H-79

**CONTENTS**

**Section NamePage**

**PROGRAMMING CONVENTIONS						  i**

**INTRODUCTION AND PARTICIPANT VERIFICATION			iii**

**INDIVIDUAL SERVICE MODULES:**

**CASE MANAGEMENT						  1**

**CONGREGATE MEALS						  6**

**HOME-DELIVERED MEALS					18**

**HOMEMAKER							30**

**TRANSPORTATION							35**

**FAMILY CAREGIVER						43**

**ADDITIONAL SERVICE LIST MODULE					75**

**PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE	81**

**DEMOGRAPHIC INTAKE MODULE					100**

**CLOSING									108**

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0985-0023. Public reporting burden for this information collection is estimated to average 30 minutes per response; response times may range from 20 minutes to 40 minutes.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Administration for Community Living, Washington, DC 20201 Attn: Dr. Heather Menne, (202) 795-7733.

Case Management		Page v

**PROGRAMMING CONVENTIONS**

The RESP segment will contain a variable, TALKWHO, which will indicate which type of interview is being administered as well as the current respondent for that interview. The interview type will never change, but the type of respondent can change. 

The values for RESP.TALKWHO are as follows:

CG1 - **Caregiver** answering themselves

CG2 - Proxy answering for caregiver

CG3 - Translator/interpreter answering for caregiver

PG1 - **Case Management** being answered by participant

PG2 - Proxy answering for participant

PG3 - Translator/interpreter answering for participant

PC1 - **Congregate Meals** being answered by participant

PC2 - Proxy answering for participant

PC3 - Translator/interpreter answering for participant

PM1 – **Home-Delivered Meals** being answered by participant

PM2 - Proxy answering for participant

PM3 - Translator/interpreter answering for participant

PH1 - **Homemaker** being answered by participant

PH2 - Proxy answering for participant

PH3 - Translator/interpreter answering for participant

PT1 - **Transportation** being answered by participant

PT2 - Proxy answering for participant

PT3 - Translator/interpreter answering for participant

FENCEPOST:	If interview was not completed in the first call, FENCEPOST designates where the interview can resume during subsequent calls.

**GLOBAL DISPLAY IN THE FOOTER OF EACH SCREEN IN CONTACTS AND INTERVIEW:**

“{DISPLAY D1} {DISPLAY D2} {DISPLAY D3}”

**PROGRAMMER NOTE: THERE ARE SEVERAL VARIABLES REFERENCED THROUGHOUT THESE SPECIFICATIONS THAT NEED TO BE PRE-LOADED FROM THE SAMPLE FILE. THESE INCLUDE:**

**NAME OF INTERVIEWEE**–– one of 4 types of persons:

Participant

Caregiver

Interpreter/translator

Proxy

**TYPE OF SERVICE:**

Case Management

Congregate meals

Home-delivered meals

Homemaker

Transportation

Family Caregiver

**AGENCY NAME**

**SERVICE PROVIDER**

**INTRODUCTION AND PARTICIPANT VERIFICATION**

**HELLO.**Hello. May I speak with {Name of Participant (PARTICIPANT)/Name of Caregiver (CAREGIVER)/NAME OF INTERPRETER (INTERPRETER)/NAME OF PROXY (PROXY)}? 

PARTICIPANT IS AVAILABLE		1	[GO TO S/P]

CAREGIVER IS AVAILABLE		2	[GO TO S/P]

INTERPRETER IS AVAILABLE		3	[GO TO S/P]

PROXY IS AVAILABLE		4	[GO TO S/P]

NOT AVAILABLE		5	[GO TO I1]

**I1**.	Is this the correct telephone number to contact {Name of Participant/Name of Caregiver/NAME OF INTERPRETER/TRANSLATOR/NAME OF PROXY}}?

YES		1

NO		2	[GO TO I3]

**I2**.	Can you provide me a better time to contact {Name of Participant/Name of Caregiver/NAME OF INTERPRETER/TRANSLATOR/NAME OF PROXY}?

YES		1	[GO TO APPOINTMENT SCREEN]

NO		2	[Thank you. I will call back later.]

RF		-7	[Thank you.]

DK		-8	[Thank you. I will call back later.]

**I3**.	Can you provide me with the correct telephone number for {NAME OF PARTICIPANT/NAME OF CAREGIVER/NAME OF INTERPRETER/TRANSLATOR/NAME OF PROXY}}?

YES		1

NO		2	[Thank you for your time. CODE PROBLEM]

**I4.**	What is the telephone number for {{NAME OF PARTICIPANT/NAME OF CAREGIVER/ INTERPRETER/TRANSLATOR/PROXY}}? RECORD RESPONSE

	(|___|___|___|) 	|___|___|___| - |___|___|___|___|

	(AREA CODE)	(TELEPHONE NUMBER)

Thank you for the information.

**S/P.**	PARTICIPANT OR CAREGIVER ON THE PHONE		1

INTERPRETER/TRANSLATOR ON THE PHONE		2

PROXY ON THE PHONE		3

PARTICIPANT Verification

**PROGRAMMER NOTE:**

**IF S/P = 1 PARTICIPANT ON THE PHONE:**

**IF TYPE OF SERVICE = CASE MANAGEMENT, GO TO CSINTRO1.**

**IF TYPE OF SERVICE = CONGREGATE MEALS, GO TO CMINTRO.**

**IF TYPE OF SERVICE = HOME DELIVERED MEALS, GO TO NRINTRO.**

**IF TYPE OF SERVICE = HOMEMAKER, GO TO HCMINTRO.**

**IF TYPE OF SERVICE = TRANSPORTATION, GO TO TRINTRO.**

**IF S/P = 2 CAREGIVER ON THE PHONE:**

**IF TYPE OF SERVICE = FAMILY CAREGIVER, GO TO CGINTRO.**

**IF S/P = 3 INTERPRETER/TRANSLATOR ON THE PHONE:**

**IF TYPE OF SERVICE = CAREGIVER, GO TO CGINTRIOINT.**

**IF TYPE OF SERVICE = CASE MANAGEMENT, GO TO CSINTROINT.**

**IF TYPE OF SERVICE = CONGREGATE MEALS, GO TO CMINTROINT**

**IF TYPE OF SERVICE = HOME DELIVERED MEALS, GO TO NRINTROINT.**

**IF TYPE OF SERVICE = HOMEMAKER, GO TO HCMINTROINT.**

**IF TYPE OF SERVICE =TRANSPORTATION, GO TO TRINTROINT.**

**IF S/P = 4 PROXY ON THE PHONE:**

**IF TYPE OF SERVICE = CAREGIVER, GO TO CGINTROPRX.**

**IF TYPE OF SERVICE = CASE MANAGEMENT, GO TO CSINTROPROX.**

**IF TYPE OF SERVICE = CONGREGATE MEALS, GO TO CMINTROPROX.**

**IF TYPE OF SERVICE = HOMEMAKER, GO TO HCMINTROPROX.**

**IF TYPE OF SERVICE = HOME DELIVERED MEALS, GO TO NRINTROPRX.**

**IF TYPE OF SERVICE = TRANSPORTATION, GO TO TRINTROPRX.**

**IF RESPONDENT GENDER IS UNKNOWN, FOR FAMILY CAREGIVER SURVEY GENDER WILL ALWAYS BE FEMALE, I.E., “SHE” OR “HER(S).”**

**IF CARE RECIPIENT NAME IS UNKNOWN, FOR THE FAMILY CAREGIVER SURVEY, USE “THE PERSON YOU CARE FOR.”**

**FOR ALL OTHER SURVEYS, GENDER WILL BE MALE, I.E., “HE” OR “HIS.”**

Page i

		Page iv

SURVEY MODULES

CASE MANAGEMENT Service (VERSION: JANUARY 2008)

**CSINTRO [PARTICPANT].** My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show you received case management services from {PROVIDER NAME/AGENCY NAME}. I would like to speak with you about those services.

