Design and Operation of the 2010 National Survey of Residential Care Facilities. APPENDIX XX: NSRCF Resident Questionnaire

11/01/2011

Question Number Question Item Code Categories Resident Asked Skip Pattern
R_A_INTRO1 In order to obtain national level data about the residents of residential care facilities such as this one, we are collecting information from a sample of current residents. I will be asking questions about the background, health status, and charges for each sampled resident. The information you provide will be held in strict confidence and will be used only by persons involved in the survey and only for the purpose of the survey. The interview for each of the selected residents should take about 20 minutes to complete. 1 CONTINUE All residents  
R_A_INTRO 1A Now I am going to ask questions about the following resident--[RESIDENT INITIALS]. 1 CONTINUE All residents  
R_A_INTRO 2 Do you have the resident records for [RESIDENT INITIALS]?
(You may want to use the resident file in answering a few of the questions in this survey. If you have not retrieved the records and would like to do so now, I can wait a few minutes while you obtain them.)		 1 RECORD OBTAINED
2 RECORD NOT OBTAINED		 All residents  
R_A1 Please tell me [RESIDENT INITIALS]gender? 1 MALE
2 FEMALE		 All residents  
R_A3 Is [RESIDENT INITIALS]of Hispanic, Latino, or Spanish origin or descent? 1 YES
2 NO		 All residents  
R_A2 Please tell me [RESIDENT INITIALS] age? 0-120 All residents  
ENDINT I am sorry but our survey is about residents that are 18 or older.
Since this person is not eligible, I wont complete an interview for this particular resident. I need to check my records for any other selected residents for whom you were identified as a caregiver.		 1 CONTINUE   R_A2 = < 18
R_A4 HAND R SHOWCARD
Which one or more of the following would you say is [RESIDENT INITIALS] race?
SELECT ALL THAT APPLY		 1 WHITE/CAUCASIAN
2 BLACK OR AFRICAN AMERICAN
3 ASIAN
4 HAWAIIAN OR OTHER PACIFIC ISLANDER
5 AMERICAN INDIAN OR ALASKA NATIVE		 All residents  
R_A5 What is the highest grade or level of education [RESIDENT INITIALS] completed...?
High school or less or
Some college or more		 1 High school or less
2 Some college or more		 All residents  
R_A6 Is [RESIDENT INITIALS] currently married, divorced, legally separated, widowed, or never married? 1 Married
2 Divorced
3 Legally separated
4 Widowed
5 Never married		 All residents  
R_A7 How well does [RESIDENT INITIALS] speak English...?
Excellent
very well
well
fair
poor or not at all		 1 Excellent
2 Very well
3 Well
4 Fair
5 Poor or not at all
6 DOES NOT SPEAK BECAUSE OF A DISABILITY, OR SEVERE DEMENTIA		 All residents  
R_A8a Overall, is [RESIDENT INITIALS] health...?
Excellent
very good
good
fair or
poor		 1 Excellent
2 Very Good
3 Good
4 Fair
5 Poor		 All residents  
R_A9 HAND R SHOWCARD
Which of these places best describes [RESIDENT INITIALS] living quarters?		 1 ROOM DESIGNED FOR ONE PERSON
2 ROOM DESIGNED FOR TWO PERSONS
3 ROOM DESIGNED FOR THREE OR MORE PERSONS
4 STUDIO APARTMENT
5 ONE BEDROOM APARTMENT
6 TWO BEDROOM APARTMENT
7 THREE BEDROOM APARTMENT		 All residents  
R_A10 Does [RESIDENT INITIALS] currently share this (room/ apartment) with another person? 1 YES
2 NO		 All residents  
R_A11 Is this person [RESIDENT INITIALS] spouse or other relative? 1 YES
2 NO		   If R_A10 = 1
R_A12 How many other residents not counting [RESIDENT INITIALS] live in the (room/apartment)? 1 ONE OTHER PERSON
2 TWO OR MORE OTHER PERSONS		   If R_A10 = 1
R_A13 Does [RESIDENT INITIALS] live in a Dementia/Alzheimers Special Care Unit? 1 YES
2 NO
3 FACILITY DOES NOT HAVE DEMENTIA/ ALZHEIMERS UNIT		 All residents  
New question HAND R SHOWCARD
Which of the following are located inside [RESIDENT INITIALS] (room/apartment)?
