WITH BED AND/OR CHAIR, CODE "YES". USUALLY = HALF THE TIME OR MORE DURING THE PAST WEEK.
YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HELPED . . . . . 02 (D6)
DID NOT GET OUT OF BED AT ALL . . . . . 03 (D7)
NOT ANSWERED . . . . . -1 (D6)
BED AND CHAIR TRANSFER
| NOTES ON HELP AND HELP NEEDED |
D5. Did someone usually life you out of bed or a chair?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
D6. During the past week, did you usually use special equipment, like a lift, to help you get out of bed or a chair? DO NOT INCLUDE USING A CANE, WALKER, OR ORDINARY FURNITURE, IN TRANSFER.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
D7. Do you feel that you need (help/more help) with getting out of bed or a chair? IF NO, PROBE: What about special equipment, do you need that?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
DRESSING
D8. The next questions are about dressing--that is, getting clothes and putting them on (including your brace).
During the past week, did you usually get dressed for the day or did you stay in night clothes? USUALLY = HALF THE TIME OR MORE DURING THE PAST WEEK.
GOT DRESSED . . . . . 01
STAYED IN NIGHT CLOTHES . . . . . 02
DID NOT CHANGE CLOTHES AT ALL . . . . . 03 (D11)
NOT ANSWERED . . . . . -1 (D11)
D9. Did someone usually help (you dress/change your night clothes) or stay in the room in case you needed help? DO NOT INCLUDE HELP IN TYING SHOES OR GROOMING.
YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HELPED . . . . . 02 (D11)
NOT ANSWERED . . . . . -1 (D11)
DRESSING
| NOTES ON HELP AND HELP NEEDED |
D10. Did someone usually (dress you/change your nigh clothes for you)?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
D11. Do you feel that you need (help/more help) with (getting dressed/changing your night clothes)?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
BATHING
D12. The next questions are about bathing--including turning on the water.
During the past week when you had a full bath, did you usually bathe in a tub or shower, at a sink or basin, or did you have bedbaths? IF MULTIPLE METHODS USED, PROBE: Which did you usually use for a full bath? USUALLY = HALF THE TIME OR MORE DURING THE PAST WEEK.
IN TUB OR SHOWER . . . . . 01
IN SINK OR BASIN . . . . . 02 (D14)
BEDBATHS/DID NOT HAVE FULL BATH . . . . . 03 (D17 )
NOT ANSWERED . . . . . -1 (D14)
D13. Did someone usually help you get in or out of the tub or shower or stay in the room in case you needed help?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
D14. During the past week, did someone usually help you bathe (at the sink or basin) or stay in the room in case you needed help?
YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HELPED . . . . . 02 (D16)
NOT ANSWERED . . . . . -1 (D16)
BATHING
| NOTES ON HELP AND HELP NEEDED |
TOILETING/CONTINENCE
| DETAILS ON TOILETING |
D15. Did someone help you wash more than your back or feet? EXCLUDE HELP WITH SHAMPOOING HAIR.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
D16. Did you usually use special equipment to help you bathe, like (a tub stool or grab bar/handle bars at the sink)?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
D17. Do you feel that you need (help/more help) with bathing? IF NO, PROBE: What about special equipment, do you need that?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
TOILETING
D18. The next questions are about personal care. The first one is about using the toilet.
During the past week, did you usually go to the bathroom to use the toilet? PROBE: For either your bowel or bladder functions?
IF NO, PROBE: What did you usually use? USUALLY = HALF THE TIME OR MORE DURING THE PAST WEEK.
YES, TOILET FOR AT LEAST ONE FUNCTION . . . . . 01
NO (BEDPAN, BEDSIDE COMMODE, CATHETER, COLOSTOMY) . . . . . 02 (D21)
NOT ANSWERED . . . . . -1 (D21)
D19. Did someone usually help you get to the bathroom to use the toilet or stay nearby in case you needed help?
YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HELPED . . . . . 02
NOT ANSWERED . . . . . -1
D20. During the past week, did you usually use special equipment like a grab bar or raised toilet seat to help you use the toilet?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
TOILETING/CONTINENCE
| NOTES ON HELP AND HELP NEEDED |
D21.. CODE WITHOUT ASKING IF KNOWN.
Do you use a device such as a catheter bag or colostomy bag?
YES . . . . . 01
NO . . . . . 02 (D23)
NOT ANSWERED . . . . . -1 (D23)
D22. Do you change (this/your DEVICE) by yourself?
SELF CARE . . . . . 01
HELP WITH CARE . . . . . 02
NOT ANSWERED . . . . . -1
D23. During the past week, did you accidentally wet or soil yourself, either day or night?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
D24. Do you feel that you need (help/more help) with (using the toilet/caring for your bladder and bowel functions)? IF NO, PROBE: What about special equipment, do you need that?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
D25. CHECKPOINT D
DOES SAMPLE MEMBER SEEM VERY CONFUSED, DISORIENTED, ANXIOUS, OR EXHAUSTED?
YES . . . . . 01
NO . . . . . 02
PROXY RESPONDENT . . . . . -4
BEDBOUND/HOUSEHOLD ACTIVITIES
| NOTES ON HELP NEEDED |
E. INSTRUMENTAL ACTIVITIES OF DAILY LIVING
BEDBOUND/HOUSEHOLD ACTIVITIES
E1. IS SM BEDBOUND (DOES NOT GET OUT OF BED OR ONLY IF LIFTED)? (SEE D4 AND D5.)
YES . . . . . 01
NO . . . . . 02 (E4)
D4 OR D5 NOT ANSWERED . . . . . 03 (E4)
E2. For how long have you been unable to get out of bed -- has it been more than one month?
YES, MORE THAN ONE MONTH . . . . . 01
NO, ONE MONTH OR LESS . . . . . 02 (E4)
NOT ANSWERED . . . . . -1 (E4)
E3. The next questions are about things that are usually done in a household.
Do you feel that you need more help with -- PROBE: In addition to help you are getting now,
YES NO NA a. getting groceries? 01 02 -1 b. work around the house, like washing dishes or cleaning floors? 01 02 -1 c. preparing meals? 01 02 -1 d. getting around inside? 01 02 -1 e. transportation (PROBE: For going to the doctor)? 01 02 -1
| *** SKIP TO E11. *** |
MEAL PREPARATION
E4. These next questions are about things done in a household, such as cleaning and cooking.
Do you usually prepare your own meals by yourself? USUALLY = HALF THE TIME OR MORE DURING THE PAST MONTH.
YES, USUALLY BY SELF . . . . . 01 (E9)
NO, USUALLY HAS HELP/NO MEALS PREPARED . . . . . 02
NOT ANSWERED . . . . . -1 (E6)
MEAL PREPARATION
| NOTES ON HELP AND HELPERS |
| NOTES ON HELP NEEDED |
E5. What is the reason you (get help preparing/don't prepare) meals?
PHYSICAL, COGNITIVE OR EMOTIONAL IMPAIRMENT . . . . . 01
DON'T KNOW HOW . . . . . 02
SITUATIONAL/PERSONAL PREFERENCE/OTHER . . . . . 03 (E7)
NOT ANSWERED . . . . . -1
E6. Are you able to prepare light meals, such as a sandwich, by yourself?