This survey will take about 30 minutes to complete. Your participation is voluntary and very important to the success of this study. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual.  We will not provide information that identifies individuals to anyone outside the study team, except as required by law. Your eligibility for services will not be affected by your decision to participate or by any of answers you give.

**GO TO CSSERVERF.**

**IF NEEDED:**{Your/His/Her} case manager is the person who sets up in-home services, such as homemaker or personal care services for {you/him/her}.  The case manager also calls to check on how {you are/NAME OF PARTICIPANT is} doing, or how {you like/s/he likes} {your/his/her} services.

**CSINTROINT [INTERPRETER].**My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show you received case management services from (PROVIDER NAME/AGENCY NAME). I would like to speak with you about those services.

This survey will take about 30 minutes to complete. Your participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual.  We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  Your eligibility for services will not be affected by your decision to participate or by any answers you give.

We would like the client to answer the questions as independently as possible. We want to be sure that, wherever possible, we are getting (NAME OF PARTICIPANT)’S actual opinions and responses.

**IF NEEDED:**We were given your name as the interpreter for (NAME OF PARTICIPANT). 

[IF NEEDED:****{Your/His/Her} case manager is the person who sets up in-home services, such as homemaker or personal care services for {you/him/her}.  The case manager also calls to check on how {you are/NAME OF PARTICIPANT is} doing, or how {you like/s/he likes} {your/his/her} services.]

**PROGRAMMER NOTE:  IF INTERPRETER WIL NOT DO INTERVIEW, GO TO CSALTCON.  OTHERWISE, GO TO CSSERVERF.**

**CSINTROPRX [PROXY].**My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show (NAME OF PARTICIPANT) received case management services from {PROVIDER NAME/AGENCY NAME}. I would like to speak with you about those services.

This survey will take about 30 minutes to complete. (NAME OF PARTICIPANT’s) participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual.  We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  {His/her} eligibility for services will not be affected by (his/her) decision to participate or by any answers (s/(he)) gives.

For the remainder of the survey I would like you to answer as though you were [Name of Participant]. All of the following question[s] pertain to {him/her} Please provide your best estimate as to his/her own response or opinion.

**IF NEEDED:** We were given your name as the proxy for (NAME OF PARTICIPANT). 

[IF NEEDED: {Your/His/Her} case manager is the person who sets up in-home services, such as homemaker or personal care services for {you/him/her}.  The case manager also calls to check on how {you are/NAME OF PARTICIPANT is} doing, or how {you like/s/he likes} {your/his/her} services.]

**PROGRAMMER NOTE: IF PROXY WILL NOT DO INTERVIEW, CONTINUE WITH CSALTCON. OTHERWISE GO TO CSSERVERF.**

**CSALTCON.** 	May I have the name and telephone number of someone else to contact?

	_________________	____________________

	FIRST NAME	LAST NAME

	(|___|___|___|) 	|___|___|___| - |___|___|___|___|

	(AREA CODE)	(TELEPHONE NUMBER)

REFERRED BACK TO PARTICIPANT		1	[GO TO CSINTRO]

REFUSED		-7	[Thank you for your time]

DON’T KNOW		-8	[Thank you for your time]

**Thank you for the information. END INTERVIEW.**

**CSSERVERF.**IF NEEDED: We show {you/s/he} may have received [TYPE OF SERVICE] services from [PROVIDER NAME/ AGENCY NAME]. Is that correct?

YES		1	[GO TO CSINTRO1]

NO		2	

REFUSED		-7		[GO TO CSMGRVER]

DON’T KNOW		-8	

PROGRAMMER NOTE: IF NO NAME OF CASE MANAGER NAME ON FILE, GO TO “IF NO.”

**CSMGRVER.**  We show {your/his/her} case manager’s name is {NAME OF CASE MANAGER}. Is that correct?

YES		1

NO		2	

REFUSED		-7		[Thank you for your time]

DON’T KNOW		-8	

PROGRAMMER NOTE:  IF PARTICIPANT OR INTERPRETER/TRANSLATOR, DISPLAY FIRST PERSON TENSE (E.G., “do you” OR “have you”) IN QUESTIONS. IF PROXY, DISPLAY SECOND PERSON TENSE (E.G., “does s/he” OR “has s/he”) WHERE INDICATED.

**CSINTRO1.**Now we are going to talk about the case management service {you receive/NAME OF PARTICIPANT receives} from {NAME OF PROVIDER}. 

	When was the last time {you/s/he} received the case management service? Was it...

**(CSDAYS)**

Today or yesterday, 		1	

More than 1 day to 1 week ago,		2	 

More than 1 week to 1 month ago, or		3	

More than 1 month ago? 		4

ONLY GOT IT ONE TIME **[INTERVIEWER NOTE: INCLUDES R WHO SAYS THEY GOT HELP FOR A SHORT TIME, E.G. AFTER A HOSPITAL STAY]**		5	 

OVER 1 YEAR AGO................		6	[GO TO THANK3]

REFUSED		-7	

DON’T KNOW		-8	                             

**THANK3.**    Thank you, but the focus of this survey is on people who have used the service within the past year. 

**FENCEPOST**

**CSINTRO2**. Now I am going to read a few statements about {your/NAME OF PARTICIPANT’s} case manager and the case management services {you are/s/he is} currently receiving. {Your/His/Her} case manager is the person who sets up in-home services, such as homemaker or personal care services for {you/him/her}. The case manager also calls to check on how {you are/NAME OF PARTICIPANT is} doing, or how {you like/s/he likes} {your/his/her} services. I will read one statement at a time, and then I will read the answer choices.  

**CSINTRO3.** Now I would like to ask you a few additional questions about the services {you/s/he} received through the case management program. 

# CS10.	How long {have you/has NAME OF PARTICIPANT} been receiving the case management services? Would {you/he/she} say...

**(CSHOWLG)**

6 months or less,		1

More than 6 months, but less than 1 year,		2

At least 1 year, but less than 2 years,		3

2 to 5 years, or		4

More than 5 years?		5

REFUSED		-7

DON’T KNOW		-8

# CS11.	Did {your/his/her} case manager develop a care plan for the service {you need/s/he needs}? [IF NEEDED: A care plan is a document that contains information about who saw {you/him/her}, {your/his/her} needs, what kinds of services {you receive/s/he receives} and how {you are/s/he is} doing once {you receive/s/he receives} the services.]

**(CSSVCPLN)**

YES		1

NO		2	[GO TO CS12]

REFUSED		-7	[GO TO CS12]

DON’T KNOW		-8	[GO TO CS12]

**CS11a.**	Did {you/NAME OF PARTICIPANT} get a copy of the plan? 

**(CCOPY)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

# CS12.	{Are you/Is s/he} able to select the services {you receive/s/he receives}?

**(CSELSVC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

# 

# CS13.	{Are you/Is s/he} able to select {your/his/her} service provider?

**(CSSELPRV)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

# CS14.	How would {you/s/he} rate the overall quality of the case management services {you have/s/he has} received? Would {you/s/he} say ...

**(CSRATE)**

Excellent,		1

Very good,		2

Good,		3

Fair, or		4

Poor?		5

Refused		-7

Don’t Know		-8

**CSINTRO4.**  Now I am going to read some statements about the services {you receive/s/he receives}. 

# FENCEPOST

**GO TO THE FOLLOWING MODULES AND COMPLETE THE QUESTIONS IN THIS SEQUENCE:**

**ADDITIONAL SERVICE LIST MODULE;**

**PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE;**

**DEMOGRAPHIC INTAKE MODULE.**

Case Management		Page 1

Case Management		Page 5

CONGREGATE Meals (Version: JANUARY 2009)

**CMINTRO [PARTICPANT].** My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show you have attended the lunch program provided by {PROVIDER NAME/AGENCY’S NAME}.  We would like to know if these services have been helpful. 

This survey will take about 30 minutes to complete. Your participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual. We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  Your eligibility for services will not be affected by your decision to participate or by any answers you give.

[IF NEEDED: Meals provided at senior centers or other places are called congregate meals or senior lunch programs.]