SELECT ALL THAT APPLY		 1 MICROWAVE
2 COOK TOP OR HOT PLATE
3 OVEN
4 REFRIGERATOR
5 KITCHEN SINK
6 NONE OF THE ABOVE		 All residents  
R_A15 Does [RESIDENT INITIALS] (room/apartment) have a door to the hallway that can be locked from the inside? 1 YES
2 NO		 All residents  
R_A15A Does [RESIDENT INITIALS] (room/apartment) have a bathroom located inside the (room/apartment) or between (rooms/apartments)? 1 YES
2 NO		 All residents  
R_A15Bath HAND R SHOWCARD
Which type of bathroom is in [RESIDENT INITIALS] (room/apartment)		 1 FULL BATHROOM INCLUDING A TOILET, SINK, AND SHOWER OR TUB
2 HALF-BATH INCLUDING A SINK AND TOILET		   If R_A15A = 1
R_A16 HAND R SHOWCARD
Please read this list of activities and tell me whether [RESIDENT INITIALS] regularly participates in any of these at least twice a month, regardless of whether or not it is arranged by the facility.
SELECT ALL THAT APPLY		 1 CARDS, BOARD GAMES, BINGO, PUZZLES
2 ARTS OR CRAFTS, SUCH AS SEWING, KNITTING, PAINTING, QUILTING, FLOWER ARRANGING
3 EXERCISE OR SPORTS
4 PLAYING OR LISTENING TO MUSIC, OR SINGING
5 READING OR WRITING
6 SPIRITUAL OR RELIGIOUS ACTIVITIES
7 SHOPPING OR TRIPS
8 WATCHING TELEVISION
9 LEAVING THE FACILITY GROUNDS
10 TALKING WITH FRIENDS OR RELATIVES
11 GOING OUT TO THE MOVIES, DINING OUT OR OTHER SOCIAL ACTIVITIES
12 GARDENING
13 TAKING CARE OF PETS
14 OTHER HOBBIES OR ACTIVITIES
15 NONE OF THE ABOVE		 All residents  
R_A16_outside HAND R SHOWCARD
Does [RESIDENT INITIALS] go outside the facility to do any of the following activities?
SELECT ALL THAT APPLY		 1 WORK AT A JOB FOR PAY
2 PARTICIPATE IN A SHELTERED WORKSHOP
3 PARTICIPATE IN A WORK TRAINING PROGRAM
4 ATTEND DAY PROGRAMS FOR SOCIAL OR RECREATIONAL ACTIVITIES
5 ATTEND AN EDUCATIONAL PROGRAM
6 ATTEND AN ADULT DAY CARE PROGRAM
7 NONE OF THE ABOVE		 All residents  
R_A17 Does [RESIDENT INITIALS] still drive? 1 YES
2 NO		 All residents  
R_A18 How often does [RESIDENT INITIALS] drive?
Daily or every other day
Once or twice a week or
Less than once per week		 1 Daily or every other day
2 Once or twice a week
3 Less than once per week		   If R-A17 = 1
R_B1Month When did [RESIDENT INITIALS] first move into this facility?
MONTH		 1 January
2 February
3 March
4 April
5 May
6 June
7 July
8 August
9 September
10 October
11 November
12 December		 All residents  
R_B1Year (When did [RESIDENT INITIALS] first move into this facility?)
YEAR		 1970-2010 All residents  
R_B1Range HAND R SHOWCARD
Please look at this card and tell me approximately how long it has been since [RESIDENT INITIALS] first moved into this facility?		 1 0 TO 3 MONTHS
2 MORE THAN 3 MONTHS TO 6 MONTHS
3 MORE THAN 6 MONTHS TO 1 YEAR
4 MORE THAN 1 YEAR TO 3 YEARS
5 MORE THAN 3 YEARS TO 5 YEARS
6 MORE THAN 5 YEARS		   If R_B1Year = DK
R_B2 When [RESIDENT INITIALS] first moved into this facility, was (he/she) directly admitted from a short-term stay at a:
READ CHOICES
hospital
rehabilitation facility
nursing home		 1 Hospital
2 Rehabilitation facility
3 Nursing home
4 NONE OF THE ABOVE		 All residents  
R_B3 HAND R SHOWCARD
Where did (he/she) live prior to (his/her) (moving to this facility/stay at the (hospital/rehabilitation facility/nursing home))?		 1 PRIVATE HOME, APARTMENT, RENTED ROOM, OR FAMILY RESIDENCE
2 DIFFERENT RESIDENTIAL CARE, ASSISTED LIVING, OR GROUP HOME FACILITY
3 RETIREMENT OR INDEPENDENT LIVING COMMUNITY
4 NURSING HOME (THIS EXCLUDES SHORT NURSING HOME STAYS FOR REHABILITATION)
5 PSYCHIATRIC FACILITY
6 JAIL
7 HOMELESS
8 OTHER		 All residents  
R_B4 For last month, what was the total charge for [RESIDENT INITIALS] to live in this facility? Include the basic monthly charge and charges for any additional services. 0-8000 All residents  
R_B5 During the last 30 days did [RESIDENT INITIALS] have any of (his/her) long-term care services at this facility paid by Medicaid? 1 YES
2 NO		 All residents  
R_B6 Is [RESIDENT INITIALS] a veteran of U.S. Military service? 1 YES
2 NO		 All residents  
R_B6a Is [RESIDENT INITIALS] the spouse, or widow/widower, of a veteran of U.S. Military service? 1 YES
2 NO		 All residents  
R_C_INTRO The next questions are about [RESIDENT INITIALS] health status and physical functioning. 1 CONTINUE All residents  
R_C1 HAND R SHOWCARD
As far as you know, has a doctor or other health professional ever diagnosed [RESIDENT INITIALS] with any of the following conditions? Please tell me the numbers that apply from this card.