CAN PREPARE LIGHT MEALS . . . . . 01 (E10)
CANNOT . . . . . 02 (E10)
NOT ANSWERED . . . . . -1 (E10)
E7. (If that were not the case,) could you prepare full meals, such as meat and a vegetable, by yourself? PROBE: If the rules permitted/If someone else didn't do it/If you had a kitchen/If you wanted to,
YES . . . . . 01 (E10)
NO . . . . . 02
NOT ANSWERED . . . . . -1
E8. Could you prepare light meals, such as a sandwich, by yourself?
YES . . . . . 01 (E10)
NO . . . . . 02 (E10)
NOT ANSWERED . . . . . -1 (E10)
E9. Is that full meals, like meat and a vegetable, or light meals, like a sandwich? PROBE: Or both?
LIGHT MEALS ONLY . . . . . 01
FULL MEALS ONLY . . . . . 02
BOTH . . . . . 03
NOT ANSWERED . . . . . -1
E10. Do you feel that you need (help/more help) with meal preparation?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
E11. Do members of your family or friends (who do not live with you) regularly prepare meals for you and bring them to your home? REGULARLY = ON A ROUTINE BASIS, AT THE PRESENT TIME, WITH AT LEAST FOUR MEALS DELIVERED A MONTH.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
E12. Do you regularly get meals delivered to your home now by an agency or organization like (Meals on Wheels/LOCAL NAME)? REGULARLY = ON A ROUTINE BASIS, AT THE PRESENT TIME, WITH AT LEAST FOUR MEALS DELIVERED A MONTH.
YES . . . . . 01
NO . . . . . 02 (E15)
NOT ANSWERED . . . . . -1 (E15)
E13. What agency or organization is that? IF MORE THAN ONE, CODE ONE USED MOST FREQUENTLY
_________________________|_____|_____|_____|
NOT ANSWERED . . . . . -1
E14. How many meals a week are delivered to your home by this agency or organization? IF "DAILY," PROBE FOR A FULL WEEK OF 7 DAYS.
MEALS A WEEK . . . . . |_____|_____|
NOT ANSWERED . . . . . -1
E15. HAS SM BEEN BEDBOUND FOR MORE THAN ONE MONTH (SEE QUESTIONS E1 AND E2)?
YES . . . . . 01 (E30)
NO . . . . . 02
NOT ANSWERED . . . . . -1
E16. Do you regularly eat meals now in a senior center or some other place with a special meal program? REGULARLY = ON A ROUTINE BASIS OF AT LEAST ONE MEAL PER WEEK AT THE PRESENT TIME.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
HOUSEKEEPING
| NOTES ON HELP AND HELPERS |
HOUSEKEEPING
E17. Do you usually do the work around the house, like washing dishes and cleaning floors, by yourself? USUALLY = HALF THE TIME OR MORE DURING THE PAST MONTH.
YES, USUALLY BY SELF . . . . . 01 (E22)
NO, USUALLY HAS HELP . . . . . 02
NO WORK DONE AROUND THE HOUSE . . . . . 03
NOT ANSWERED . . . . . -1 (E19)
E18. What is the reason you (get help with/don't do) work around the house?
PHYSICAL, COGNITIVE OR EMOTIONAL IMPAIRMENT . . . . . 01
DON'T KNOW HOW . . . . . 02
SITUATIONAL/PERSONAL PREFERNCE/OTHER . . . . . 03 (E20)
NOT ANSWERED . . . . . -1
E19. Are you able to do light work around the house, such as washing dishes, by yourself?
CAN DO LIGHT HOUSEWORK . . . . . 01 (E23)
NOT AT ALL . . . . . 02 (E23)
NOT ANSWERED . . . . . -1 (E23)
E20. (If that were not the case,) could you do heavy work around the house, such as cleaning floors, by yourself? PROBE: If someone else didn't do it/If the rules permitted/If you wanted to,
YES . . . . . 01 (E23)
NO . . . . . 02
NOT ANSWERED . . . . . -1
HOUSEKEEPING
| NOTES ON HELP NEEDED |
| NOTES ON LAUNDRY |
SHOPPING
| NOTES ON HELP AND HELPERS |
E21. Could you do light work, such as washing dishes, by yourself?
YES . . . . . 01 (E23)
NO . . . . . 02 (E23)
NOT ANSWERED . . . . . -1 (E23)
E22. Is that heavy work, like cleaning floors or light work, like washing dishes? PROBE: Or both?
LIGHT WORK ONLY . . . . . 01
HEAVY WORK ONLY . . . . . 02
BOTH . . . . . 03
NOT ANSWERED . . . . . -1
E23. Do you feel that you need (help/more help) with work around the house?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
SHOPPING
E24. Do you usually shop for most of your groceries by yourself? PROBE: Or does someone help by going with you or doing it for you? CODE TELEPHONE SHOPPING AS "HAS HELP." USUALLY = HALF THE TIME OR MORE DURING THE PAST MONTH.
YES, USUALLY BY SELF . . . . . 01 (E29)
NO, USUALLY HAS HELP . . . . . 02
NOT ANSWERED . . . . . -1 (E26)
E25. What is the reason you get help with grocery shopping?
PHYSICAL, COGNITIVE OR EMOTIONAL IMPAIRMENT . . . . . 01
SITUATIONAL/PERSONAL PREFERENCE/OTHER . . . . . 02 (E27)
NOT ANSWERED . . . . . -1
SHOPPING
| NOTES ON HELP NEEDED |
E26. Are you able to go grocery shopping if someone goes with you to help you manage? PROBE: If you had transportation,
YES, CAN WITH HELP . . . . . 01 (E29)
NO, CANNOT GO AT ALL . . . . . 02 (E29)
NOT ANSWERED . . . . . -1 (E29)
E27. (If that were not the case,) could you go grocery shopping by yourself?
YES . . . . . 01 (E29)
NO . . . . . 02
NOT ANSWERED . . . . . -1
E28. Could you go grocery shopping if someone went with you to help you manage?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
E29. Do you feel you need (help/more help) with grocery shopping?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
E30. Do members of your family or friends regularly buy groceries for you with their money? REGULARLY = ON A ROUTINE BASIS AT THE PRESENT TIME, WITH AT LEAST $10 WORTH OF GROCERIES A MONTH.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
TAKING MEDICINE
| NOTES ON HELP AND HELPERS |
TAKING MEDICINE
E31. The next questions are about taking medicine.
Does someone usually help you to take the correct amounts of medicine at the proper time? PROBE: When you take medicine. USUALLY = HALF THE TIME OR MORE WHEN MEDICINE TAKEN DURING THE PAST MONTH.
YES, USUALLY HAS HELP . . . . . 01
NO, USUALLY BY SELF . . . . . 02 (e36)
NOT ANSWERED . . . . . -1 (E33)
E32. What is the reason you get help with taking medicine?
PHYSICAL, COGNITIVE OR EMOTIONAL IMPAIRMENT . . . . . 01
SITUATIONAL/PERSONAL PREFERENCE/OTHER . . . . . 02 (E34)
NOT ANSWERED . . . . . -1
E33. If someone measures out the amount of medicine beforehand and reminds you to take it, are you able to do the rest by yourself? IF NEEDS REMINDER AND/OR PREMEASURED AMOUNT, BUT CAN DO REST, CODE "YES".