**GO TO CMSERVERF.**

**CMINTROINT [INTERPRETER].**My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show {NAME OF PARTICIPANT} has attended the lunch program provided by {PROVIDER NAME/AGENCY’S NAME}.  We would like to know if these services have been helpful. 

We would like the client to answer the questions as independently as possible. We want to be sure that, wherever possible, we are getting {NAME OF PARTICIPANT}’s actual opinions and responses. 

This survey will take about 30 minutes to complete. {His/Her} participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual. We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  {His /Her} eligibility for services will not be affected by {his /her} decision to participate or by any answers {s/he} gives.

**IF NEEDED:**We were given your name as the interpreter for {NAME OF PARTICIPANT}.

[IF NEEDED: Meals provided at senior centers or other places are called congregate meals or senior lunch programs.]

PROGRAMMER NOTE:  IF INTERPRETER WILL NOT DO INTERVIEW, GO TO CMALTCON. OTHERWISE GO TO CMSERVERF.

**CMINTROPRX [PROXY].** My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show {NAME OF PARTICIPANT} has the lunch program provided by {PROVIDER NAME/AGENCY’S NAME}.  We would like to know if these services have been helpful. 

For the remainder of the survey I would like you to answer as though you were {NAME OF PARTICIPANT}. All of the following questions pertain to {him/her}. Please provide your best estimate as to {his/her} own response or opinion. 

This survey will take about 30 minutes to complete. Your participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual.  We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  {His/Her} eligibility for services will not be affected by your decision to participate or by any answers you give.

**IF NEEDED:**We were given your name as the proxy for {NAME OF PARTICIPANT}. 

[IF NEEDED: A lunch program, or congregate meal is a meal which is provided in a group setting, such as at a senior center.]

PROGRAMMER NOTE:  IF PROXY WILL NOT DO INTERVIEW, CONTINUE WITH CMALTCON. OTHERWISE GO TO CMSERVERF.

**CMALTCON.**  May I have the name and telephone number of someone else to contact?

	_________________	____________________

	FIRST NAME	LAST NAME

	(|___|___|___|) 	|___|___|___| - |___|___|___|___|

	(AREA CODE)	(TELEPHONE NUMBER)

REFERRED BACK TO PARTICIPANT		1	[GO TO CMINTRO]

REFUSED		-7	[Thank you for your time]

DON’T KNOW		-8	[Thank you for your time]

**Thank you for the information. END INTERVIEW.**

**CMSERVERF.**IF NEEDED: We show {you/s/he} may have received {TYPE OF SERVICE} services from {PROVIDER NAME/ AGENCY NAME}. Is that correct?

YES		1

NO		2	[Thank you for your time]    

REFUSED		-7	[Thank you for your time]    

DON’T KNOW		-8	[Thank you for your time]    

**CNRINTRO1.**Now we are going to talk about the lunch program {you attend/NAME OF PARTICIPANT attends} {at NAME OF PROVIDER/through {AGENCY NAME}.

**CNR1.**	When was the last time {you/s/he} ate lunch at the at the senior center or meal site? Was it 

	. . .

**(CMDAYS)**

Today or yesterday, 		1	

More than 1 day to 1 week ago,		2	 

More than 1 week to 1 month ago, or		3	

More than 1 month ago? 		4  

I ONLY USED ATE THERE ONCE		5	[GO TO THANK3]

OVER 1 YEAR AGO		6	[GO TO THANK3]   

REFUSED		-7	[GO TO THANK3]

DON’T KNOW		-8	[GO TO THANK3]

**THANK3.**    Thank you, but the focus of this survey is on people who have used the service within the past year. 

**CNR2.**	How long {have you/has NAME OF PARTICIPANT} been attending the lunch program?  Would {you/NAME OF PARTICIPANT} say...

**(CMRECEV)**

6 months or less,		1

More than 6 months, but less than 1 year,		2 	

At least 1 year, but less than 2 years,		3 	

2 to 5 years, or		4 	

More than 5 years?		5 	

REFUSED		-7	

DON’T KNOW		-8

**PROGRAMMER NOTE: HARD RANGE FOR CNR3=0 TO 7.**

**CNR3.**	How many days each week {do you/does s/he} eat at the senior center or meal site for lunch?

**(CMDAYSWK)**

NUMBER OF DAYS		|___|___|

REFUSED		-7 

DON’T KNOW		-8

**FENCEPOST**

**CNRINTRO2.**The following questions are about {your/NAME OF PARTICIPANT’S} eating habits.

**CNR4.**	Think about the amount of food {you eat/s/he eats} from the lunch program. On the days {you eat/NAME OF PARTICIPANT eats} a meal from the Senior Center or meal site, what portion of all the foods {you eat/s/he eats} in a day does this meal represent? Would {you/s/he} say...

###### (CMPORTN)

Less than one-third,		1

Between one-third and one-half,		2

About one-half, or		3

More than one-half?		4

OTHER		91

(Please Specify: 	)

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**CNRINTRO3.**Please answer the following questions by telling me which response best represents the 		           amount and type of food {you usually eat/NAME OF PARTICIPANT usually eats}.

**CNR5.**	Considering all the food {you eat/s/he eats} in a day, how many servings of **fruit** {do you/does NAME OF PARTICIPANT} usually eat? One serving of fruit is one piece of fruit; one-half cup chopped, cooked, or canned fruit; or three-fourths cup of juice.

**(CMFRUIT)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99.  NUMBER OF SERVINGS: RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**CNR6.**	When {you eat/s/he eats} lunch at the senior center or meal site, {do you/does s/he} usually eat the fruit****that is provided?

**(CMEATFRT)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

**CNR7.**Considering all the food {you eat/s/he eats} in a day, how many servings of **potatoes** {do you/does NAME OF PARTICIPANT} usually eat? One serving is 1 small baked potato; one-half cup mashed or boiled potatoes; ten (10) French fries; or one-half cup hashed browns.

**(CMPOTATO)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR PORTION OF A SERVING, CODE 99.  NUMBER OF SERVINGS:  RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7

DON’T KNOW		-8

**CNR8.**	When {you eat/s/he eats} lunch at the senior center or meal site, {do you/does s/he} usually eat the **potatoes**that are provided?

**(CMEATPOT)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

**FENCEPOST**

**CNR9.**	Considering all the food {you eat/s/he eats} in a day, how many servings of **vegetables**, other than potatoes, {do you/does NAME OF PARTICIPANT} usually eat? One serving is   one cup of raw leafy greens; one-half cup cooked or chopped raw vegetables; or three-fourths cup juice.

**(CMVEGS)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99. NUMBER OF SERVINGS: RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7 

DON’T KNOW		-8

**CNR10.**	When {you eat/s/he eats} lunch at the senior center or meal site, {do you/does s/he} usually eat the vegetables, other than potatoes,****that are provided?

**(CMEATVEG)**

YES		 1

NO		2

REFUSED		-7 

DON’T KNOW		-8

**FENCEPOST**

**CNR11.**	Considering all the food you eat in a day, how many servings of bread, cereal, rice, pasta, noodles, or tortillas do you usually eat every day?  One serving is 1 piece of bread or a tortilla or a small pancake; 1 cup of cold cereal or one-half cup hot cereal; or one-half cup, rice, pasta, or noodles.

**(CMBREAD)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99. NUMBER OF SERVINGS: RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7 

DON’T KNOW		-8

**CNR12.**	When {you eat/s/he eats} lunch at the senior center or meal site, {do you/does s/he} usually eat the bread, cereal, rice, pasta, noodles, or tortillas that are provided?

**(CMEATBRD)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

**CNR12A.**	Considering all the food {you eat/s/he eats} in a day, how many servings of pastry and desserts {do you/does NAME OF PARTICIPANT} usually eat every day? One serving is one-half doughnut, one-half slice of pie or cake, or 2 medium cookies.

**(CMDES)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99.  NUMBER OF SERVINGS: RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7 

DON’T KNOW		-8

**CNR12B.**	When {you eat/s/he eats} lunch at the senior center or meal site, {do you/does NAME OF PARTICIPANT} usually eat the pastry and desserts that are provided? 

