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
Assessment Date(s): _________________________
Assessment Interview: _________________________
Client Name: _________________________
I.D. Number: [_____]_____] - [_____]_____]_____]_____]_____] - [_____]
Birth Date: _________________________
Sex: M F
Respondent: Client Proxy
NATIONAL LONG TERM CARE DEMONSTRATION
CLINICAL BASELINE ASSESSMENT 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 and Temple University
June 22, 1983
This questionnaire was prepared for the Department of Health and Human Services under Contract No. HHS-100-80-0157 and Contract No. HHS 100-80-0133.
| 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
NOT ANSWERED . . . . . -1[HOW LONG] _____
A2. Do you live alone?
YES, ALONE . . . . . 01 (A6)
NO, WITH OTHERS . . . . . 02
NO, IN GROUP HOME, NOT WITH RELATIVES . . . . . 03 (A6)
NOT ANSWERED . . . . . -1[TYPE OF RESIDENCE] _________________________
A3. Please tell me the names of everyone who usually lived with you.
A4. How old is NAME?
A5. How is NAME related to you?
NOT ANSWERED . . . . . -1
NAME AGE RELATIONSHIP
A6. Do you have any children (who do not live with you)? INCLUDE ONLY LIVING CHILDREN.
YES
How many? . . . . . [_____]_____]
NO . . . . . 00 (A8)
NOT ANSWERED . . . . . -1 (A8)
[ NAME ] [ ADDRESS ] [ TELEPHONE ]
A7. (Do any of these children/Does this child) live within one-half hour travel time of you?
YES
NO . . . . . 00
NOT ANSWERED . . . . . -1
A8. 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?
NAME ADDRESS TELEPHONE
A9. 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
A10. READ CATEGORIES IF NECESSARY:
What is your racial or ethnic background? PROBE: Are you of Spanish origin?
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
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
[ NAME ] [ ADDRESS ] [ TELEPHONE ] [ LAST VISIT ] _________________________
[ NEXT APPOINTMENT ] _________________________
B3. In the last year, how many times were you admitted to any kind of hospital? TRANSFER BETWEEN HOSPITALS = MULTIPLE ADMISSIONS.
ADMISSIONS . . . . . [_____]_____]
NONE . . . . . 00
NOT ANSWERED . . . . . -1
[ HOSPITAL ] [ DATE ] [ REASON ]
B4. In the last year, were you a resident in a nursing home, convalescent home or similar place?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
[ NURSING HOME ] [ DATE ] [ REASON ]
B5. Have you applied to get into a nursing home?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ WHERE ] _________________________
[ ATTITUDE TOWARD NURSING HOME ] _________________________
B6. 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 B7. 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, e.g., 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 [ DETAILS OF HEALTH CONDITIONS/RISK FACTORS. INCLUDE SMOKING, ALCOHOL CONSUMPTION, COMPLIANCE WITH DOCTOR'S ORDERS.] _________________________
B8. 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 thre any non-prescription medicines you take regularly like vitamins, aspirin, or laxatives?
MEDICINE DOSAGE FREQUENCY DOCTOR DATE
B9. Do you have medical treatments at home like injections, therapies, oxygen, or changing of bandages?
YES . . . . . 01
NO . . . . . 02 (B11)
NOT ANSWERED . . . . . -1 (B11)[ TREATMENTS ] _________________________
[ WHO WILL DO IT ] _________________________
[ FREQUENCY ] _________________________
B10. 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[ HELP NEEDED ] _________________________
B11. Often what you eat is important to your health. Could you please tell me what you usually eat? 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
DOES NOT EAT AT ALL (IV TUBES) . . . . . 06
NOT ANSWERED . . . . . -1[ DETAILS ] _________________________
B12. Are you on a special diet?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ TYPE ] _________________________
[ WHO PRESCRIBED ] _________________________
B13. Now, I'd like to talk about special equipment you may use. Do you use any of the following special equipment or aids?