SELECT ALL THAT APPLY		 1 ALZHEIMER'S DISEASE OR OTHER DEMENTIA
2 ANEMIA
3 ARTHRITIS OR RHEUMATOID ARTHRITIS
4 ASTHMA
5 CANCER OR MALIGNANT NEOPLASM OF ANY KIND
6 CEREBRAL PALSY
7 CHRONIC BRONCHITIS
8 CONGESTIVE HEART FAILURE
9 COPD
10 CORONARY HEART DISEASE
11 DEPRESSION
12 DIABETES
13 EMPHYSEMA
14 GLAUCOMA
15 GOUT, LUPUS, OR FIBROMYALGIA
16 HEART ATTACK (MYOCARDIAL INFARCTION)
17 HIGH BLOOD PRESSURE OR HYPERTENSION
18 INTELLECTUAL OR DEVELOPMENTAL DISABILITIES SUCH AS MENTAL RETARDATION, SEVERE AUTISM, OR DOWN SYNDROME
19 KIDNEY DISEASE
20 MACULAR DEGENERATION
21 MUSCULAR DYSTROPHY
22 NERVOUS SYSTEM DISORDERS, INCLUDING MULTIPLE SCLEROSIS, PARKINSON'S DISEASE, AND EPILEPSY
23 OSTEOPOROSIS
24 OTHER MENTAL, EMOTIONAL OR NERVOUS CONDITION
25 PARTIAL OR TOTAL PARALYSIS
26 SERIOUS MENTAL PROBLEMS SUCH AS SCHIZOPHRENIA OR PSYCHOSIS
27 SPINAL CORD INJURY
28 STROKE
29 TRAUMATIC BRAIN INJURY
30 ANY OTHER KIND OF HEART CONDITION OR HEART DISEASE (OTHER THAN LISTED ABOVE)
31 OTHER
32 NONE OF THESE		 All residents  
R_C1OTH Specify other condition. SPECIFY   R_C1 = 31
R_C1_Cancer What kind of cancer?
SELECT ALL THAT APPLY		 1 BLADDER
2 BLOOD
3 BONE
4 BRAIN
5 BREAST
6 CERVIX
7 COLON
8 ESOPHAGUS
9 GALLBLADDER
10 KIDNEY
11 LARYNX, WINDPIPE
12 LEUKEMIA
13 LIVER
14 LUNG
15 LYMPHOMA
16 MELANOMA
17 MOUTH, TONGUE, OR LIP
18 OVARY
19 PANCREAS
20 PROSTATE
21 RECTUM
22 SKIN, NON-MELANOMA
23 SKIN, DON'T KNOW WHAT KIND
24 SOFT TISSUE (MUSCLE OR FAT)
25 STOMACH
26 TESTIS
27 THROAT, PHARYNX
28 THYROID
29 UTERUS
30 OTHER		   R_C1 = CANCER
R_C1FLU1 HAND R SHOW CARD
Please look at this card and tell me which category best describes [RESIDENT INITIALS] documented vaccination status for a flu shot during the past 12 months.		 1 VACCINATED WHILE RESIDING AT THIS FACILITY
2 VACCINATED BEFORE ADMISSION TO THIS FACILITY
3 NOT VACCINATED IN past 12 MONTHS--NO RECORD OF DOCTOR'S ORDER OR OF VACCINATION OFFERED
4 NOT VACCINATED IN past 12 MONTHS--VACCINATION MEDICALLY CONTRAINDICATED
5 NOT VACCINATED IN past 12 MONTHS--RESIDENT/ FAMILY REFUSED VACCINATION
6 NOT VACCINATED IN past 12 MONTHS--OTHER REASON
7 NOT VACCINATED IN PAST 12 MONTHS--REASON UNKNOWN
8 DID NOT RESIDE IN THE FACILITY DURING THE MOST RECENT FLU SEASON		 All residents  
R_C1FLU2 HAND R SHOW CARD
Which statement on this card best describes the documented vaccination status for whether [RESIDENT INITIALS] has ever had a pneumococcal vaccine?		 1 VACCINATED WHILE RESIDING AT THIS FACILITY
2 VACCINATED BEFORE ADMISSION TO THIS FACILITY
3 NEVER VACCINATED--NO RECORD OF DOCTOR'S ORDER OR OF VACCINATION OFFERED
4 NEVER VACCINATED-- VACCINATION MEDICALLY CONTRAINDICATED
5 NEVER VACCINATED-- RESIDENT/FAMILY REFUSED VACCINATION
6 NEVER VACCINATED-- OTHER REASON
7 NEVER VACCINATED-- REASON UNKNOWN		 All residents  
R_C1_impair_4 HAND R SHOWCARD
Which statement on this card best describes [RESIDENT INITIALS] hearing without a hearing aid?		 1 HEARING IS GOOD
2 HAS A LITTLE TROUBLE HEARING
3 HAS A LOT OF TROUBLE HEARING
4 DEAF		 All residents  
R_C1_impair_6 Is [RESIDENT INITIALS] blind in both eyes or unable to see? 1 YES
2 NO		 All residents  
R_C1_impair_5 Does [RESIDENT INITIALS] have any trouble seeing even when wearing glasses or contact lenses 1 YES
2 NO		   R_C1_impair_6 = 2
R_C2a These next questions refer to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).