**(CMEATDES)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

**FENCEPOST**

**CNR13.**	Considering all the food {you eat/s/he eats} in a day, how many servings of **milk, cheese, yogurt, or calcium rich soy products such as tofu or soy milk** {do you/does NAME OF PARTICIPANT} usually eat? One serving is one cup of milk or yogurt; one and one-half ounces of natural cheese, such as cheddar cheese; or two ounces or two slices of processed cheese, such as American cheese.

**(CMDAIRY)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99. NUMBER OF SERVINGS: RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7 

DON’T KNOW		-8

**CNR14.**	When {you eat/s/he eats} at the senior center or meal site, {do you/does s/he} usually eat or drink the milk, cheese, yogurt**, or calcium rich soy products** (such as tofu or soy milk) that are provided?

**(CMEATDAR)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

**FENCEPOST**

**CNR15.**	Considering all the food {you eat/s/he eats} in a day, how many servings of **meat, chicken, turkey, fish, and eggs {**do you/does NAME OF PARTICIPANT} usually eat? One serving is a 2 or 3 ounce chicken breast, hamburger patty, or fish filet; or 2 to 3 eggs.

**(CMMEAT)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99.  NUMBER OF SERVINGS: RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7 

DON’T KNOW		-8

**CNR16.**	When {you eat/s/he eats} lunch at the senior center or meal site, {do you/does s/he} usually eat the meat, turkey, chicken, fish, or eggs that are provided?

**(CMEATMET)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

**FENCEPOST**

**CNR17.**	Considering all the food {you eat/s/he eats} in a day, how many servings of **nuts, tofu, and beans** such as baked beans, pinto beans, kidney beans, lima beans, soybeans, or black-eyed peas {do you/does NAME OF PARTICIPANT} usually eat? One serving is one-half cup of beans or tofu; 2 tablespoons of peanut butter; or about one ounce of nuts.

**(CMBEANS)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 OUNCE, CODE 99] NUMER OF OUNCES, RECORD VERBATIM ANSWER]**

|___|___| . |___|

REFUSED		-7 	

DON’T KNOW		-8	

**CNR18.**	When {you eat/ s/he eats} lunch at the senior center or meal site, {do you/does s/he} usually eat the nuts, tofu, or beans if they are provided?

**(CMEATBNS)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

**FENCEPOST**

Now I am going to ask about the services {you receive/s/he receives}.

**CNR19.**	How would {you/NAME OF PARTICIPANT} rate the lunch program overall?  Would {you/s(he} say...

**(CMRATE)**

Excellent		 1

Very good		 2

Good		 3

Fair		 4

Poor		 5

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**CNR20.**     Would {you/NAME OF PARTICIPANT} recommend this service to a friend?

**(CMRECOM)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CNR21.**	{Do you/Does NAME OF PARTICIPANT} eat healthier foods as a result of the meals program?

**(CMVARFD)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CNR22.**	Does eating at the lunch program improve {your/NAME OF PARTICIPANT’S} health?

**(CMFLBTR)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CNR23.**	Do the meal programs help {you/NAME OF PARTICIPANT} to stay in your own home?

**(CMSTAYHM)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CNR24.**	{Do you/Does NAME OF PARTICIPANT} like the meals that {you get/s/he gets} at the lunch program?

**(CMLIKE)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CNR25.**	As a result of receiving meals, {do you/does NAME OF PARTICIPANT} feel better?

**(CMFLBR2)**

YES		1

NO		2

REFUSED		-7	

DON’T KNOW		-8	

**CNR26.**	As a result of receiving meals, {do you/does NAME OF PARTICIPANT} see {your/his/her} friends more often?

**(CMFRNDS)**

YES		1

NO		2

REFUSED		-7	

DON’T KNOW		-8	

I’m going to read some statements about the lunch program.  

**CNR27.** 	Think about all the foods that {you receive/s/he receives} from the lunch program.  Now tell me, how often {are you/is s/he} satisfied with the way the food tastes?  Would {you/s/he say}......

**(CMTASTES)**

Always,		1

Usually,		2

Sometimes		3

Seldom, or		4

Never?		5

REFUSED		-7

DON’T KNOW		-8

**CNR28.** 	Think about all the foods that {you receive/s/he receives} from the lunch program.  Now tell me, how often {are you/is s/he} satisfied with the variety of the foods?  Would {you/s/he say}......

**(CMVR2FD)**

Always,		1

Usually,		2

Sometimes		3

Seldom, or		4

Never?		5

REFUSED		-7

DON’T KNOW		-8

**CNR28a1.**	Within the last 12 months, have you noticed any changes in the amount or quality of the food in your lunch program?

**(CMFQYN)**

YES	..	     1      [GO TO CNR28A2]

NO		2	   [GO TO CNRINTRO4]

REFUSED		-7		[GO TO CNRINTRO4]

DON’T KNOW		-8	   [GO TO CNRINTRO4]

**CNR28a2.**	How has your lunch program changed?

[IF NEEDED:  Please tell me more about the changes you have noticed.]

[PROBE:  Anything else?]

**[INTERVIEWER, CODE ALL THAT APPLY]**

**(CMFQ1-10; CMFQ91)**

AMOUNT/QUANTITY) OF FOOD HAS DECREASED	.	 1

QUALITY OF FOOD HAS DECLINED		 2 

LUNCH PROGRAMS ARE PROVIDED LESS OFTEN		3 

FEWER LUNCHES ARE PROVIDED OR FEWER PERSONS ARE SERVED		4

FEWER FOOD CHOICES ARE OFFERED		 5

PACKAGING OF MEALS HAS CHANGED		 6 

MORE COLD MEALS ARE PROVIDED		7 

FEWER CELEBRATION (HOLIDAY OR BIRTHDAY) MEALS ARE PROVIDED		8

FEWER CONDIMENTS ARE PROVIDED		 9

[**TRAINING/CODING NOTE**:  FOR CONGREGATE MEALS, “PACKAGING OF MEALS” MAY INCLUDE COMMENTS ABOUT HOW THE FOOD IS SERVED AND PRESENTED, E.G., PAPER PLATES VS. CHINA PLATES; PLASTIC OR DISPOSABLE SILVERWARE VS. WASHABLE METAL SILVERWARE; PACKAGED OREO COOKIES REPLACING HOME-MADE BAKED GOODS.]

**CNRINTRO4.**	Now, I would like to ask a few questions about buying food.

**CNR29.**	{Do you/Does NAME OF PARTICIPANT} always have enough money or food stamps to buy the food {you need/ NAME OF PARTICIPANT needs}?

**(CMENUF)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

**CNR30.**	During the past month, did {you/NAME OF PARTICIPANT} have to choose between buying food or buying medication?

**(CMRXFD)**

YES		1

NO		2

REFUSED		-7	

DON’T KNOW		-8	

**CNR31.**	During the past month did {you/NAME OF PARTICIPANT} have to choose between buying food or paying {your/his/her} rent or utility bills?

**(CMBILFD)**

YES		1

NO		2

REFUSED		-7	

DON’T KNOW		-8	

**CNR32.**	On one or more days during the past month, did {you/NAME OF PARTICIPANT} skip meals because {you/s/he} had no food and no money or food stamps to buy food?

**(CMSKP)**

YES		1

NO		2

REFUSED		-7	

DON’T KNOW		-8	

**GO TO THE FOLLOWING MODULES AND COMPLETE THE QUESTIONS IN THIS SEQUENCE:**

**ADDITIONAL SERVICE LIST MODULE;**

**PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE;**

**DEMOGRAPHIC INTAKE MODULE.**

Congregate Meals 		Page 6

Congregate Meals		Page 17

Home-delivered Meals (Version: JANUARY 2009)

**NRINTRO [PARTICPANT].**  My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show you have received Home-Delivered Meals sometimes called Meals on Wheels from {PROVIDER NAME/AGENCY’S NAME}.  We would like to know if these services have been helpful. 