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 brace? 01 02 -1 f. A pacemaker (for your heart)? 01 02 -1 g. A hearing aid? 01 02 -1 h. Glasses or contact lenses? 01 02 -1 i. Any other special equipment that I haven't mentioned? (SPECIFY) _________________________ 01 02 -1 [EQUIPMENT USE] _________________________
| IF THE CLIENT HAS BEEN UNABLE TO GET OUT OF BED FOR MORE THAN ONE MONTH, OR WHEN LIFTED OUT STILL CANNOT AMBULATE, SKIP TO B16. |
INDOOR MOBILITY
B14. The next questions are about getting around indoors,(inside this house/apartment/on this floor).
How do you usually get around inside?
(SPECIFY) _________________________
[ PROBLEMS WITH MOBILITY/AMBULATION ] _________________________
B15. 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[ # OF FLIGHTS:
STREET TO DWELLING UNIT _____
INSIDE DWELLING UNIT _____
B16. Do you feel that you will need (help/more help) with getting around inside?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ HELP NEEDED ] _________________________
OUTDOOR MOBILITY
B17. What about outdoors? How do you usually get around when you go outdoors?
DOES NOT GO OUTDOORS . . . . . [_____]
(SPECIFY) _________________________
B18. (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 CLIENT'S NATIVE LANGUAGE newspaper?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1_________________________
B19. CAN THE CLIENT HEAR WELL ENOUGH TO UNDERSTAND NORMAL CONVERSATION (WITH A HEARING AID IF USUALLY WORN)?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1_________________________
B20. WHICH OF THE FOLLOWING BEST DESCRIBES THE CLIENT'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
C. PHYSICAL ACTIVITIES OF DAILY LIVING
EATING
C1. The next questions are about taking care of yourself.
First, I'd like to ask you abut 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 CODE HELP WITH CUTTING MEAT OR BUTTERING BREAD. USUALLY = HALF THE TIME OR MORE DURING THE PAST WEEK.
YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HELPED . . . . . 02 (C3)
IV, TUBES . . . . . 03 (C4)
NOT ANSWERED . . . . . -1 (C3)
[ WHO HELPS ] [ HOW ]
C2. Did someone usually feed you?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
C3. Do you feel that you will need (help/more help) with eating?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ HELP NEEDED ] _________________________
BED AND CHAIR TRANSFER
C4. 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".
YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HELPED . . . . . 02 (C6)
DID NOT GET OUT OF BED AT ALL . . . . . 03 (C6)
NOT ANSWERED . . . . . -1 (C6)
[WHO HELPS] [HOW]
C5. Did someone usually lift you out of bed or a chair?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ SPECIAL EQUIPMENT USED ] _________________________
C6. 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[ HELP NEEDED ] _________________________
DRESSING
C7. 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?
GOT DRESSED . . . . . 01
STAYED IN NIGHT CLOTHES . . . . . 02
DID NOT CHANGE CLOTHES AT ALL . . . . . 03 (C10)
NOT ANSWERED . . . . . -1 (C10)
C8. Did someone help you (dress/change your night clothes) or stay in the room in case you needed help? DO NOT CODE HELP IN TYING SHOES OR GROOMING.
YES, USUALLY HELPED . . . . . 01
NO, NOT USUALLY HELPED . . . . . 02 (C10)
NOT ANSWERED . . . . . -1 (C10)
[WHO HELPS] [HOW]
C9. Did someone usually (dress you/change your night clothes for you)?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
C10. Do you feel that you will need (help/more help) with (getting dressed/changing your night clothes)?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ HELP NEEDED ] _________________________
BATHING
C11. 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?
IN TUB OR SHOWER . . . . . 01
IN SINK OR BASIN . . . . . 02 (C13)
BEDBATHS . . . . . 03 (C16)
DID NOT HAVE FULL BATH . . . . . 04 (C16)
NOT ANSWERED . . . . . -1 (C13)[ IF BEDBATH, WHO HELPS ] _________________________
C12. 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
C13. 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 (C15)
NOT ANSWERED . . . . . -1 (C15)
[ WHO HELPS ] [ HOW ]
C14. Did someone help you wash more than your back or feet? DO NOT CODE HELP WITH SHAMPOOING HAIR.