YES . . . . . 01 (E36)
NO . . . . . 02 (E36)
NOT ANSWERED . . . . . -1 (E36)
E34. (If that were not the case,) could you take the correct amounts at the proper time without any help from another person? PROBE: If the rules permitted it/If someone else didn't do it/If you wanted to,
YES . . . . . 01 (E36)
NO . . . . . 02
NOT ANSWERED . . . . . -1
E35. If someone measured out the amount of medicine beforehand and reminded you to take it, could you do the rest by yourself?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
MEDICINES
| NOTES ON HELP NEEDED |
E36. Do you feel you need (help/more help) when you take medicine?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
E37. HAS SM BEEN BEDBOUND FOR MORE THAN ONE MONTH (SEE QUESTION E15)?
YES . . . . . 01 (E51)
NO . . . . . 02
E15 NOT ANSWERED . . . . . -1
INDOOR MOBILITY
E38. The next questions are about getting around indoors,(inside this house/apartment/on this floor).
How do you usually get around inside? IF WALKS, PROBE: Do you use a cane, walker, or crutches? USUALLY = HALF THE TIME OR MORE DURING THE PAST WEEK,
CIRCLE ONE WALKS, NO EQUIPMENT 01 WALKS, CANE 02 WALKS, WALKER 03 WALKS, CRUTCHES 04 WALKS, COMBINATION/OTHER AIDS 05 WHEELCHAIR 06 NOT AT ALL 07 (E41) NOT ANSWERED -1
INDOOR MOBILITY
| NOTES ON HELP, HELPERS AND ARCHITECTURAL BARRIERS |
| NOTES ON HELP NEEDED |
E39. Does someone usually help you get around inside or stay near you in case you need help?
YES, USUALLY HAS HELP . . . . . 01
NO, USUALLY BY SELF . . . . . 02
NOT ANSWERED . . . . . -1
E40. IF IN WHEELCHAIR, CODE WITHOUT ASKING. How difficult is it for you to climb one flight of stairs--is it: PROBE: If there were stairs here, how difficult would it be for you to climb them?
not difficult, . . . . . 01
somewhat difficult, . . . . . 02
very difficult, or . . . . . 03
can't you do it at all? . . . . . 04
IN WHEELCHAIR . . . . . 05
NOT ANSWERED . . . . . -1
E41. Do you feel that you need (help/more help) with getting around inside?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
OUTDOOR MOBILITY
| COMMENTS ON CLIENT'S PHYSICAL STAMINA |
TRAVEL/TRANSPORTATION
| NOTES ON HELP AND HELPERS |
OUTDOOR MOBILITY
E42. What about outdoors? How do you usually get around when you go outdoors? PROBE: Do you walk or use a wheelchair? IF WALKS, PROBE: Do you use a case, walker, or crutches? USUALLY = HALF THE TIME OR MORE WHEN OUTDOORS OVER THE PAST MONTH.
CIRCLE ONE WALKS, NO EQUIPMENT 01 WALKS, CANE 02 WALKS, WALKER 03 WALKS, CRUTCHES 04 WALKS, COMBINATION/OTHER AIDS 05 WHEELCHAIR 06 DOES NOT GO OUTDOORS AT ALL 07 (E44) NOT ANSWERED -1
E43. Does someone usually help you get around outdoors or stay near you in case you need help?
YES, USUALLY HAS HELP . . . . . 01
NO, USUALLY BY SELF . . . . . 02
NOT ANSWERED . . . . . -1
TRAVEL/TRANSPORTATION
E44. What kind of transportation do you usually use? PROBE: What about going to the doctor? USUALLY = HALF THE TIME OR MORE WHEN TRAVELING OVER THE PAST MONTH.
BUS/SUBWAY . . . . . 01
CAR/VAN/TAXI . . . . . 02
AMBULANCE ONLY . . . . . 03 (E50)
DOES NOT TRAVEL AT ALL . . . . . 04 (E50)
NOT ANSWERED . . . . . -1 (D18)
E45. Can you travel in a car, van, or taxi by yourself?
YES . . . . . 01 (E47)
NO . . . . . 02
NOT ANSWERED . . . . . -1
E46. Can you travel in a car, van, or taxi if someone goes with you to help you manage?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
TRAVEL/TRANSPORTATION
| NOTES ON HELP NEEDED |
MONEY MANAGEMENT
| NOTES ON HELP AND HELPERS |
E47. Do you regularly have help with transportation from an agency or organization, like LOCAL NAME? REGULARLY = ON A RECURRING BASIS OF AT LEAST ONE TRIP A MONTH AT THE PRESENT TIME.
YES . . . . . 01
NO . . . . . 02 (E50)
NOT ANSWERED . . . . . -1 (E50)
E48. What agency or organization is that? IF MORE THAN ONE, CODE ONE USED MOST FREQUENTLY
_________________________|_____|_____|_____|
NOT ANSWERED . . . . . -1
E49. Since DATE 2 MONTHS AGO, how many trips have you received from (that agency/NAME OF AGENDY IN E48? ROUND TRIP = 1 TRIP.
TRIPS . . . . . |_____|_____|
NOT ANSWERED . . . . . -1
E50. Do you feel that you need (help/more help) with transportation?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
MONEY MANAGEMENT
E51.. The next questions are about managing your money, regardless of how much or little you have.
Do you usually write checks or pay bills by yourself? USUALLY = HALF THE TIME OR MORE DURING THE PAST MONTH.
YES, USUALLY BY SELF . . . . . 01 (E57)
NO, USUALLY HAS HELP . . . . . 02
NO, HAS NO BILLS . . . . . 03
NOT ANSWERED . . . . . -1 (E54)
E52. Do you have a legal guardian, conservator, or payee?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
MONEY MANAGEMENT
| NOTES ON HELP NEEDED |
E53. What is the reason you (get help/don't have bills)?
CAN'T GET OUT . . . . . 01 (E55)
OTHER PHYSICAL IMPAIRMENT/COGNITIVE OR EMOTIONAL IMPAIRMENT . . . . . 02
SITUATIONAL/PERSONAL PREFERENCE/OTHER . . . . . 03 (E55)
NOT ANSWERED . . . . . -1
E54. Are you able to take care of money for day-to-day pruchases by yourself?
YES . . . . . 01 (E57)
NO . . . . . 02 (E57)
NOT ANSWERED . . . . . -1 (E57)
E55. (If that were not the case,) could you write checks or pay bills by yourself? PROBE: If someone else didn't do it/If you could get out/If you had bills.
YES . . . . . 01 (E57)
NO . . . . . 02
NOT ANSWERED . . . . . -1
E56. Could you take care of money for day-to-day purchases by yourself?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
E57. Do you feel that you need (help/more help) with managing your money?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
E58. Do members of your family or friends regularly pay bills for you with their money? REGULARLY = ON A ROUTINE BASIS AT THE PRESENT TIME, WITH AT LEAST $10 WORTH OF BILLS A MONTH.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
TELEPHONE
| NOTES ON VOLUNTEER CALLING/EMERGENCY RESPONSE SYSTEM |
TELEPHONE
E59. The next questions are about using the telephone.
Can you use a regular telephone or do you need a phone with special equipment such as an amplifier or enlarged dial?
REGULAR . . . . . 01
NEEDS SPECIAL EQUIPMENT . . . . . 02
DOES NOT USE TELEPHONE AT ALL . . . . . 03 (E62)
NOT ANSWERED . . . . . -1
E60. (Using this special telephone,) can you get telephone numbers and place the calls by yourself? PROBE: Can you do both?