This survey will take about 30 minutes to complete. Your participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual. We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  Your eligibility for services will not be affected by your decision to participate or by any answers you give.

 [IF NEEDED: Meals on Wheels or Home Delivered Meals are meals that are usually delivered to eat at home.]

**GO TO NRSERVERF.**

**NRINTROINT [INTERPRETER].**My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show {NAME OF PARTICIPANT} has received Home-Delivered Meals sometimes called Meals on Wheels from {PROVIDER NAME/AGENCY’S NAME}.  We would like to know if these services have been helpful. 

We would like the client to answer the questions as independently as possible. We want to be sure that, wherever possible, we are getting {NAME OF PARTICIPANT}’s actual opinions and responses. 

This survey will take about 30 minutes to complete. {His/Her} participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual. We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  {His /Her} eligibility for services will not be affected by {his /her} decision to participate or by any answers {s/he} gives.

**IF NEEDED:**We were given your name as the interpreter for {NAME OF PARTICIPANT}.

[IF NEEDED: Meals on Wheels or Home Delivered Meals are meals that are usually delivered to eat at home.]

**PROGRAMMER NOTE: IF INTERPRETER WILL NOT DO INTERVIEW GO TO NRALTCON. OTHERWISE GO TO NRSERVERF.**

**NRINTROPRX [PROXY].**  My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show {NAME OF PARTICIPANT} has received Home-Delivered Meals sometimes called Meals on Wheels from {PROVIDER NAME/AGENCY’S NAME}.  We would like to know if these services have been helpful. 

For the remainder of the survey I would like you to answer as though you were {NAME OF PARTICIPANT}. All of the following questions pertain to {him/her}. Please provide your best estimate as to {his/her} own response or opinion. 

This survey will take about 30 minutes to complete. Your participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual. We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  {His/Her} eligibility for services will not be affected by your decision to participate or by any answers you give.

**IF NEEDED:**We were given your name as the proxy for {NAME OF PARTICIPANT}. 

[IF NEEDED: Meals on Wheels or Home Delivered Meals are meals that are usually delivered to eat at home.]

**NRALTCON.**  May I have the name and telephone number of someone else to contact?

	_________________	____________________

	FIRST NAME	LAST NAME

	(|___|___|___|) 	|___|___|___| - |___|___|___|___|

	(AREA CODE)	(TELEPHONE NUMBER)

REFERRED BACK TO PARTICIPANT		1	[GO TO NRINTRO]

REFUSED		-7	[Thank you for your time]

DON’T KNOW		-8	[Thank you for your time]

**Thank you for the information. END INTERVIEW.**

**NRSERVERF.**IF NEEDED: We show {you/s/he} may have received {TYPE OF SERVICE} services from {PROVIDER NAME/AGENCY NAME}. Is that correct?

YES		1

NO		2	

REFUSED		-7		[Thank you for your time]

DON’T KNOW		-8	

**HNRINTRO1.**  Now we are going to talk about the Meals on Wheels {you receive/NAME OF PARTICIPANT receives} from {NAME OF PROVIDER}.

**HNR1.**	When was the last time {you/s/he} received a meal?  Was it . . . 

**(HMDAYS)**

Today or yesterday, 		1

More than 1 day to 1 week ago,		2

More than 1 week to 1 month ago, or		3

More than 1 month ago?		4

ONLY GOT 1 MEAL **[INTERVIEWER NOTE: INCLUDES R WHO SAYS THEY GOT MEALS FOR A SHORT TIME, E.G. AFTER A HOSPITAL STAY]**		5	   [GO TO THANK3]

OVER 1 YEAR AGO................		6		[GO TO THANK3] 

REFUSED		-7	   [GO TO THANK3]

DON’T KNOW		-8	   [GO TO THANK3]

**THANK3.**  	Thank you, but the focus of this survey is on people who have used the service within the past year. 

**HNR2.**	How long {have you/has NAME OF PARTICIPANT} been receiving Meals on Wheels?  Would {you/NAME OF PARTICIPANT} say...

**(HMRECEV)**

6 months or less,		1

More than 6 months, but less than 1 year,		2

At least 1 year, but less than 2 years,		3

2 to 5 years, or		4

More than 5 years?		5

REFUSED		-7

DON’T KNOW		-8

**HNRINTRO2.**Now, I am going to ask about the days {you receive/NAME OF PARTICIPANT receives} 	Meals on Wheels.

**PROGRAMMER NOTE:  SOFT RANGE FOR HNR3=0 TO 4; HARD RANGE = 0 TO 6**

**HNR3.**	How many meals {do you/does s/he} get on the days that {you receive/s/he receives} Meals on Wheels? 

**(HMATTENA)**

NUMBER OF MEALS	**|___|___|  [INTERVIEWER NOTE:  IF NUMBER VARIES, ENTER 91]**

OTHER		91

(Please Specify: 	)

REFUSED		-7

DON’T KNOW		-8

**PROGRAMMER NOTE:  HARD RANGE FOR HNR4 = 0 to 7**

**HNR4.**	How many days each week {do you/does s/he} receive Meals on Wheels?

**(HMDAYSWK)**

NUMBER OF DAYS	|___|___|

REFUSED		-7

DON’T KNOW		-8

**HNR5.**	Think about the amount of food {you eat/s/he eats} from Meals on Wheels.  On the days {you eat/NAME OF PARTICIPANT eats} a meal from Meals on Wheels, what portion of all the foods {you eat/s/he eats} in a day does this meal represent? Would {you/s/he} say...

**(HMPORTN)**

Less than one-third,		1

Between one-third and one-half,		2

About one-half, or		3

More than one-half?		4

OTHER		91

(Please Specify: 	)

REFUSED		-7

DON’T KNOW		-8

**HNRINTRO3.**Please answer the following questions by telling me which response best represents the      amount and type of food {you usually eat/NAME OF PARTICIPANT usually eats}.

**HNR6.**	Considering all the food {you eat/s/he eats} in a day, how many servings of **fruit** {do you/does NAME OF PARTICIPANT} usually eat?  One serving of fruit is one piece of fruit; one-half cup chopped, cooked, or canned fruit; or three-fourths cup of juice.

**(HMFRUIT)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99. NUMBER OF SERVINGS:  RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7      

DON’T KNOW		-8

**HNR7.**	When {you eat/s/he eats} the meal from Meals on Wheels, {do you/does s/he} usually eat the fruit****that is provided?

**(HMEATFRT)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

# FENCEPOST 

**HNR8.**	Considering all the food {you eat/s/he eats} in a day, how many servings of **potatoes** {do you/does NAME OF PARTICIPANT} usually eat? One serving is one (1) small baked potato; one-half cup mashed or boiled potatoes; ten (10) French fries; or one-half cup hashed browns.

**(HMPOTATO)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99.  NUMBER OF SERVINGS: RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7

DON’T KNOW		-8

**HNR9.**	When {you eat/s/he eats} the meal from Meals on Wheels, {do you/does s/he} usually eat the **potatoes**that are provided?

**(HMEATPOT)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

# FENCEPOST

**HNR10.**	Considering all the food {you eat/s/he eats} in a day, how many servings of **vegetables**, other than potatoes, {do you/does NAME OF PARTICIPANT} usually eat?  One serving is one (1) cup of raw leafy greens; one-half cup cooked or chopped raw vegetables; or three-fourths cup juice.

**(HMVEGS)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99.  NUMBER OF SERVINGS: RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7 

DON’T KNOW		-8

**HNR11.**	When {you eat/s/he eats} the meal from Meals on Wheels, {do you/does s/he} usually eat the vegetables, other than potatoes,****that are provided?

**(HMEATVEG)**

YES		 1

NO		2

REFUSED		-7 

DON’T KNOW		-8

# FENCEPOST

**HNR12.**	Considering all the food you eat in a day, how many servings of bread, cereal, rice, pasta, noodles, or tortillas do you usually eat every day?  One serving is one (1) piece of bread or a tortilla or a small pancake; one (1) cup of cold cereal or one-half cup hot cereal; or one-half cup rice, pasta, or noodles.