During this time, has [RESIDENT INITIALS] been treated in a hospital emergency room?		 1 YES
2 NO		 All residents  
R_C2b (This question refers to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).)
During this time, has [RESIDENT INITIALS] been a patient in a hospital overnight or longer (excluding trips to the emergency room that did not result in a hospital stay)?		 1 YES
2 NO		 All residents  
R_C2c (This question refers to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).)
During this time has [RESIDENT INITIALS] had a stroke?		 1 YES
2 NO		 All residents  
R_C2d (This question refers to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).)
During this time has [RESIDENT INITIALS] had a heart attack?		 1 YES
2 NO		 All residents  
R_C2e (This question refers to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).)
During this time has [RESIDENT INITIALS] had a fall that caused a hip fracture?		 1 YES
2 NO		 All residents  
R_C2f (This question refers to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).)
During this time has [RESIDENT INITIALS] had a fall that caused an injury other than a hip fracture?		 1 YES
2 NO		 All residents  
R_C2g (This question refers to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility).)
During this time has [RESIDENT INITIALS] had a stay in a nursing home?		 1 YES
2 NO		 All residents  
R_C2i During the (past 12 months/# months since [RESIDENT INITIALS] moved into this residential care facility).
During this time, has [RESIDENT INITIALS] had a stay in a rehabilitation facility?		 1 YES
2 NO		 All residents  
R_C3 During the (past 12 months/# months since [RESIDENT INITIALS] moved into this residential care facility).
How many times has [RESIDENT INITIALS] been treated in a hospital emergency room over this period?		 1-35   R_C2a = 1
R_C4 HAND R SHOWCARD
Does [RESIDENT INITIALS] currently use any of the items listed on this card?
SELECT ALL THAT APPLY		 1 DENTURES, INCLUDING A PARTIAL PLATE
2 GLASSES OR CONTACT LENSES
3 HEARING AID
4 CANE, INCLUDING A TRIPOD CANE
5 WALKER
6 MANUAL WHEEL CHAIR
7 ELECTRIC OR MOTORIZED WHEEL CHAIR OR SCOOTER
8 OXYGEN
9 COMMUNICATION BOARD OR OTHER APPLIANCE TO COMMUNICATE
10 ARTIFICIAL LIMB
11 NONE OF THE ABOVE		 All residents  
R_C4a Does [RESIDENT INITIALS] currently use telescopic lenses, Braille, readers, a guide dog, white cane, or any other equipment for people with severe visual impairments? 1 YES
2 NO		   R_C1_impair_ 6 = 1
R_C5a Is [RESIDENT INITIALS] limited in any way because of difficulty remembering or because [RESIDENT INITIALS] experiences periods of confusion? 1 YES
2 NO		 All residents  
R_C5 During the last 7 days, has [RESIDENT INITIALS] given evidence of a problem with short-term memory, such as difficulty remembering what (he/she) had for breakfast or something you told (he/she) a few minutes earlier? 1 YES
2 NO		 All residents  
R_C6 During the last 7 days, has [RESIDENT INITIALS] given evidence of a problem with long-term memory, such as forgetting how old (he/she) is or forgetting that (he/she) was married? 1 YES
2 NO		 All residents  
R_C7 During the last 7 days, has [RESIDENT INITIALS] had any of the following problems with orientation, such as:
Knowing the location of (his/her) bedroom?