ONE ONLY . . . . . 01
BOTH . . . . . 02 (E62)
NEITHER . . . . . 03
NOT ANSWERED . . . . . -1
E61. (Using this special telephone,) can you answer the telephone and call the operator by yourself? PROBE: Can you do both?
ANSWER ONLY . . . . . 01
CALL OPERATOR ONLY . . . . . 02
BOTH . . . . . 03
NEITHER . . . . . 04
NOT ANSWERED . . . . . -1
E62. DOES SM LIVE ALONE (SEE A3 AND A4)? THOSE IN GROUP QUARTERS DO NOT LIVE ALONE.
YES . . . . . 01 (F7)
NO . . . . . 02
A3 or A4 NOT ANSWERED . . . . . 03
RELATIONSHIP CODES:
SPOUSE . . . . . 01
CHILD . . . . . 02
SIBLING . . . . . 03
OTHER RELATIVE . . . . . 04
LIVE-IN STAFF . . . . . 05
OTHER NON-RELATIVE . . . . . 06
| NOTES ON HOUSEHOLD CAREGIVERS |
F. SERVICES AND SUPPORT
HOUSEHOLD SUPPORT SYSTEM
F1. Now I have some more questions about the people who help you.
First, please tell me who lives with yu who regularly helps you to take care of yourself or who does things around the house. REGULARLY = ON A ROUTINE BASIS AT THE PRESENT TIME WITH HELP RECEIVED AT LEAST ONCE A MONTH. IF MORE THAN 3 NAMED: I have some questions about the 3 of these who help you the msot. Who are they?
| RECORD FIRST NAME OR RELATIONSHIP ONLY ON GRID. | |||
| ASK F2-F6 FOR EACH HOUSEHOLD CAREGIVER | NAME 1 _________________________ | NAME 2 _________________________ | NAME 3 _________________________ |
| NO HOUSEHOLD CAREGIVERS . . . . . -4 (F7) | |||
| F2. How is NAME related to you? SEE CODES ON 32a. | RELATIONSHIP |_____|_____| NOT ANSWERED . . . . . -1 | RELATIONSHIP |_____|_____| NOT ANSWERED . . . . . -1 | RELATIONSHIP |_____|_____| NOT ANSWERED . . . . . -1 |
| F3. When is NAME generally at home to help you if you need it? CIRCLE ALL THAT APPLY | WEEK NIGHTS . . . . . 01 WEEK DAYS . . . . . 02 WEEKENDS . . . . . 03 NOT ANSWERED . . . . . -1 | WEEK NIGHTS . . . . . 01 WEEK DAYS . . . . . 02 WEEKENDS . . . . . 03 NOT ANSWERED . . . . . -1 | WEEK NIGHTS . . . . . 01 WEEK DAYS . . . . . 02 WEEKENDS . . . . . 03 NOT ANSWERED . . . . . -1 |
| F4. Is NAME employed? | YES . . . . . 01 NO . . . . . 02 NOT ANSWERED . . . . . -1 | YES . . . . . 01 NO . . . . . 02 NOT ANSWERED . . . . . -1 | YES . . . . . 01 NO . . . . . 02 NOT ANSWERED . . . . . -1 |
| F5. What does NAME regularly help you with? PROBE: Anything else? CIRCLE ALL THAT APPLY. IF NO MENTION OF PERSONAL CARE, PROBE: Does NAME help you with eating, getting out of bed or a chair, dressing, bathing, or using the toilet? | PERSONAL CARE . . . . . 01 PREPARING MEALS . . . . . 02 HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03 TAKING MEDICINE . . . . . 04 MEDICAL TREATMENTS . . . . . 05 TRANSPORTATION . . . . . 06 MANAGING MONEY . . . . . 07 MONITORING . . . . . 08 OTHER (SPECIFY) _________________________ . . . . . 09 NOT ANSWERED . . . . . -1 | PERSONAL CARE . . . . . 01 PREPARING MEALS . . . . . 02 HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03 TAKING MEDICINE . . . . . 04 MEDICAL TREATMENTS . . . . . 05 TRANSPORTATION . . . . . 06 MANAGING MONEY . . . . . 07 MONITORING . . . . . 08 OTHER (SPECIFY) _________________________ . . . . . 09 NOT ANSWERED . . . . . -1 | PERSONAL CARE . . . . . 01 PREPARING MEALS . . . . . 02 HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03 TAKING MEDICINE . . . . . 04 MEDICAL TREATMENTS . . . . . 05 TRANSPORTATION . . . . . 06 MANAGING MONEY . . . . . 07 MONITORING . . . . . 08 OTHER (SPECIFY) _________________________ . . . . . 09 NOT ANSWERED . . . . . -1 |
| F6. WAS ANOTHER HOUSEHOLD CAREGIVER NAMED? | YES (Repeat F2-F6) . . . . . 01 NO (GO TO F7) . . . . . 02 | YES (Repeat F2-F6) . . . . . 01 NO (GO TO F7) . . . . . 02 | GO TO F7 |
RELATIONSHIP CODES:
SPOUSE . . . . . 01
CHILD . . . . . 02
SIBLING . . . . . 03
OTHER RELATIVE . . . . . 04
CODES 05 AND 06 ARE NOT APPLICABLE
FRIEND . . . . . 07
NEIGHBOR . . . . . 08
DECIMAL FRACTIONS OF AN HOUR:
10 MINUTES = 00.2 HOURS
15 MINUTES = 00.2 HOURS
20 MINUTES = 00.3 HOURS
30 MINUTES = 00.5 HOURS
45 MINUTES = 00.8 HOURS
| NOTES ON INFORMAL CAREGIVERS |
INFORMAL SUPPORT SYSTEM
F7. Next, please tell me the names of friends, neighbors or family members (who do not live with you) who regularly help you. Please do not include people who help you as part of their paid or volunteer work. REGULARLY = ON A ROUTINE BASIS AT THE PRESENT TIME WITH HELP RECEIVED AT LEAST ONCE A MONTH. IF MORE THAN 3 NAMED: I have some questions about the 3 of these who help you the most. Who are they?