**(HMBREAD)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99. NUMBER OF SERVINGS: RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7 

DON’T KNOW		-8

**HNR13.**	When {you eat/s/he eats} the meal from Meals on Wheels, {do you/does s/he} usually eat the bread, cereal, rice, pasta, noodles, or tortillas that are provided?

**(HMEATBRD)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

**HNR13A.**	Considering all the food {you eat/s/he eats} in a day, how many servings of pastry and desserts {do you/does s/he} usually eat every day? One serving is one-half doughnut, one-half slice of pie or cake, or two (2) medium cookies.

**(HMEATBRD)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99.  NUMBER OF SERVINGS: RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7

DON’T KNOW		-8

**HNR13B.**	When {you eat/s/he eats} the meal from Meals on Wheels, {do you/does s/he} usually eat the pastry and desserts that are provided?

**(HMEATBRD)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

# FENCEPOST

**HNR14.**	Considering all the food {you eat/s/he eats} in a day, how many servings of **milk, cheese, yogurt, or calcium rich soy products such as tofu or soy milk** {do you/does NAME OF PARTICIPANT} usually eat? One serving is one cup of milk or yogurt; one and one-half ounces of natural cheese, such as cheddar cheese; or two ounces or two slices of processed cheese, such as American cheese.

**(HMDAIRY)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99. NUMBER OF SERVINGS: RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7 

DON’T KNOW		-8

**HNR15.**	When {you eat/s/he eats} the meal from Meals on Wheels, {do you/does s/he} usually eat or drink the milk, cheese, yogurt**, or calcium rich soy products (such as tofu or soy milk)** that are provided?

**(HMEATDAR)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

# FENCEPOST

**HNR16.**	Considering all the food {you eat/s/he eats} in a day, how many servings of **meat, chicken, turkey, fish, and eggs** {do you/does NAME OF PARTICIPANT} usually eat? One serving is a two or three ounce chicken breast, hamburger patty or fish filet; or two to three eggs.

**(HMMEAT)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99. NUMBER OF SERVINGS:  RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7 

DON’T KNOW		-8

**HNR17.**	When {you eat/s/he eats} the meal from Meals on Wheels, {do you/does s/he} usually eat the meat, chicken, turkey, fish, or eggs that are provided?

**(HMEATMET)**

YES		 1

NO		 2

REFUSED		-7 

DON’T KNOW		-8

# FENCEPOST

**HNR18.**	Considering all the food {you eat/s/he eats} in a day, how many servings of **nuts, tofu, and beans** such as baked beans, pinto beans, kidney beans, lima beans, soybeans, or black-eyed peas {do you/does NAME OF PARTICIPANT} usually eat? One serving is one-half cup of beans or tofu; 2 tablespoons of peanut butter; or about one ounce of nuts.

**(HMBEANS)**

**[INTERVIEWER NOTE:  IF RESPONDENT ANSWERS LESS THAN 1 DAILY SERVING OR A PORTION OF A SERVING, CODE 99. NUMBER OF SERVINGS:  RECORD VERBATIM ANSWER.]**

|___|___| . |___|

REFUSED		-7 	

DON’T KNOW		-8	

**HNR19.**When {you eat/ s/he eats} the meal from Meals on Wheels, {do you/does s/he} usually eat the nuts, tofu, or beans if they are provided?

**(HMEATBNS)**

YES		 1

NO		2

REFUSED		-7

DON’T KNOW		-8

**HNR20.**How would {you/NAME OF PARTICIPANT} rate the Meals on Wheels program overall?  Would {you/s(he)} say...

###### (HMRATE)

Excellent,		1

Very good,		2

Good,		3

Fair, or		4

Poor?		5

REFUSED		-7

DON’T KNOW		-8

                     I’m going to read some statements about the meals program.  

**HNR21.** 	Think about all the foods that {you receive/s/he receives} from the Meals on Wheels program.  Now tell me, how often {are you/is s/he} satisfied with the way the food tastes?  Would {you/s/he say}......

**(HMTASTES)**

Always,		1

Usually,		2

Sometimes,		3

Seldom, or		4

Never?		5

REFUSED		-7

DON’T KNOW		-8

**HNR22.** 	Think about all the foods that {you receive/s/he receives} from the Meals on Wheels program.  Now tell me, how often {are you/is s/he} satisfied with the variety of the foods?  Would {you/s/he say}......

**(HMVR2FD)**

Always,		1

Usually,		2

Sometimes,		3

Seldom, or		4

Never?		5

REFUSED		-7

DON’T KNOW		-8

**HNR22a1.**	Within the last 12 months, have you noticed any changes in the amount or quality of the food in your Meals-on-Wheels service?

**(HNRFQYN)**

YES		    1      [GO TO HNR22a2]

NO		2	  [GO TO HNR23]

REFUSED		-7	  [GO TO HNR23]

DON’T KNOW		-8	  [GO TO HNR23]

**HNR22a2.**	How has your Meals-on-Wheels service changed?

**[IF NEEDED:  Please tell me more about the changes you have noticed.]**

**[PROBE:  Anything else?]**

**[INTERVIEWER, CODE ALL THAT APPLY]**

**(HNRFQ1-10; HNRFQ91)**

AMOUNT/QUANTITY OF FOOD HAS DECREASED.		 1

QUALITY OF FOOD HAS DECLINED 		 2 

MEAL SERVICE IS PROVIDED LESS OFTEN		3 

FEWER MEALS ARE PROVIDED		4

FEWER FOOD CHOICES ARE OFFERED		 5

PACKAGING OF MEALS HAS CHANGED		 6 

MORE COLD OR FROZEN MEALS ARE PROVIDED		7 

FEWER CELEBRATION (HOLIDAY OR BIRTHDAY) MEALS ARE PROVIDED		8

FEWER CONDIMENTS ARE PROVIDED		 9

LESS COFFEE OR TEA IS PROVIDED		10 

OTHER		91

(SPECIFY: 	)

[**TRAINING/CODING NOTE**:  FOR HOME-DELIVERED MEALS, “PACKAGING OF MEALS” MAY INCLUDE COMMENTS ABOUT HOW THE FOOD IS SERVED AND PRESENTED, E.G., PLASTIC MICROWAVEABLE TRAYS VS. ALUMINUM FOIL TRAYS WITH CRIMPED EDGES; REUSABLE OR ENVIRONMENTALLY-FRIENDLY PACKAGING.]

**HNR23.**	Do the meals from Meals on Wheels arrive when expected?

**(HMONTIME)**

Always,		1

Usually,		2

Sometimes		3

Seldom, or		4

Never?		5

REFUSED		-7

DON’T KNOW		-8

**HNR24.**	{Do you/Does NAME OF PARTICIPANT} like the meals {you get/s/he gets} from the Meals on Wheels program?

**(HNRLIKE)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**HNR25.**	Would you recommend this service to a friend?

**(HNRRECOM)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**HNR26.**	Do you eat healthier foods as a result of the meals program?

**(HMVARFD)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**HNR27.**	Does receiving Meals on Wheels improve (your/NAME OF PARTICIPANT’S) health?

**(HMFLBTR)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**HNR28.**	Do Meals on Wheels help (you/NAME OF PARTICIPANT) to stay in your own home?

**(HMSTAYHM)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**HNR29.**	As a result of receiving Meals on Wheels, {do you/does NAME OF PARTICIPANT} feel better?

**(HMFLBR2)**

YES		1

NO		2

REFUSED		-7	

DON’T KNOW		-8	

****

**HNRINTRO4.**	Now, I would like to ask a few questions about buying food.

**HNR30.**	{Do you/Does NAME OF PARTICIPANT} always have enough money or food stamps to buy the food {you need/NAME OF PARTICIPANT needs}?