Recognizing staff names or faces?
Knowing that (he/she) is in a facility?
Knowing what the season of the year it is?
READ CHOICES. SELECT ALL THAT APPLY		 1 Knowing the location of (his/her) bedroom
2 Recognizing staff names or faces
3 Knowing that (he/she) is in a facility
4 Knowing what the season of the year it is
5 NONE OF THE ABOVE		 All residents  
R_C8 HAND R SHOWCARD
The next question refers to the residents actual performance in making everyday decisions about the tasks or activities of daily living.
During the last 7 days, which of these answers best describes [RESIDENT INITIALS] decision-making about such things as what to wear, how to organize (his/her) day, etc?		 1 INDEPENDENT--DECISIONS WERE CONSISTENT, REASONABLE
2 MODIFIED INDEPENDENCE--HE/SHE HAD SOME DIFFICULTY IN NEW SITUATIONS
3 MODERATELY IMPAIRED-- HIS/HER DECISIONS WERE POOR; CUES AND SUPERVISION WERE REQUIRED
4 SEVERELY IMPAIRED--HE/ SHE NEVER OR RARELY MADE DECISIONS		 All residents  
R_C9 HAND R SHOWCARD
During the last 7 days, which of these answers best describes [RESIDENT INITIALS] ability to make (himself/ herself) understood by others?		 1 ALWAYS UNDERSTOOD BY OTHERS
2 USUALLY UNDERSTOOD-- DIFFICULTY FINDING WORDS OR FINISHING THOUGHTS
3 SOMETIMES UNDERSTOOD-- ABILITY IS LIMITED TO MAKING CONCRETE REQUESTS
4 RARELY OR NEVER UNDERSTOOD		 All residents  
R_C9a Is [RESIDENT INITIALS] difficulty in making (himself/herself) understood by others due to a severe speech impairment or other disability? 1 YES
2 NO		   R_C9 = 2-4
R_C10 Next, I would like to ask about everyday activities and whether [RESIDENT INITIALS] receives any assistance in doing them.
By assistance, I mean help from special equipment, another person or both.		 1 CONTINUE    
R_c10a Does [RESIDENT INITIALS] currently receive assistance in bathing or showering? This includes standby assistance. 1 YES
2 NO		 All residents  
R_c10a1 Does [RESIDENT INITIALS] bathe or shower with the help of:
Special Equipment
Another Person		 1 Special Equipment
2 Another Person		   R_c10a = 1
R_c10b Does [RESIDENT INITIALS] currently receive assistance in dressing?
This includes standby assistance.		 1 YES
2 NO		 All residents  
R_c10b1 Does [RESIDENT INITIALS] dress with the help of:
Special Equipment, such as zipper pulls or button hook aids, or another person, or both?		 1 Special Equipment
2 Another Person		   R_c10b = 1
R_c10c Does [RESIDENT INITIALS] currently receive assistance in eating, such as cutting up food, or cueing? 1 YES
2 NO		 All residents  
R_c10c1 Does [RESIDENT INITIALS] eat with the help of:
Special Equipment
Another Person		 1 Special Equipment
2 Another Person		   R_c10c = 1
R_C10d Is [RESIDENT INITIALS] confined to bed by health problems? 1 YES
2 NO		 All residents  
R_C10e Is [RESIDENT INITIALS] confined to a chair by health problems? 1 YES
2 NO		   R_C10d = 2
R_C10f Does [RESIDENT INITIALS] currently receive any assistance in transferring in and out of bed or a chair? 1 YES
2 NO		   R_C10e = 2
R_C10f1 Does [RESIDENT INITIALS] transfer in or out of a bed or a chair with the help of:
Special Equipment
Another Person		 1 Special Equipment
2 Another Person		   R_C10f = 1
R_C10g Does [RESIDENT INITIALS] currently receive any assistance in walking? 1 YES
2 NO		   R_C10d = 2 and R_C10e = 2
R_C10g1 Does [RESIDENT INITIALS] walk with the help of:
Special Equipment
Another Person		 1 Special Equipment
2 Another Person		   R_C10g = 1
R_C10h Does [RESIDENT INITIALS] currently receive any assistance going outside the grounds of this facility? 1 YES
2 NO
3 DOES NOT GO OUTSIDE FACILITY GROUNDS		   R_C10d = 2 and R_C10e = 2
R_C10h1 When [RESIDENT INITIALS] goes outside the grounds does [RESIDENT INITIALS] require the help of:
Special Equipment