| RECORD FIRST NAME OR RELATIONSHIP ONLY ON GRID. | |||
| ASK F8-F13 FOR EACH INFORMAL CAREGIVER | NAME 1 _________________________ | NAME 2 _________________________ | NAME 3 _________________________ |
| NO INFORMAL CAREGIVERS . . . . . -4 (F14) | |||
| F8. How is NAME related to you? SEE CODES ON 33a. | RELATIONSHIP |_____|_____| NOT ANSWERED . . . . . -1 | RELATIONSHIP |_____|_____| NOT ANSWERED . . . . . -1 | RELATIONSHIP |_____|_____| NOT ANSWERED . . . . . -1 |
| F9. IF RELATIVE, Is NAME employed? | YES . . . . . 01 NO . . . . . 02 NOT RELATIVE . . . . . -4 NOT ANSWERED . . . . . -1 | YES . . . . . 01 NO . . . . . 02 NOT RELATIVE . . . . . -4 NOT ANSWERED . . . . . -1 | YES . . . . . 01 NO . . . . . 02 NOT RELATIVE . . . . . -4 NOT ANSWERED . . . . . -1 |
| F10. About how often does NAME come to help you? PROBE: In the average week or month? | [_____]_____] VISITS PER WEEK . . . . . 01 PER MONTH . . . . . 02 NOT ANSWERED . . . . . -1 | [_____]_____] VISITS PER WEEK . . . . . 01 PER MONTH . . . . . 02 NOT ANSWERED . . . . . -1 | [_____]_____] VISITS PER WEEK . . . . . 01 PER MONTH . . . . . 02 NOT ANSWERED . . . . . -1 |
| F11. About how long does NAME usually stay each visit? PROBE: On the average? | |_____|_____| . |_____|HOURS NOT ANSWERED . . . . . -1 | |_____|_____| . |_____|HOURS NOT ANSWERED . . . . . -1 | |_____|_____| . |_____|HOURS NOT ANSWERED . . . . . -1 |
| F12. What does NAME regularly help you with? PROBE: Anything else? CIRCLE ALL THAT APPLY. IF NO MENTION OF PERSONAL CARE, PROBE: Does NAME help you with eating, getting out of bed or a chair, dressing, bathing, or using the toilet? | PERSONAL CARE . . . . . 01 PREPARING MEALS . . . . . 02 HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03 TAKING MEDICINE . . . . . 04 MEDICAL TREATMENTS . . . . . 05 TRANSPORTATION . . . . . 06 MANAGING MONEY . . . . . 07 MONITORING . . . . . 08 OTHER (SPECIFY) _________________________ . . . . . 09 NOT ANSWERED . . . . . -1 | PERSONAL CARE . . . . . 01 PREPARING MEALS . . . . . 02 HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03 TAKING MEDICINE . . . . . 04 MEDICAL TREATMENTS . . . . . 05 TRANSPORTATION . . . . . 06 MANAGING MONEY . . . . . 07 MONITORING . . . . . 08 OTHER (SPECIFY) _________________________ . . . . . 09 NOT ANSWERED . . . . . -1 | PERSONAL CARE . . . . . 01 PREPARING MEALS . . . . . 02 HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03 TAKING MEDICINE . . . . . 04 MEDICAL TREATMENTS . . . . . 05 TRANSPORTATION . . . . . 06 MANAGING MONEY . . . . . 07 MONITORING . . . . . 08 OTHER (SPECIFY) _________________________ . . . . . 09 NOT ANSWERED . . . . . -1 |
| F13. WAS ANOTHER INFORMAL CAREGIVER NAMED? | YES (Repeat F8-F13) . . . . . 01 NO (GO TO F14) . . . . . 02 | YES (Repeat F8-F13) . . . . . 01 NO (GO TO F14) . . . . . 02 | GO TO F14 |
DECIMAL FRACTIONS OF AN HOUR:
10 MINUTES = 00.2 HOURS
15 MINUTES = 00.2 HOURS
20 MINUTES = 00.3 HOURS
30 MINUTES = 00.5 HOURS
45 MINUTES = 00.8 HOURS
| NOTES ON FORMAL CAREGIVERS |
FORMAL SUPPORT SYSTEM
F14. Now, please tell me the people who regularly (come to) help you as part of their paid or volunteer work. These could be people who come from an agency or organization or (people you or your family hired/people on the staff here). REGULARLY = ON A ROUTINE BASIS AT THE PRESENT TIME WITH HELP RECEIVED AT LEAST ONCE A MONTH. IF MORE THAN 3 NAMED: I have some questions about the 3 of these who help you the most. Who are they?
| RECORD FIRST NAME OR RELATIONSHIP ONLY ON GRID. | |||
| ASK F15-F19 FOR EACH FORMAL CAREGIVER | NAME 1 _________________________ | NAME 2 _________________________ | NAME 3 _________________________ |
| NO FORMAL CAREGIVERS . . . . . -4 (E20) | |||
| F15. Do you have a card or letter from the agency so that I can get the correct spelling? IF NO CARD, ASK FOR AGENCY NAME. IF CANNOT NAME AGENCY, PROBE FOR HELPER'S NAME AND TELEPHONE NUMBER. | _________________________ _________________________ _________________________ NOT WITH AGENCY . . . . . -4 NOT ANSWERED . . . . . -1 | _________________________ _________________________ _________________________ NOT WITH AGENCY . . . . . -4 NOT ANSWERED . . . . . -1 | _________________________ _________________________ _________________________ NOT WITH AGENCY . . . . . -4 NOT ANSWERED . . . . . -1 |
| F16. How often does NAME come to help you? | [_____]_____] VISITS PER WEEK . . . . . 01 PER MONTH . . . . . 02 NOT ANSWERED . . . . . -1 | [_____]_____] VISITS PER WEEK . . . . . 01 PER MONTH . . . . . 02 NOT ANSWERED . . . . . -1 | [_____]_____] VISITS PER WEEK . . . . . 01 PER MONTH . . . . . 02 NOT ANSWERED . . . . . -1 |
| F17. How long does NAME usually stay each visit? | |_____|_____| . |_____|HOURS NOT ANSWERED . . . . . -1 | |_____|_____| . |_____|HOURS NOT ANSWERED . . . . . -1 | |_____|_____| . |_____|HOURS NOT ANSWERED . . . . . -1 |
| F18. What does NAME regularly help you with? PROBE: Anything else? CIRCLE ALL THAT APPLY. IF NO MENTION OF PERSONAL CARE, PROBE: Does NAME help you with eating, getting out of bed or a chair, dressing, bathing, or using the toilet? | PERSONAL CARE . . . . . 01 PREPARING MEALS . . . . . 02 HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03 TAKING MEDICINE . . . . . 04 MEDICAL TREATMENTS . . . . . 05 TRANSPORTATION . . . . . 06 MANAGING MONEY . . . . . 07 MONITORING . . . . . 08 OTHER (SPECIFY) _________________________ . . . . . 09 NOT ANSWERED . . . . . -1 | PERSONAL CARE . . . . . 01 PREPARING MEALS . . . . . 02 HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03 TAKING MEDICINE . . . . . 04 MEDICAL TREATMENTS . . . . . 05 TRANSPORTATION . . . . . 06 MANAGING MONEY . . . . . 07 MONITORING . . . . . 08 OTHER (SPECIFY) _________________________ . . . . . 09 NOT ANSWERED . . . . . -1 | PERSONAL CARE . . . . . 01 PREPARING MEALS . . . . . 02 HOUSEWORK, LAUNDRY, SHOPPING, CHORES . . . . . 03 TAKING MEDICINE . . . . . 04 MEDICAL TREATMENTS . . . . . 05 TRANSPORTATION . . . . . 06 MANAGING MONEY . . . . . 07 MONITORING . . . . . 08 OTHER (SPECIFY) _________________________ . . . . . 09 NOT ANSWERED . . . . . -1 |
| F19. WAS ANOTHER FORMAL CAREGIVER NAMED? | YES (Repeat F15-F19) . . . . . 01 NO (GO TOF20) . . . . . 02 | YES (Repeat F15-F19) . . . . . 01 NO (GO TOF20) . . . . . 02 | GO TO F20 |
| NOTES ON SOCIAL, RELIGIOUS, AND RECREATIONAL ACTIVITIES |
F20. I'd like to know how you arranged for FORMAL CAREGIVER NAME 1 (and NAME 2 and NAME 3) to help you. Did someone come to see you from LOCAL AGENCIES WITH CASE MANAGEMENT SERVICES to arrange for this help? PROBE: Like a nurse or social worker?
YES . . . . . 01
NO . . . . . 02 (F22)
NOT ANSWERED . . . . . -1 (F22)
F21. What agency or organization was that?