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
C15. 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[ TYPE ] _________________________
C16. Do you feel that you will need (help/more help) with bathing? IF NO, PROBE: What about special equipment, do you need that?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ HELP NEEDED ] _________________________
TOILETING
C17. 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? _________________________
YES, TOILET FOR AT LEAST ONE FUNCTION . . . . . 01
NO (BEDPAN, BEDSIDE COMMODE) . . . . . 02 (C22)
NO (CATHETER, COLOSTOMY) . . . . . 03 (C20)
NOT ANSWERED . . . . . -1 (C20)[ IF BEDPAN/COMMODE, WHO HELPS ] _________________________
C18. 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
[ WHO HELPS ] [ HOW ]
C19. 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[ TYPE ] _________________________
C20. Do you use a device such as a catheter bag or colostomy bag?
YES . . . . . 01
NO . . . . . 02 (C22)
NOT ANSWERED . . . . . -1[ TYPE ] _________________________
C21. Do you change (this/your DEVICE) by yourself?
SELF CARE . . . . . 01
HELP WITH CARE . . . . . 02
NOT ANSWERED . . . . . -1[ WHO HELPS ] _________________________
C22. During the past week, did you accidentally wet or soil yourself, either day or night?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
C23. 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[ HELP NEEDED ] _________________________
D. INSTRUMENTAL ACTIVITIES OF DAILY LIVING
IF CLIENT HAS BEEN UNABLE TO GET OUT OF BED FOR MORE THAN ONE MONTH, OR WHEN LIFTED OUT STILL CANNOT AMBULATE, ASK ONLY THE QUESTIONS MARKED WITH A STAR  . |
MEAL PREPARATION
D1. 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 (D4)
NO, NOT USUALLY HAS HELP/NO MEALS PREPARED . . . . . 02
NOT ANSWERED . . . . . -1 (D3)
[ WHO HELPS ] [ HOW ]
D2. What is the reason you (get help preparing/don't prepare) meals?
(SPECIFY) _________________________
D3. Are you able to prepare light meals, such as a sandwich, by yourself?
CAN PREPARE LIGHT MEALS . . . . . 01
CANNOT . . . . . 02
NOT ANSWERED . . . . . -1
D4. Do you feel that you need (help/more help) with meal preparation?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ HELP NEEDED ] _________________________
HOUSEKEEPING
D5. Do you usually do the work around the house, like washing dishes and cleaning floors, by yourself?
YES, USUALLY BY SELF . . . . . 01 (D7)
NO, USUALLY HAS HELP . . . . . 02
NO WORK DONE AROUND THE HOUSE . . . . . 03
NOT ANSWERED . . . . . -1
[ WHO HELPS ] [ HOW ] [ REASON ]
D6. Are you able to do light work around the house, such as washing dishes, by yourself?
CAN DO LIGHT HOUSEWORK . . . . . 01
NOT AT ALL . . . . . 02
NOT ANSWERED . . . . . -1
D7. Do you feel that you need (help/more help) with work around the house?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ HELP NEEDED ] _________________________
SHOPPING
D8. Do you usually shop for most of your groceries by yourself?
YES, USUALLY BY SELF . . . . . 01 (D10)
NO, USUALLY HAS HELP . . . . . 02
NOT ANSWERED . . . . . -1
[ WHO HELPS ] [ HOW ] [ REASON ]
D9. 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
NO, CANNOT GO AT ALL . . . . . 02
NOT ANSWERED . . . . . -1
D10. Do you feel you need (help/more help) with grocery shopping?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ HELP NEEDED ] _________________________
TAKING MEDICINE
D11. 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.
YES . . . . . 01
NO . . . . . 02 (D14)
NOT ANSWERED . . . . . -1 (D13)
[ WHO HELPS ] [ HOW ]
D12. What is the reason you get help with taking medicine?
(SPECIFY) _________________________
D13. 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
NO . . . . . 02
NOT ANSWERED . . . . . -1
D14. Do you feel that you need (help/more help) when you take medicine?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ HELP NEEDED ] _________________________
TRAVEL/TRANSPORTATION
D15. What kind of transportation do you usually use? PROBE: What about going to the doctor?