**(HMENUF)**

YES		 1

NO		 2

REFUSED		-7	

DON’T KNOW		-8	

**HNR31.**	During the past month, did {you/NAME OF PARTICIPANT} have to choose between buying food or buying medication?

**(HMRXFD)**

YES		1

NO		2

REFUSED		-7	

DON’T KNOW		-8	

**HNR32.**	During the past month did {you/NAME OF PARTICIPANT} have to choose between buying food or paying {your/his/her} rent or utility bills?

**(HMBILFD)**

YES		1

NO		2

REFUSED		-7	

DON’T KNOW		-8	

**HNR33.**	On one or more days during the past month, did {you/NAME OF PARTICIPANT} skip meals because {you/s/he} had no food and no money or food stamps to buy food?

**(HMSKP)**

YES		1

NO		2

REFUSED		-7	

DON’T KNOW		-8	

**GO TO THE FOLLOWING MODULES AND COMPLETE THE QUESTIONS IN THIS SEQUENCE:**

**ADDITIONAL SERVICE LIST MODULE;**

**PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE;**

**DEMOGRAPHIC INTAKE MODULE.**

Home Delivered-Meals 		Page 18

Home Delivered Meals		Page 30

HomeMaker Service (VERSION: JANUARY 2008)

**HCMINTRO [PARTICIPANT].**  My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show you received homemaker services from (PROVIDER NAME/AGENCY NAME). I would like to speak with you about those services.

This survey will take about 30 minutes to complete. Your participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual.  We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  Your eligibility for services will not be affected by your decision to participate or by any answers you give.

[IF NEEDED: Homemaker or Housekeeping Services are services that may include help with doing light housework, laundry, preparing meals or shopping.] 

**GO TO HCMSERVERF.**

**HCMINTROINT [INTERPRETER].**My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show you received homemaker services from (PROVIDER NAME/AGENCY NAME). I would like to speak with you about those services.

This survey will take about 30 minutes to complete. Your participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual.  We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  Your eligibility for services will not be affected by your decision to participate or by any answers you give.

We would like the client to answer the questions as independently as possible. We want to be sure that, wherever possible, we are getting (NAME OF PARTICIPANT)’S actual opinions and responses.

**IF NEEDED:**We were given your name as the interpreter for (NAME OF PARTICIPANT). 

[IF NEEDED: Homemaker or Housekeeping Services are services that may include help with doing light housework, laundry, preparing meals or shopping.] 

PROGRAMMER NOTE:  IF INTERPRETER WILL NOT DO INTERVIEW GO TO HCMALTCON. OTHERWISE GO TO HCMSERVERF.

**HCMINTROPRX [PROXY].**My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show (NAME OF PARTICIPANT) received Homemaker Services from {PROVIDER NAME/AGENCY NAME}. I would like to speak with you about those services.

This survey will take about 30 minutes to complete. (NAME OF PARTICIPANT’s) participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual.  We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  {His/her} eligibility for services will not be affected by (his/her) decision to participate or by any answers (s/(he)) gives.

For the remainder of the survey I would like you to answer as though you were [Name of Participant]. All of the following question[s] pertain to {him/her} Please provide your best estimate as to his/her own response or opinion.

**IF NEEDED:** We were given your name as the proxy for (NAME OF PARTICIPANT). 

[IF NEEDED: Homemaker or Housekeeping Services are services that may include help with doing light housework, laundry, preparing meals or shopping.] 

PROGRAMMER NOTE: IF PROXY WILL NOT DO INTERVIEW, CONTINUE WITH HCMALTCON. OTHERWISE GO TO HCMSERVERF.

**HCMALTCON.** 	May I have the name and telephone number of someone else to contact?

	_________________	____________________

	FIRST NAME	LAST NAME

	(|___|___|___|) 	|___|___|___| - |___|___|___|___|

	(AREA CODE)	(TELEPHONE NUMBER)

REFERRED BACK TO PARTICIPANT		1	[GO TO HCMINTRO]

REFUSED		-7	[Thank you for your time]

DON’T KNOW		-8	[Thank you for your time]

**Thank you for the information. END INTERVIEW.**

**HCMSERVERF.**IF NEEDED: We show {you/s/he} may have received [TYPE OF SERVICE] services from [PROVIDER NAME/AGENCY NAME]. Is that correct?

YES		1

NO		2	 [Thank you for your time]

REFUSED		-7	 [Thank you for your time]

DON’T KNOW		-8	 [Thank you for your time]

PROGRAMMER NOTE:  IF PARTICIPANT OR INTERPRETER/TRANSLATOR, DISPLAY FIRST PERSON TENSE (E.G., “do you” OR “have you”) in questions. If proxy, display second person tense (e.g., “does s/he” OR “has s/he”) WHERE INDICATED.

**HCINTRO1.**Now we are going to talk about the homemaker or housekeeping service {you receive/NAME OF PARTICIPANT receives} from {NAME OF PROVIDER}

**HC1.**	When was the last time {you/s/he} received the homemaker or housekeeping service? Was it...

**(HCDAYS)**

Today or yesterday, 		1	

More than 1 day to 1 week ago,		2	 

More than 1 week to 1 month ago, or		3	

More than 1 month ago? 		4

ONLY GOT IT ONE TIME **[INTERVIEWER NOTE: INCLUDES R WHO SAYS THEY GOT HELP FOR A SHORT TIME, E.G. AFTER A HOSPITAL STAY]**		5	[GO TO THANK3] 

OVER 1 YEAR AGO................		6	[GO TO THANK3]

REFUSED		-7	[GO TO THANK3]

DON’T KNOW		-8	[GO TO THANK3]

**THANK3.**    Thank you, but the focus of this survey is on people who have used the service within the past year. 

**HC2.**	How long {have you/has NAME OF PARTICIPANT} been receiving homemaker services?  Would {you/ NAME OF PARTICIPANT} say...

**(HCRECEV)**

6 months or less,		1

More than 6 months, but less than 1 year,		2

At least 1 year, but less than 2 years,		3

2 to 5 years, or		4

More than 5 years?		5

REFUSED		-7

DON’T KNOW		-8

**PROGRAMMER NOTE: HARD RANGE IN HCMOFT IS 0 to 7.**

**HC3.**	How often does the homemaker help with housework?

**(HCMOFT and HCWEEK and HCMONTH)**

NUMBER OF TIMES PER WEEK		1	

NUMBER OF TIMES PER MONTH		2	

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

****

**HC4.**  	When the homemaker comes, how many hours of help {do you/does s/he} receive?

**(SHCHRS)**

NUMBER OF HOURS	|___|___|

REFUSED		-7

DON’T KNOW		-8

**HC5.**	Does {your/his/her} homemaker do things the way {you want/s/he wants} them done?  

**(HCHM07)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**HC6.**	Does {your/his/her} homemaker do what {you ask/s/he asks} them to? 

**(SHCHM09)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**HC7.**	        How would {you/NAME OF PARTICIPANT} rate the quality of your homemaker service?  

	        Would (you/Name of Participant) say...

**(HCARATE)**

Excellent,		1 

Very good,		2

Good,		3

Fair, or		4

Poor?		5

REFUSED		-7 

DON’T KNOW		-8 

**FENCEPOST**

**HCINTRO2.**I’m going to read some statements about the homemaker program.  Please tell me:

**FENCEPOST**

**GO TO THE FOLLOWING MODULES AND COMPLETE THE QUESTIONS IN THIS SEQUENCE:**

**ADDITIONAL SERVICE LIST MODULE;**

**PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE;**

**DEMOGRAPHIC INTAKE MODULE.**

Homemaker 		Page 31

Homemaker		Page 35

Transportation (Version: JANUARY 2008)

**TRINTRO [PARTICIPANT].** My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show you have received Transportation Services from {PROVIDER NAME/AGENCY’S NAME}.  We would like to know if these services have been helpful. 

This survey will take about 30 minutes to complete. Your participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual. We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  Your eligibility for services will not be affected by your decision to participate or by any answers you give.

[IF NEEDED: Transportation is a bus or other vehicle that picks people up and takes them places such as to the doctor, the senior center or shopping [IF NEEDED:  Includes recreational trips].]