_________________________
NOT ANSWERED . . . . . -1
F22. Do you regularly attend a social, religious, or recreational program like at a senior center or (church/temple)? REGULARLY = ON A RECURRING BASIS OF AT LEAST ONE VISIT A MONTH AT THE PRESENT TIME.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
F23. DOES AREA HAVE DAY HEALTH PROGRAM?
YES . . . . . 01
NO . . . . . 02 (F25)
F24. Do you regularly go to a group program where people help you take care of yourself during the day like AREA PROGRAM TITLE? REGULARLY = ON A ROUTINE BASIS OF AT LEAST ONCE A WEEK AT THE PRESENT TIME.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
F25. IS THE RESPONDENT A SAMPLE MEMBER OR A PROXY?
SAMPLE MEMBER . . . . . 01
PROXY . . . . . 02 (H1)
| NOTES ON AFFECT |
G. MENTAL FUNCTIONING
| *** THIS SECTION IS NOT TO BE ASKED OF A PROXY *** |
Next, I'd like to ask you some questions that might describe your attitudes and feelings about your life.
G1. In general, how satisfying do you find the way you're spending your life these days? Would you call it completely satisfying, pretty satisfying or not very satisfying?
COMPLETELY SATISFYING . . . . . 01
PRETTY SATISFYING . . . . . 02
NOT VERY SATISFYING . . . . . 03
NOT ANSWERED . . . . . -1
G2. Day to day, how much choice do you have about what you do and when you do it? Would you say you have --
a great deal of choice . . . . . 01
some choice, or . . . . . 02
not very much choice? . . . . . 03
NOT ANSWERED . . . . . -1
G3. How confident are you of figuring out how to deal with your problems? Would you say you feel--
very confident . . . . . 01
somewhat confident, or . . . . . 02
not very confident? . . . . . 03
NOT ANSWERED . . . . . -1
G4. How much do you worry about not knowing who to turn to for help? Would you say you worry--
a lot, . . . . . 01
some, or . . . . . 02
not very much? . . . . . 03
NOT ANSWERED . . . . . -1
G5. How confident are you of getting services when you need them? Would you say you feel--
very confident . . . . . 01
somewhat confident, or . . . . . 02
not very confident? . . . . . 03
NOT ANSWERED . . . . . -1
G6. FOR CLIENT, ASK: As you know, the purpose of this program is to help people living in the community. However, we also want to study how people in general feel about moving to a nursing home. Under what circumstances would you consider it?
FOR CONTROL, ASK: The purpose of the next question is to help us study how people in general feel about moving to a nursing home. Under what circumstances would you consider it?
WOULD NOT DO AT ALL/RATHER DIE . . . . . 01
HEALTH POOR . . . . . 02
HEALTH POOR AND NO ONE TO TAKE CARE OF ME . . . . . 03
HEALTH POOR AND ADVANTAGE OF NURSING HOME MENTIONED . . . . . 04
NOT ANSWERED . . . . . -1
G7. Now I'm going to read a list of questions to you. Please answer "Yes" or "No" for each of them.
YES NO NA a. Do you often have trouble getting to sleep or staying asleep? 01 02 -1 b. Do you often find yourself feeling unhappy or depressed? 01 02 -1 c. Are you troubled by your heart pounding or shortness of breath? 01 02 -1 d. Do you usually have a good appetite? 01 02 -1 e. Have you recently had periods of days or weeks when you couldn't "get going"? (you were constantly tired) 01 02 -1 f. Have you had crying spells or problems shaking off the blues? 01 02 -1 g. Do you often have trouble keeping your mind on what you are doing? 01 02 -1
| NOTES ON SOCIAL ACTIVITIES |
G8. Have you had any counseling or treatment for personal problems or emotional stress since DATE 6 MONTHS AGO?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
G9. My next question is about talking to friends and relatives (who do not live with you).
During the past week, how many times did you talk to friends or relatives in person of over the telephone? READ RESONSE CATEGORIES IF NECESSARY.
NOT AT ALL . . . . . 01
ONCE . . . . . 02
2-6 TIMES . . . . . 03
ONCE A DAY OR MORE . . . . . 04
NOT ANSWERED . . . . . -1
G10. Do you find yourself feeling lonely quite often, sometimes, or almost never?
QUITE OFTEN . . . . . 01
SOMETIMES . . . . . 02
ALMOST NEVER . . . . . 03
NOT ANSWERED . . . . . -1
G11. (Besides your (husband/wife), have any friends or family members you felt close to died within the past year?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
G12. DID YOU USE CHECKPOINT A, B, OR D TO SKIP TO B19 AND/OR SECTION G? (SEE A14, B21, AND D25.)
YES . . . . . 01
NO . . . . . 02 (B1)
G13. Do you feel you need more help with -- PROBE: Not counting any help you may be getting now,
YES NO NA a. preparing meals? 01 02 -1 b. work around the house, like washing dishes or cleaning floors? 01 02 -1 c. getting around inside? 01 02 -1 d. transportation to places out of walking distance? 01 02 -1 e. grocery shopping? 01 02 -1 f. taking your medicine? 01 02 -1 g. managing your money? 01 02 -1 h. eating? 01 02 -1 i. getting out of bed or a chair? 01 02 -1 j. dressing? 01 02 -1 k. bathing? 01 02 -1 l. (using the toilet/controlling your bladder and bowel functions? 01 02 -1
| THANK RESPONDENT. |
| COMPLETE SECTION J. |
H. FINANCIAL RESOURCES
H1. The next questions are about your insurance.
Are you covered by --
YES NO NOT ANSWERED a. Medicare-Plan A for hospitalization? 01 02 -1 b. Medicare-Plan B for doctors? bills?
PROBE: Is something deducted from your Social Security check?01 02 -1 c. Medicaid?
PROBE: Do you have a LOCAL COLOR (Medicaid) card?01 02 -1
H2. IF MEDICARE OR MEDICAID REPORTED: May I please see your (Medicare/Medicaid) card to be sure I write down the number correctly?
YES NO NOT APPLICABLE a. MEDICARE CARD SEEN 01 02 -4 B. MEDICAID CARD SEEN 01 02 -4
| VERIFY MEDICARE/MEDICAID COVERAGE AND NUMBER ON CONTACT SHEET, (QUESTIONS 7 AND 8). ENTER CORRECT NUMBERS, AS NECESSARY, IN QUESTIONS 16 AND 17 ON CONTACT SHEET. |
H3. What about the following kinds of medical or health plans? Are you covered by any of these?
YES NO NOT ANSWERED a. Private insurance with supplements Medicare, like LOCAL NAME? 01 02 -1 b. Private insurance, such as Blue Cross, which covers hospitalization? 01 02 -1 c. Private insurance, such as Blue Shield, which covers doctors' bills? 01 02 -1 d. Membership in an HMO (Health Maintenance Organization), like LOCAL NAME? 01 02 -1 e. Veterans medical benefits? 01 02 -1 f. Any other medical or health insurance? (SPECIFY) _________________________ 01 02 -1
H4. In the past six months, has anyone in your family (not counting your husband/wife) paid medical or nursing home bills for you with their money? EXCLUDE BORROWING FROM FAMILY.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
The next questions are about sources of income and assets you may have.
FOR CLIENT, ASK: This information is needed to see if you may be able to get services you do not now have.
FOR CONTROL, ASK: This information is needed to help understand the problems of people like you.