BUS/SUBWAY . . . . . 01 (D17)
CAR/VAN/TAXI . . . . . 02
AMBULANCE ONLY . . . . . 03
DOES NOT TRAVEL AT ALL . . . . . 04 (D18)
NOT ANSWERED . . . . . -1 (D18)
D16. 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[ ESCORT NEEDED ] _________________________
[ WHO HELPS ] [ HOW ]
D17. Do you have help with transportation from an agency or organization, like LOCAL NAME?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ AGENCY NAME ] _________________________
D18. Do you feel that you will need (help/more help) with transportation?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ HELP NEEDED ] _________________________
MONEY MANAGEMENT
D19. 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?
YES, USUALLY BY SELF . . . . . 01
NO, USUALLY HAS HELP . . . . . 02
NO, HAS NO BILLS . . . . . 03
NOT ANSWERED . . . . . -1[ WHO HELPS ] _________________________
[ REASON HAS HELP/NO BILLS ] _________________________
D20. Do you have a legal guardian, conservator, or payee?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ NAME ] _________________________
[ TYPE ] _________________________
[ ADDRESS ] _________________________
[ PHONE # ] _________________________
D21. Are you able to take care of money for day-to-day purchases by yourself?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1
D22. Do you feel that you need (help/more help) with managing your money?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ HELP NEEDED ] _________________________
TELEPHONE
The next questions are about using the telephone.
D23. Can you get telephone numbers and place the calls by yourself? PROBE: Can you do both?
ONE ONLY . . . . . 01
BOTH . . . . . 02 (D25)
NEITHER . . . . . 03
NOT ANSWERED . . . . . -1[ USES SPECIAL EQUIPMENT ] _________________________
[ NEEDS SPECIAL EQUIPMENT ] _________________________
D24. 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
D25. DOES CLIENT LIVE ALONE (SEE A2 AND A3)? THOSE IN GROUP QUARTERS DO NOT LIVE ALONE.
YES . . . . . 01 (E7)
NO . . . . . 02
A2 or A3 NOT ANSWERED . . . . . 03
E. SERVICES AND SUPPORT
HOUSEHOLD SUPPORT SYSTEM
E1. 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.
| ASK E2-E6 FOR EACH HOUSEHOLD CAREGIVER | NAME 1 _________________________ | NAME 2 _________________________ | NAME 3 _________________________ |
| NO HOUSEHOLD CAREGIVERS . . . . . -4 (E7) | |||
| E2. How is NAME related to you? | _________________________ NOT ANSWERED . . . . . -1 | _________________________ NOT ANSWERED . . . . . -1 | _________________________ NOT ANSWERED . . . . . -1 |
| E3. 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 |
| E4. Is NAME employed? | YES . . . . . 01 NO . . . . . 02 NOT ANSWERED . . . . . -1 | YES . . . . . 01 NO . . . . . 02 NOT ANSWERED . . . . . -1 | YES . . . . . 01 NO . . . . . 02 NOT ANSWERED . . . . . -1 |
| E5. What does NAME regularly help you with? PROBE: Anything else? 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 |
| E6. WAS ANOTHER HOUSEHOLD CAREGIVER NAMED? | YES (Repeat E2-E6) . . . . . 01 NO (GO TO E7) . . . . . 02 | YES (Repeat E2-E6) . . . . . 01 NO (GO TO E7) . . . . . 02 | GO TO E7 |
INFORMAL SUPPORT SYSTEM
E7. 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.
| ASK E8-E13 FOR EACH HOUSEHOLD CAREGIVER | NAME 1 _________________________ | NAME 2 _________________________ | NAME 3 _________________________ |
| NO HOUSEHOLD CAREGIVERS . . . . . -4 (E14) | |||
| E8. How is NAME related to you? | _________________________ NOT ANSWERED . . . . . -1 | _________________________ NOT ANSWERED . . . . . -1 | _________________________ NOT ANSWERED . . . . . -1 |
| E9. 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 |
| E10. About how often does NAME come to help you? PROBE: In the avg. 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 |
| E11. About how long does NAME usually stay each visit? PROBE: On the avg? | _____HOURS _____MINS. NOT ANSWERED . . . . . -1 | _____HOURS _____MINS. NOT ANSWERED . . . . . -1 | _____HOURS _____MINS. NOT ANSWERED . . . . . -1 |
| E12. What does NAME regularly help you with? PROBE: Anything else? 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 |
| E13. WAS ANOTHER INFORMAL CAREGIVER NAMED? | YES (Repeat E8-E13) . . . . . 01 NO (GO TO E14) . . . . . 02 | YES (Repeat E8-E13) . . . . . 01 NO (GO TO E14) . . . . . 02 | GO TO E14 |
FORMAL SUPPORT SYSTEM
E14. 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).