Another Person		 1 Special Equipment
2 Another Person		   R_C10h = 1
R_C10i Does [RESIDENT INITIALS] have an ostomy, an indwelling catheter or similar device? 1 YES
2 NO		 All residents  
R_C10i1 Does [RESIDENT INITIALS] receive any help from another person in caring for this device? 1 YES
2 NO		   R_C10i = 1
R_C10j Does [RESIDENT INITIALS] currently receive any assistance using the bathroom? 1 YES
2 NO
3 DOES NOT USE TOILET (AN OSTOMY PATIENT, CHAIRFAST, ETC.)		 All residents  
R_C10j1 When [RESIDENT INITIALS] uses the bathroom, does [RESIDENT INITIALS] require the help of:
Special equipment
Another person		 1 Special equipment
2 Another person		   R_C10j = 1
R_C10k Has [RESIDENT INITIALS] had any episode of bowel incontinence during the last 7 days? 1 YES
2 NO
3 NOT APPLICABLE (E.G., HAD A COLOSTOMY, ILEOSTOMY)		 All residents  
R_C10l Has [RESIDENT INITIALS] had any episode of urinary incontinence during the last 7 days? 1 YES
2 NO
3 NOT APPLICABLE (E.G., HAS AN INDWELLING CATHETER, HAD A UROSTOMY)		 All residents  
R_C10m Is [RESIDENT INITIALS] able to get out of the facility without the help of another person in case of an emergency? 1 YES
2 NO		   R_C10d≠1 and R_C10e≠1
R_C11 HAND R SHOWCARD
For the next questions, please tell me whether or not [RESIDENT INITIALS] needs help from another person or does not perform this activity.		 1 CONTINUE    
R_C11a Does [RESIDENT INITIALS] currently need help from another person with:
Going shopping for personal items, such as toilet items or medicine.
If the only help [RESIDENT INITIALS] needs is for transportation to and from the store, choose No.		 1 YES, NEEDS HELP
2 NO, DOES NOT NEED HELP
3 DOES NOT PERFORM THIS ACTIVITY		 All residents  
R_C11b (Does [RESIDENT INITIALS] currently need help from another person with:)
Managing money, such as keeping track of expenses or paying bills?		 1 YES, NEEDS HELP
2 NO, DOES NOT NEED HELP
3 DOES NOT PERFORM THIS ACTIVITY		 All residents  
R_C11c Does [RESIDENT INITIALS] currently need help from another person or a special device with:
Using the telephone? This includes TTY or dialing out.		 1 YES, NEEDS HELP
2 NO, DOES NOT NEED HELP
3 DOES NOT PERFORM THIS ACTIVITY		 All residents  
R_C11c_1 Does [RESIDENT INITIALS] receive help using the telephone from another person or a special device? 1 ANOTHER PERSON
2 SPECIAL DEVICE
3 BOTH		   R_C11c = 1
R_C11d Does [RESIDENT INITIALS] currently need help from another person with:
Doing light housework, like straightening up (his/her) room or apartment?		 1 YES, NEEDS HELP
2 NO, DOES NOT NEED HELP
3 DOES NOT PERFORM THIS ACTIVITY		 All residents  
R_C11e (Does [RESIDENT INITIALS] currently need help from another person with:)
Taking medication--this includes opening the bottle, remembering to take medication on time, and taking the prescribed dosage?		 1 YES, NEEDS HELP
2 NO, DOES NOT NEED HELP
3 DOES NOT PERFORM THIS ACTIVITY		 All residents  
R_C12a Does [RESIDENT INITIALS] now use an amplifier for the telephone, a TDD, TTY or teletype, closed caption TV, assistive listening or signaling devices, an interpreter, or any other equipment for people with hearing or speech impairments? 1 YES
2 NO		 All residents  
R_C13 Does [RESIDENT INITIALS] have a landline telephone or cellular telephone in (his/her) room? 1 YES
2 NO		 All residents  
R_C12 HAND R SHOWCARD
Over the last 30 days, how often did [RESIDENT INITIALS] receive one or more outside visitors?		 1 EVERY DAY
2 AT LEAST SEVERAL TIMES A WEEK
3 ABOUT ONCE A WEEK
4 SEVERAL TIMES DURING THE PAST 30 DAYS BUT LESS THAN EVERY WEEK
5 AT LEAST ONCE IN THE LAST 30 DAYS
6 NOT AT ALL IN THE LAST 30 DAYS		 All residents  
R_C12a1 HAND R SHOWCARD
Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...