Do you (and your husband/wife) now have any income from--
IF YES Hb. What is the monthly amount of that income? YES NO NA NOT ANSWERED a. Social Security or railroad retirement, including Social Security disability payments?
PROBE: That is, a green check.
EXCLUDE SSI.01 02 -1 SM: $|_____|_____|_____|_____| -1 SPOUSE: $|_____|_____|_____|_____| -1 BOTH: $|_____|_____|_____|_____| -1 b. Other checks from the government such as SSI (that is, a gold check), aid to the blind or disabled, or old age assistnace? 01 02 -1 SM: $|_____|_____|_____|_____| -1 SPOUSE: $|_____|_____|_____|_____| -1 BOTH: $|_____|_____|_____|_____| -1 c. Veterans' disability payments? 01 02 -1 SM: $|_____|_____|_____|_____| -1 SPOUSE: $|_____|_____|_____|_____| -1 BOTH: $|_____|_____|_____|_____| -1 d. Retirement pensions or annuities from government organizations, private employers, unions or military service? 01 02 -1 NOT APPLICABLE e. Any other income from things like wages, money from your family, disability, interest, dividends, or rent from property or rooms? 01 02 -1 NOT APPLICABLE
H7. Before taxes and deductions, how much is your (and your husband's/wife's) total monthly income? CHECK CONSISTENCY WITH H5.
$|_____|_____|_____|_____| (H9)
NOT ANSWERED . . . . . -1
H8. Could you give me an idea of the range? Is it --
less than $500, . . . . . 01
between $500 and $1,000 . . . . . 02
or $1,000 or more a month? . . . . . 03
NOT ANSWERED . . . . . -1
H9. DOES SM LIVE ALONE, WITH SPOUSE ONLY, OR WITH OTHERS (SEE A3, A4, AND A7)?
ALONE . . . . . 01 (H11)
WITH SPOUSE ONLY . . . . . 02 (H11)
WITH OTHERS, NOT IN A GROUP HOME. . . . . 03
WITH OTHERS, IN A GROUP HOME . . . . . 04 (H11)
A3, A4 OR A7 NOT ANSWERED . . . . . 05
H10. Do the people who live with you usually share living expenses? USUALLY = HALF THE TIME OR MORE IN USUAL HOME.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
H11. How many people live on your income? PROBE: How many people depend on your income for at least half of their support?
TOTAL NUMBER (SELF ONLY = 01) |_____|_____|
NOT ANSWERED . . . . . -1
H12. Are you (or is anyone in your household) receiving food stamps?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
H13. Do you (and your husband/wife) have any assets like real estate (other than your usual home), savings accounts, savings certificates, stocks or bonds, or money market funds? PROBE: Do you hae any bank accounts? IF OWNED BY SPOUSE, CODE "YES."
YES . . . . . 01
NO . . . . . 02 (H15)
NOT ANSWERED . . . . . -1 (H15)
H14. Would you say that the total value of (this/these) asset(s) is--
less than $5,000, . . . . . 01
between $5,000 and $10,000 . . . . . 02
or more than $10,000? . . . . . 03
NOT ANSWERED . . . . . -1
H15. In the past six months, have you had to take money out of savings or sell assets to pay bills or meet living expenses?
YES . . . . . 01
NO . . . . . 02 (I1)
NOT ANSWERED . . . . . -1 (I1)
H16. Was that for--
YES NO NOT ANSWERED a. Nursing home bills? 01 02 -1 b. Medical expenses, like hospital or doctor bills or for medicines?
EXCLUDE NURSING HOME BILLS.01 02 -1 c. Living expenses? 01 02 -1
I. PHYSICAL ENVIRONMENT
I1. Do you (and your (husband/wife)) own or rent your (usual) home? IF HOME OWNED BY SPOUSE, CODE "OWNS OR IS BUYING." IF GROUP HOME, CODE AS "RENTS."
OWNS OR IS BUYING . . . . . 01
RENTS . . . . . 02 (I3)
OCCUPIES RENT-FREE OR FOR EXCHANGE OF SERVICES . . . . . 03 (I5)
OTHER (SPECIFY) _________________________ . . . . . 04 (I5)
NOT ANSWERED . . . . . -1 (I5)
I2. Do you (and your husband/wife) make a monthly housing payment on a mortgage? EXCLUDE UTILITIES, TAXES, MAINTENANCE, COMDOMINIUM FEES, PARKING FEES.
YES . . . . . 01 (I5)
NO/MORTGAGE IS PAID UP . . . . . 02 (I5)
NOT ANSWERED . . . . . -1 (I5)
I3. IF NOT OBVIOUS, ASK: Is your (usual) home in a public housing project? That is, is the rent paid to NAME OF LOCAL HOUSING AUTHORITY?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
I4. Do you receive any (other) assistance from the government in paying your rent?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
I5. In the past year, have you received any help from the federal, state or local government in paying your (fuel/electric) bills? PROBE: Under (the Energy Assistance Program/LOCAL NAME)?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
I6. Have you had to move when you did not want to within the last year?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
I7. Are you now on a waiting list to go to a nursing home?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
I8. (Have you applied to get into a nursing home/Did you apply for the nursing home) since DATE 2 MONTHS AGO?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
I9. IS THE RESPONDENT A SAMPLE MEMBER OR A PROXY?
SAMPLE MEMBER . . . . . 01
PROXY . . . . . 02 (END, P.48)
I10. The last questions are about how you feel about your home. The purpose of these questions is to help us understand how people feel about where they live.
How satisfied are you with this place as a place to live? Are you --
very satisfied, . . . . . 01
fairly satisfied, . . . . . 02
or not very satisfied? . . . . . 032
NOT ANSWERED . . . . . -1
I11. How safe do you feel inside here at night? Would you say very safe, somewhat safe, or very unsafe?
VERY SAFE . . . . . 01
SOMEWHAT SAFE . . . . . 02
VERY UNSAFE . . . . . 032
NOT ANSWERED . . . . . -1
I12. How satisfied are you with the state of repairs or maintenance here? Are you --
very satisfied, . . . . . 01
fairly satisfied, . . . . . 02
or not very satisfied? . . . . . 032
NOT ANSWERED . . . . . -1
I13. Is there anything about the structure of this building that makes it hard for you to go outside? PROBE FOR PROBLEMS RELATED TO ARCHITECTURE OR REPAIR. CIRCLE ALL THAT APPLY.
YES, STAIRS . . . . . 01
YES, OTHER PROBLEM . . . . . 02
NO . . . . . 032
NOT ANSWERED . . . . . -1
I14. How convenient is this place for visiting with friends? Is it --
very convenient, . . . . . 01
fairly convenient, . . . . . 02
or not very convenient? . . . . . 032
NOT ANSWERED . . . . . -1
I15. How much does any noise from the outside bother you here? Does it bother you--
not much, . . . . . 01
a little, . . . . . 02
or a lot? . . . . . 032
NOT ANSWERED . . . . . -1
I16. How satisfied are you with the amount of privacy you have here, that is, being able to do what you wish without other people seeing you or hearing you? Would you say that you are --
very satisfied, . . . . . 01
fairly satisfied, . . . . . 02
or not very satisfied? . . . . . 032
NOT ANSWERED . . . . . -1
THANK RESPONDENT.
| IF COMPLETED IN ONE SESSION, CODE END TIME. |
| END TIME: |_____|_____| : |_____|_____| AM . . . . . 01 PM . . . . . 02 |
J. OBSERVATIONS
J1. SAMPLE MEMBER'S SEX:
MALE . . . . . 01
FEMALE . . . . . 02
NO INFORMATION . . . . . -1
J2. TYPE OF COMMUNITY IN WHICH SAMPLE MEMBER LIVES:
LARGE CITY (250,000 OR MORE) . . . . . 01
SUBURB OF LARGE CITY . . . . . 02
MEDIUM-SIZED CITY (50,000-250,000) . . . . . 03
SUBURB OR MEDIUM CITY . . . . . 04
SMALL CITY (5,000-50,000) . . . . . 05
SMALL TOWN . . . . . 06
RURAL . . . . . 07
OTHER (SPECIFY) _________________________ . . . . . 08
NO INFORMATION. . . . . -1
J3. SAMPLE MEMBER'S CURRENT LIVING ARRANGEMENT: (CODES 02 - 05 ARE NOT APPLICABLE IN THE COMMUNITY VERSION.)