| ASK E15-E19 FOR EACH FORMAL CAREGIVER | NAME 1 _________________________ | NAME 2 _________________________ | NAME 3 _________________________ |
| NO FORMAL CAREGIVERS . . . . . -4 (E20) | |||
| E15. 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 |
| E16. 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 |
| E17. How long does NAME usually stay each visit? | _____HOURS _____MINS. NOT ANSWERED . . . . . -1 | _____HOURS _____MINS. NOT ANSWERED . . . . . -1 | _____HOURS _____MINS. NOT ANSWERED . . . . . -1 |
| E18. What does NAME regularly help you with? PROBE: Anything else? 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 |
| E19. WAS ANOTHER FORMAL CAREGIVER NAMED? | YES (Repeat E15-E19) . . . . . 01 NO (GO TO E20) . . . . . 02 | YES (Repeat E15-E19) . . . . . 01 NO (GO TO E20) . . . . . 02 | GO TO E20 |
E20. 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[ WHERE ] _________________________
E21. Did 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[ ANY MEALS THERE ] _________________________
[ DAILY ACTIVITIES ] _________________________
F. MENTAL FUNCTIONING
| *** THIS SECTION IS NOT TO BE ASKED OF A PROXY *** |
F1. Now I'm going to read a list of questions to you. Please answer "Yes" or "No" for each of them.
YES NO ASK 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
F2. Do you find yourself feeling lonely quite often, sometimes, or almost never?
QUITE OFTEN . . . . . 01
SOMETIMES . . . . . 02
ALMOST NEVER . . . . . 03
NOT ANSWERED . . . . . -1
F3. 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[ WHERE ] _________________________
F4. (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
| DO NOT ASK OF A PROXY RESPONDENT |
F5. 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)? _________________________ 01 02 d. What is your telephone number? IF CLIENT 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 COVER 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 CLIENT'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, 2) 01 02 Thank you. That's all of those questions.
|_____|_____| NUMBER CORRECT
F6. THINKING ABOUT THE CLIENT'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
F7. DURING THE ASSESSMENT, DID THE CLIENT'S BEHAVIOR STRIKE YOU AS:
YES NO CANNOT
DETERMINEMENTALLY 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 [ BEHAVIOR AND EMOTIONAL FUNCTIONING ] _________________________
G. FINANCIAL RESOURCES
G1. The next questions are about your insurance.
Are you covered by --
YES NO NOT
ANSWEREDa. Medicare? . . . . . A . . . . . B [ # FROM CARD ] _________________________ 01 02 -1 b. Medicaid? [ # FROM CARD ] _________________________ 01 02 -1
G2. Any (other) medical insurance or health plan such as Blue Cross, Blue Shield, VA or HMO?
[ DETAILS/NUMBERS ] YES NO NOT
ANSWERED01 02 -1 01 02 -1 01 02 -1 01 02 -1 01 02 -1 01 02 -1
G3. The next questions are about sources of income and assets you may have. This information is needed to see if you may be able to get services you do not now have.