Walk a quarter mile, about three city blocks?		 1 NOT AT ALL DIFFICULT
2 ONLY A LITTLE DIFFICULT
3 SOMEWHAT DIFFICULT
4 VERY DIFFICULT
5 CAN'T DO AT ALL--HEALTH REASON
6 DOES NOT DO--OTHER REASON		   R_C10d and R_C10e≠1
R_C12a2 Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...
Walk up 10 steps without resting?		 1 NOT AT ALL DIFFICULT
2 ONLY A LITTLE DIFFICULT
3 SOMEWHAT DIFFICULT
4 VERY DIFFICULT
5 CAN'T DO AT ALL--HEALTH REASON
6 DOES NOT DO--OTHER REASON		   R_C10d≠1 and R_C10e≠1
R_C12a3 Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...
Stand or be on feet for about two hours?		 1 NOT AT ALL DIFFICULT
2 ONLY A LITTLE DIFFICULT
3 SOMEWHAT DIFFICULT
4 VERY DIFFICULT
5 CAN'T DO AT ALL--HEALTH REASON
6 DOES NOT DO--OTHER REASON		   R_C10d≠1 and R_C10e≠1
R_C12a4 (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] ...)
Sit for about two hours?		 1 NOT AT ALL DIFFICULT
2 ONLY A LITTLE DIFFICULT
3 SOMEWHAT DIFFICULT
4 VERY DIFFICULT
5 CAN'T DO AT ALL--HEALTH REASON
6 DOES NOT DO--OTHER REASON		 All residents  
R_C12a5 (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...)
Stoop, bend, or kneel?		 1 NOT AT ALL DIFFICULT
2 ONLY A LITTLE DIFFICULT
3 SOMEWHAT DIFFICULT
4 VERY DIFFICULT
5 CAN'T DO AT ALL--HEALTH REASON
6 DOES NOT DO--OTHER REASON		   R_C10d≠1 and R_C10e≠1
R_C12a6 (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...)
Reach up over head?		 1 NOT AT ALL DIFFICULT
2 ONLY A LITTLE DIFFICULT
3 SOMEWHAT DIFFICULT
4 VERY DIFFICULT
5 CAN'T DO AT ALL--HEALTH REASON
6 DOES NOT DO--OTHER REASON		 All residents  
R_C12a7 (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...)
Use fingers to grasp or handle small objects?		 1 NOT AT ALL DIFFICULT
2 ONLY A LITTLE DIFFICULT
3 SOMEWHAT DIFFICULT
4 VERY DIFFICULT
5 CAN'T DO AT ALL--HEALTH REASON
6 DOES NOT DO--OTHER REASON		 All residents  
R_C12a8 (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...)
Lift or carry something as heavy as 10 pounds, such as a bag of groceries?		 1 NOT AT ALL DIFFICULT
2 ONLY A LITTLE DIFFICULT
3 SOMEWHAT DIFFICULT
4 VERY DIFFICULT
5 CAN'T DO AT ALL--HEALTH REASON
6 DOES NOT DO--OTHER REASON		 All residents  
R_C12a9 (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...)
Push or pull a large object like a living room chair?		 1 NOT AT ALL DIFFICULT
2 ONLY A LITTLE DIFFICULT
3 SOMEWHAT DIFFICULT
4 VERY DIFFICULT
5 CAN'T DO AT ALL--HEALTH REASON
6 DOES NOT DO--OTHER REASON		 All residents  
R_C12a10 (Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to...)
Go out to do things like shopping, movies, or sporting events?		 1 NOT AT ALL DIFFICULT
2 ONLY A LITTLE DIFFICULT
3 SOMEWHAT DIFFICULT
4 VERY DIFFICULT
5 CAN'T DO AT ALL--HEALTH REASON
6 DOES NOT DO--OTHER REASON		   R_C10d≠1 and R_C10e≠1
R_C14 In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors? 1 CONTINUE    
R_C14a HAND R SHOWCARD
(In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?)
Refusing to take prescribed medicines at the appropriate time or in the prescribed dosage		 1 OFTEN
2 SOMETIMES (INCLUDES 1 TIME)
3 NEVER
4 RESIDENT DOES NOT TAKE ANY PRESCRIBED MEDICATIONS
5 FACILITY DOES NOT HANDLE RESIDENTS' MEDICATIONS		 All residents  
R_C14c (In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?)