PRIVATE HOME, ROOM OR APARTMENT . . . . . 01 (J5)
SUPPORTIVE HOUSING WITH CONGREGATE MEALS (NAME: _________________________) . . . . . 06 (J5)
SUPPORTIVE HOUSING WITH OTHER SERVICES (NAME: _________________________) . . . . . 07 (J5)
PERSON CARE HOME (NAME: _________________________) . . . . . 08
OTHER (SPECIFY) _________________________ . . . . . 09 (J5)
NO INFORMATION. . . . . -1 (J5)
| DURING THE ASSESSMENT, DID THE CLIENT'S BEHAVIOR STRIKE YOU AS: | |||
| YES | NO | CANNOT DETERMINE | |
| MENTALLY ALERT AND STIMULATING | 01 | 02 | 03 |
| PLEASANT AND COOPERATIVE | 01 | 02 | 03 |
| DEPRESSED AND/OR TEARFUL | 01 | 02 | 03 |
| FEARFUL, ANXIOUS, OR EXTREMELY TENSE | 01 | 02 | 03 |
| FULL OF UNREALISTIC COMPLAINTS | 01 | 02 | 03 |
| SUSPICIOUS (MORE THAN REASONABLE) | 01 | 02 | 03 |
| BIZARRE OR INAPPROPRIATE (E.G., DISRUPTIVE, WANDERING, ABUSIVE) | 01 | 02 | 03 |
| WITHDRAWN OR LETHARGIC | 01 | 02 | 03 |
| AGITATED, QUICK, LOUD, AND EMOTIONALLY OVERRESPONSIVE | 01 | 02 | 03 |
| NOTES ON BEHAVIOR |
| NOTES ON ALCOHOL OR DRUG ABUSE |
J4. IF PERSONAL CARE HOME, SITE-SPECIFIC CODE FOR TYPE:
|_____|_____| - |_____|_____|
NO INFORMATION. . . . . -1
J5. DID THE SAMPLE MEMBER HAVE DIFFICULTY IN SPEAKING?
YES . . . . . 01
NO . . . . . 02 (J7)
NO OPPORTUNITY TO OBSERVE. . . . . -1 (J7)
J6. WHICH OF THE FOLLOWING BEST DESCRIBES THE SAMPLE MEMBER'S SPEECH?
PARTIALLY IMPAIRED (CAN USUALLY BE UNDERSTOOD BUT HAS DIFFICULTY WITH SOME WORDS) . . . . . 01
SEVERELY IMPAIRED (CAN BE UNDERSTOOD ONLY WITH DIFFICULTY AND CANNOT CARRY ON A NORMAL CONVERSATION) . . . . . 02
COMPLETELY IMPAIRED (SPEECH IS UNINTELLIGIBLE OR CANNOT SPEAK) . . . . . 03
J7. THINKING ABOUT THE SAMPLE MEMBER'S UNDERSTANDING OF THE QUESTIONS, MENTAL FUNCTIONING AND ABILITY TO COMMUNICATE, WOULD YOU SAY THE RESPONSES TO THE QUESTIONS ASKED OF HIM/HER WERE:
COMPLETELY RELIABLE . . . . . 01
RELIABLE ON MOST ITEMS . . . . . 02
RELIABLE ON SOME ITEMS . . . . . 03
COMPLETELY UNRELIABLE . . . . . 04
NO QUESTIONS ASKED OF SAMPLE MEMBER . . . . . -4
| THE PHYSICAL ENVIRONMENT |
CHECK IF A PROBLEM OBSERVED FOR EACH OF THE FOLLOWING
|
| COMMENTS ON THE PHYSICAL ENVIRONMENT |
J8. CHECKLIST ON THE PHYSICAL ENVIRONMENT OF THE SAMPLE MEMBER:
PROBLEM NOT A
PROBLEMUNABLE TO
OBSERVEA. LOOSE, SHAKY STAIRS 01 02 -1 B. BROKEN WINDOWS 01 02 -1 C. ADEQUATE HANDRAILS ON STAIRS 01 02 -1 D. INTERIOR OR EXTERIOR IN NEED OF MAJOR REPAIRS 01 02 -1 E. NO DEADBOLT OR OTHER SECURE LOCK ON DOOR 01 02 -1 F. FREEZING IN WINTER, SWELTERING IN SUMMER 01 02 -1 G. FIRE HAZARDS SUCH AS UNSAFE HEATING OR LIGHTING EQUIPMENT OR BARE WIRES 01 02 -1 H. ACCUMULATION OF TRASH OR GARBAGE IN OR AROUND DWELLING UNIT 01 02 -1 I. RATS OR MICE OR THEIR DROPPINGS 01 02 -1 J. PRESENCE OR STRONG ODOR OF EXCREMENT 01 02 -1 K. FLOODING OR STAQNDING WATER INSIDE 01 02 -1 L. INFESTATION WITH BUDS OF INSECTS 01 02 -1
| COMMENTS ON ARCHITECTURAL BARRIERS |
J9. HOW MANY FLIGHTS OF STAIRS WOULD THE SAMPLE MEMBER HAVE TO CLIMB TO GET FROM THE STREET TO HIS/HER DWELLING UNIT (OR ROOM)? DO NOT COULD FLIGHTS OF STAIRS IF ELEVATORS OR RAMPS ARE AVAILABLE. ANY STAIRS FROM STREET TO BUILDING COUNT AS ONE FLIGHT.
FLIGHTS . . . . . |_____|_____|
NONE . . . . . 00
UNABLE TO OBSERVE . . . . . -1
J10. ARE THERE STEPS WITHIN THE DWELLING UNIT THAT THE SAMPLE MEMBER HAS TO CLIMB? IF YES, HOW MANY STEPS? DO NOT COUNT STEPS IF BEDROOM, BATHROOM, AND KITCHEN ARE ON ONE LEVEL.
STEPS . . . . . |_____|_____|
NONE . . . . . 00
UNABLE TO OBSERVE . . . . . -1
| *** COMPLETE CONTACT SHEET. *** |
| DATA REFERENCE CHART | |||
| Six Months | Two Months | ||
| If the current month is: | The month six months ago was: | If the current month is: | The month two months ago was: |
| January | July | January | November |
| February | August | February | December |
| March | September | March | January |
| April | October | April | February |
| May | November | May | March |
| June | December | June | April |
| July | January | July | May |
| August | February | August | June |
| September | March | September | July |
| October | April | October | August |
| November | May | November | September |
| December | June | December | October |