Do you (and your husband/wife) now have any income from --
IF YES G4. What is the monthly amount of that income? YES NO NA NOT
ANSWEREDa. Social Security or railroad retirement, including Social Security disability payments? PROBE: That is, a green check. EXCLUDE SSI. 01 02 -1 CLIENT: __________
SPOUSE: __________
BOTH: __________-1
-1
-1b. Other checks from the government such as SSI (that is, a gold check)? 01 02 -1 CLIENT: __________
SPOUSE: __________
BOTH: __________-1
-1
-1c. Veterans' disability payments? 01 02 -1 CLIENT: __________
SPOUSE: __________
BOTH: __________-1
-1
-1d. Retirement pensions? 01 02 -1 __________ -1 e. Any other incomes? 01 02 -1 __________ -1
G5. Before taxes and deductions, how much is your (and your husband's/wife's) total monthly income? ESTIMATE OK
$|_____|_____|_____|_____|
NOT ANSWERED . . . . . -1
G6. Are you (or is anyone in your household) receiving food stamps?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ AMOUNT ] _________________________
G7. Do you (and your husband/wife) have any assets like real estate (other than your usual home), savings accounts, saving certificates, stocks or bonds, or money market funds? PROBE: Do you have any bank accounts? IF OWNED BY SPOUSE, CODE "YES".
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ COMMENTS ON FINANCIAL ELIGIBILITY: FOLLOW SITE-SPECIFIC PROCEDURE ] _________________________
H. PHYSICAL ENVIRONMENT
H1. 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
OCCUPIES RENT-FREE OR FOR EXCHANGE OF SERVICES . . . . . 03
OTHER (SPECIFY) _________________________ . . . . . 04
NOT ANSWERED . . . . . -1[ HOUSING EXPENSES ] _________________________
H2. Do you receive any (other) assistance from the government in paying your rent?
YES . . . . . 01
NO . . . . . 02
NOT ANSWERED . . . . . -1[ TYPE ] _________________________
H3. 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[ TYPE ] _________________________
| ASK OF CLIENT ONLY |
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.
H4. Is there any thing 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 . . . . . 03
NOT ANSWERED . . . . . -1[ PROBLEMS ] _________________________
H5. How satisfied are you with the state of repairs or maintenance here? (Are you --
very satisfied, . . . . . 01
fairly satisfied, . . . . . 02
or not very satisfied?) . . . . . 03
NOT ANSWERED . . . . . -1[ COMMENTS ] _________________________
H6. 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 . . . . . 03
NOT ANSWERED . . . . . -1[ COMMENTS ] _________________________
H7. How satisfied are you with this place as a place to live? (Are you --
very satisfied, . . . . . 01
fairly satisfied, . . . . . 02
or not very satisfied?) . . . . . 03
NOT ANSWERED . . . . . -1[ COMMENTS ] _________________________
[ SATISFACTION WITH THINGS IN GENERAL ] _________________________
H8. THE PHYSICAL ENVIRONMENT
CHECK IF A PROBLEM OBSERVED FOR EACH OF THE FOLLOWING: A. LOOSE, SHAKY STAIRS M. PEELING PAINT B. BROKEN WINDOWS N. NO CURTAINS OR SHADES C. ADEQUATE HANDRAILS ON STAIRS O. INADEQUATE VENTILATION D. INTERIOR OR EXTERIOR IN NEED OF MAJOR REPAIRS P. BLOCKED PATHWAYS/ACCESS TO FIRE EXITS E. NO DEADBOLT OR OTHER SECURE LOCK ON DOOR Q. SLIPPERY, STICKY OR CLUTTERED FLOORS THAT MIGHT CAUSE SLIPPING OR TRIPPING F. FREEZING IN WINTER, SWELTERING IN SUMMER R. EVIDENCE OF SPOILED FOOD G. FIRE HAZARDS SUCH AS UNSAFE HEATING OR LIGHTING EQUIPMENT OR BARE WIRES S. DIRTY FOOD PREPARATION SURFACES H ACCUMULATION OF TRASH OR GARBAGE IN OR AROUND DWELLING UNIT T. MORE THAN ONE DAY'S DIRTY DISHES IN SINK I. RATS OR MICE OR THEIR DROPPINGS U. BEDDING NOT FRESH J. PRESENCE OR STRONG ODOR OF EXCREMENT V. TOILET AREA FILTHY OR ODOROUS K. FLOODING OR STANDING WATER INSIDE W. NO GRAB BARS NEAR TOILET AND/OR TUB L. INFESTATION WITH BUDS OR INSECTS
/M-19
6/22/83