Design and Operation of the 2010 National Survey of Residential Care Facilities. APPENDIX IV: Facesheet

11/01/2011

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

CASE ID:
Facility Name:
Facility City:

_X_Original Preloads   ___Facility & Director   ___Chain   ___Completed Mailouts   ___Appointment
Proceed to form

NSRCF FACESHEET
Original Preloads
CASEID:

FACILITY NAME
FACILITY STREET ADDRESS
FACILITY CITY
FACILITY STATE
FACILITY ZIPCODE
FACILITY PHONE
FACILITY STRATA
FACILITY NUMBER OF BEDS
FACILITY CONTACT NAME
ADDITIONAL PHONE NUMBERS, IF ANY
ADDITIONAL NOTES, IF ANY

CASE ID:
Facility Name:
Facility City:

___Original Preloads   _X_Facility & Director   ___Chain   ___Completed Mailouts   ___Appointment
Proceed to form

FACILITY & DIRECTOR
CASEID:

RECRUITER: CONFIRM/COLLECT GREEN INFORMATION DURING THE ADVANCE PACKAGE CALL. RTI WILL SEND THE ADVANCE PACKAGE TO THE ADDRESSEE ON THIS SCREEN.

RECRUITER AND INTERVIEWER: REVIEW THE INFORMATION ON THIS SCREEN BEFORE CALLING, SCREENING, APPOINTING OR INTERVIEWING FACILITY. ANY UPDATES MADE IN THE SCREENER WILL BE REFLECTED ON THIS SCREEN IN 24 HOURS.

FACILITY NAME:
FACILITY STRATA (PRE PRELOAD):
FACILITY NUMBER OF BEDS (PER PRELOAD):
FACILITY STREET ADDRESS LINE 1*
FACILITY CITY*
FACILITY STATE*
FACILITY ZIPCODE*
FACILITY PHONE

* IF FIELD IS UPDATED, CASE MUST RECEIVE PROJECT APPROVAL BEFORE PROCEEDING

FACILITY MAILING ADDRESS IF DIFFERENT FROM THE ABOVE

MAILING ADDRESS LINE 1
MAILING ADDRESS LINE 2
FACILITY CITY*
FACILITY STATE*
FACILITY ZIPCODE*
MAILING ADDRESS (PER SCREENER)

NAME OF DIRECTOR
TITLE OF DIRECTOR
EMAIL OF DIRECTOR (ENTER REFUSED OR NONE IF APPLICABLE)
PHONE OF DIECTOR
PHONE2 OF DIRECTOR

___NOTE THAT ACCORDING TO THE COMPLETED SCREENER, THIS RESIDENTIAL CARE FACILITY...INDEPENDENT LIVING, NURSING HOME, REHABILITATION OR HOSPITAL AT SAME LOCATION

SAVE

CASE ID:
Facility Name:
Facility City:

___Original Preloads   ___Facility & Director   _X_Chain   ___Completed Mailouts   ___Appointment
Proceed to form

NSRCF FACESHEET
CHAIN
CASEID:

IS THIS FACILITY IN A CHAIN
CHAIN ID
ORGANIZATION
CONTACT NAME
ADDRESS LINE 1
ADDRESS LINE 2
CITY
STATE
ZIP
CONTACT PHONE

CHAIN OUTREACH PACKAGE SENT PRIOR TO FIELD

SENT ON

IF YOU WOULD LIKE THE CHAIN OUTREACH PACKAGE MAILED TO THE CHAIN, ENTER INFORMATION HERE:

ORGANIZATION
CONTACT NAME
CONTACT TITLE
ADDRESS LINE 1
ADDRESS LINE 2
CITY
STATE
ZIP
CONTACT PHONE
NOTES FROM SCIENTIFIC STAFF

SAVE

CASE ID:
Facility Name:
Facility City:

___Original Preloads   ___Facility & Director   ___Chain   _X_Completed Mailouts   ___Appointment
Proceed to form

NSRCF FACESHEET
COMPLETED MAILOUTS
CASEID:

DATE RTI SENT ADVANCE PACKAGE
ADVANCE PACKAGE TRACKING NUMBER
ADVANCE PACKAGE DELIVERED ON DATE
ADVANCE PACKAGE SIGNED FOR BY:
DATE TRI SENT PREFIELD CHANGE OUTREACH PACKAGE
CHAIN PACKAGE TRACKING NUMBER
PREFIELD CHAIN OUTREACH PACKAGE DELIVERED ON DATE
PREFIELD CHAIN OUTREACH PACKAGE SIGNED FOR BY:
DATE RTI SENT CHAIN OUTREACH PACKAGE AT FI REQUEST:
CHAIN OUTREACH PACKAGE AT FI REQUEST TRACKING NUMBER:
CHAIN OUTREACH PACKAGE FI REQUEST DELIVERED ON DATE:
CHAIN OUTREACH PACKAGE FI REQUEST SIGNED FOR BY:
DATE RTI SENT PIW
PIW TRACKING NUMBER
PIW DELIVERED ON DATE:
PIW SIGNED FOR BY:
DATE RTI SENT "TROUBLE REACHING YOU" LETTER:
DATE RTI SENT "NO TIME LETTER" LETTER:
DATE RTI SENT "NOT INTERESTED/NOT IF VOLUNTARY" LETTER:
DATE RTI SENT "CANCELLED APPOINTMENT" LETTER:

SAVE

CASE ID:
Facility Name:
Facility City:

___Original Preloads   ___Facility & Director   ___Chain   ___Completed Mailouts   _X_Appointment
Proceed to form

NSRCF FACESHEET
APPOINTMENT
CASEID:

Event Calendar

DAY OF WEEK
DATE
TIME
PRESUMED FI
CONFIRMED FI (TO BE ENTERED BY FS)
WHO TO ASK FOR WHEN ARRIVE
PARKING
APPOINTMENT NOTES
OTHER NOTES
OBSERVER
OBSERVER ORGANIZATION
OBSERVER CELL PHONE
NAME OF RESPONDENT TO FACILITY QUEX (PER SCREENER)
NAME OF RESPONDENT TO FACILITY QUEX (IF NECESSARY TO UPDATE OUTSIDE OF SCREENER)
NAME OF RESPONDENT TO SELECTION QUEX (PER SCREENER)
NAME OF RESPONDENT TO SELECTION QUEX (IF NECESSARY TO UPDATE POST-SCREENER)
NAME OF PERSON TO REMIND
EMAIL OF PERSON TO REMIND
PHONE OF PERSON TO REMIND
PHONE2 OF PERSON TO REMIND
NOTES ABOUT REMINDER CALL

SAVE

Delete Appointment

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