Creating disturbances or being excessively noisy by knocking on doors or yelling or being verbally abusive?		 1 Often
2 Sometimes (INCLUDES 1 TIME)
3 Never		 All residents  
R_C14cc (In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?)
Wandering or moving aimlessly about in the building or on the grounds?		 1 Often
2 Sometimes (INCLUDES 1 TIME)
3 Never		 All residents  
R_C14d (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?)
Refusing to bathe or clean (himself/herself)?		 1 Often
2 Sometimes (INCLUDES 1 TIME)
3 Never		 All residents  
R_C14e (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?)
Rummaging through or taking other peoples belongings?		 1 Often
2 Sometimes (INCLUDES 1 TIME)
3 Never		 All residents  
R_C14f (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?)
Damaging or destroying property?		 1 Often
2 Sometimes (INCLUDES 1 TIME)
3 Never		 All residents  
R_C14g (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?)
Verbally threatening other persons including staff or other residents?		 1 Often
2 Sometimes (INCLUDES 1 TIME)
3 Never		 All residents  
R_C14h (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?)
Being physically aggressive towards other persons including staff or other residents?		 1 Often
2 Sometimes (INCLUDES 1 TIME)
3 Never		 All residents  
R_C14i (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?)
Removing clothing in public?		 1 Often
2 Sometimes (INCLUDES 1 TIME)
3 Never		 All residents  
R_C14j (In the page 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?)
Making unwanted sexual advances towards staff or other residents?		 1 Often
2 Sometimes (INCLUDES 1 TIME)
3 Never		 All residents  
R_C15 Does a physician ever prescribe medications to help control [RESIDENT INITIALS] behavior or to reduce agitation? 1 YES
2 NO		   R_C14a-j = 1 or 2 in any of these questions
R_C16 HAND R SHOWCARD
The following services may be offered by facility staff or provided at the facility by non-facility staff. Please look at this Showcard and tell me if [RESIDENT INITIALS] uses any of these services.
SELECT ALL THAT APPLY		 1 SPECIAL DIETS
2 ASSISTANCE WITH ACTIVITIES OF DAILY LIVING
3 ASSISTANCE WITH A BATH OR SHOWER AT LEAST ONCE A WEEK
4 SKILLED NURSING SERVICES
5 BASIC HEALTH MONITORING SUCH AS BLOOD PRESSURE AND WEIGHT CHECKS
6 SOCIAL AND RECREATIONAL ACTIVITIES WITHIN THE FACILITY
7 SOCIAL AND RECREATIONAL ACTIVITIES OUTSIDE THE FACILITY
8 INCONTINENCE CARE
9 TRANSPORTATION TO MEDICAL APPOINTMENTS
10 TRANSPORTATION TO STORES AND ELSEWHERE
11 PERSONAL LAUNDRY
12 LINEN LAUNDRY SERVICES
13 SOCIAL SERVICES COUNSELING
14 NONE OF THE ABOVE		 All residents  
R_C17a HAS THIS RESPONDENT ALSO COMPLETED EITHER THE FACILITY QUESTIONNAIRE OR ANOTHER RESIDENT'S QUESTIONNAIRE? 1 YES
2 NO		    
R_C17 The next few questions are about you.
How long have you worked at this facility?		 1 6 MONTHS OR LESS
2 MORE THAN 6 MONTHS BUT LESS THAN ONE YEAR
3 AT LEAST ONE YEAR TO LESS THAN TWO YEARS 4 TWO YEARS OR MORE		   R_C17a = 2
R_C18 HAND R SHOWCARD
Please look at this card and tell me which best describes your position at this facility.		 1 RN
2 LPN
3 CERTIFIED MEDICATION AIDE
4 NURSING ASSISTANT/CNA/ PERSONAL CARE AIDE
5 ACTIVITY DIRECTOR OR STAFF
6 OWNER, ADMINISTRATOR, EXECUTIVE DIRECTOR, ASSISTANT DIRECTOR, DIRECTOR OF OPERATIONS, OR MANAGER
7 SOME OTHER POSITION		   R_C17a = 2
R_CEND Thank you. These are all the questions I have for you regarding this resident. Now I need to check my records if there are any other selected residents for whom you were identified as a caregiver. 1 CONTINUE

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Disability, Aging and Long-Term Care ResearchPublicationsWhat's NewHealth Services, FormalAssisted Living/Congregate CareHighlighted IssuesAssisted Living/Residential CareLong-Term Care