PROGRAMMER NOTE: GO TO TRSERVERF.

**TRINTROINT [INTERPRETER]**. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show {NAME OF PARTICIPANT} has received Transportation Services from {PROVIDER NAME/AGENCY NAME}.  We would like to know if these services have been helpful. 

We would like the client to answer the questions as independently as possible. We want to be sure that, wherever possible, we are getting {NAME OF PARTICIPANT’S} actual opinions and responses.

This survey will take about 30 minutes to complete. {NAME OF PARTICIPANT’s} participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual.  We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  {His/Her} eligibility for services will not be affected by {NAME OF PARTICIPANT’s} decision to participate or by any answers {s/he} gives.

**IF NEEDED:**We were given your name as the interpreter for {NAME OF PARTICIPANT)} 

[IF NEEDED: Transportation is a bus or other vehicle that picks people up and takes them places such as to the doctor, the senior center or shopping [IF NEEDED:  Includes recreational trips].]

PROGRAMMER NOTE: IF INTERPRETER WILL NOT DO INTERVIEW GO TO TRALTCON. OTHERWISE GO TO TRSERVERF.

**TRINTROPRX [PROXY]**. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}. We show {NAME OF PARTICIPANT} has received Transportation Services from {PROVIDER NAME/AGENCY’S NAME}.  We would like to know if these services have been helpful. 

For the remainder of the survey I would like you to answer as though you were {NAME OF PARTICIPANT}. All of the following question{s} pertain to {him/her}. Please provide your best estimate as to {his/her} own response or opinion.

This survey will take about 30 minutes to complete. (NAME OF PARTICIPANT’s) participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual.  We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  {His/Her} eligibility for services will not be affected by (his/her) decision to participate or by any answers you give.

**IF NEEDED:**We were given your name as the proxy for (NAME OF PARTICIPANT). 

[IF NEEDED: Transportation is a bus or other vehicle that picks people up and takes them places such as to the doctor, the senior center or shopping [IF NEEDED:  Includes recreational trips].]

PROGRAMMER NOTE: IF PROXY WILL NOT DO INTERVIEW CONTINUE WITH TRALTCON. OTHERWISE GO TO TRSERVERF.

**TRALTCON**.  May I have the name and telephone number of someone else to contact?

	_________________	____________________

	FIRST NAME	LAST NAME

	(|___|___|___|) 	|___|___|___| - |___|___|___|___|

	(AREA CODE)	(TELEPHONE NUMBER)

REFERRED BACK TO PARTICIPANT		1	[GO TO TRINTRO]

REFUSED		-7	[Thank you for your time.]

DON’T KNOW		-8	[Thank you for your time.]

**Thank you for the information. END INTERVIEW.**

**TRSERVERF.**IF NEEDED: We show {you/s/he} may have received {TYPE OF SERVICE} services from {PROVIDER NAME/AGENCY NAME}. Is that correct?

YES		1

NO		2	[Thank you for your time.]

REFUSED		-7	[Thank you for your time.]

DON’T KNOW		-8	[Thank you for your time.]

PROGRAMMER NOTE:  IF PARTICIPANT OR INTERPRETER/TRANSLATOR, DISPLAY FIRST PERSON TENSE (E.G., “do you” OR “have you”) IN QUESTIONS. IF PROXY, DISPLAY SECOND PERSON TENSE (E.G., “does s/he” OR “has s/he”) WHERE INDICATED.

**TRINTRO1.** First, I am going to ask some questions about the transportation service {you receive/NAME OF PARTICIPANT receives} from {PROVIDER NAME/AGENCY NAME}.

**[NEWTR1/OLD TR2]**	When was the last time {you/s/he} used this service?   Was it...

**(TRDAYS)**

Today or yesterday, 		1

More than 1 day to 1 week ago,		2

More than 1 week to 1 month ago, or 		3

More than 1 month ago?		4

ONLY GOT IT ONE TIME **[INTERVIEWER NOTE: INCLUDES R WHO SAYS THEY GOT HELP FOR A SHORT TIME, E.G. AFTER A HOSPITAL STAY]**		5	[GO TO THANK3 

OVER 1 YEAR AGO................		6	[GO TO THANK3]

REFUSED		-7	[GO TO THANK3

DON’T KNOW		-8	[GO TO THANK3

**THANK3.**    Thank-you, but the focus of this survey is on people who have used the service within the past year. 

**[NEWTR2/OLDTR1]**About how long ago did {you/s/he} start using this transportation service?  Was it ...

**(HOWLONG)**

6 months or less,		1 	

More than 6 months, but less than 1 year,		2

At least 1 year, but less than 2 years,		3

2 to 5 years, or		4

More than 5 years?		5

REFUSED		-7	

DON’T KNOW		-8

**FENCEPOST**

**TR3.**	How often {do you/does s/he} use the transportation service?

**(TROFTEN)**

5 or more times per week,		1

2 to 4 times per week,	 	2

Once per week,		3

1 to 3 times per month, or		4

Less than once per month?		5

ONLY USED IT ONCE/FOR A SHORT TIME **[INTERVIEWER NOTE:  IF RESPONDENT SAYS THEY**

**USED IT FOR A SHORT TIME]**		6	[GO TO THANK3]

REFUSED		-7	[GO TO THANK3

DON’T KNOW		-8	[GO TO THANK3

**TR4.**	About how many local one-way trips a month {do you/does NAME OF PARTICIPANT} make using this service? For example, if {you go/s/he goes} to the grocery store and then {come/comes} back using this service, that counts as 2 one-way trips.

**(TRMONTH)**

NUMBER OF TRIPS	 	|___|___|___|SOFT RANGE = 0-30HARD RANGE = 0-100

LESS THAN ONCE A MONTH		L

OTHER		91

(SPECIFY:_______________________________________)

REFUSED		-7

DON’T KNOW		-8

PROGRAMMER NOTE: IF TROFTEN=6, AUTOCODE TRPROP THEN GO TO TRRATE.

**TR5.**	In an average month, would {you/ NAME OF PARTICIPANT} say {you rely/s/he relies} on this transportation service for:

**(TRPROP and TRPROPOS)**

Just a few of {your/ his/her} local trips,		1	

About 1/4 of all {your/ his/her} local trips,		2	

About 1/2 of all {your/ his/her} local trips,		3	

About 3/4 of all {your/ his/her} local trips, or		4	

Nearly all of {your/ his/her} local trips?		5	

OTHER		91

(SPECIFY:_______________________________________)

REFUSED	  	-7

DON’T KNOW	  	-8	

**TR6.**	When using {PROVIDER OF SERVICE} where {do you/does NAME OF PARTICIPANT} get on the vehicle? Would {you/s/he} say . . . 

**(TRGTSON)**

The driver comes to {your/ his/her} door,		1

The vehicle stops in front of {your / his/her} home or in 

the driveway,		2

The vehicle stops down the block, or		3

{You have/ NAME OF PARTICIPANT has} to walk several

blocks to get on the vehicle?		4

{YOU GET/NAME OF PARTICIPANT GETS} ON THE 

BUS AT THE SENIOR CENTER?		5

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

**TRINTRO2.**For the next few questions, please tell me how frequently these statements apply to {your/ NAME OF PARTICIPANT’s} overall experience with {PROVIDER NAME/AGENCY NAME}. Please select one of these five responses: always, usually, sometimes, seldom, or never.

**TR14**.	{Do you/Does NAME OF PARTICIPANT} need help getting into and out of {your/his/her} home?

**(NEEDHLP)**

YES		1 

NO		2	[GO TO TR15]

REFUSED		-7	[GO TO TR15]

DON’T KNOW		-8	[GO TO TR15]                           

**TR14b**.	Does the driver or aide help {you/him/her} get into and out of {your/his/her} home?

**(GETHELP)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**TR15**.	{Do you/Does NAME OF PARTICIPANT} need help getting into or out of the van or bus?

**(NEEDBHLP)**

YES		1 

NO		2	[GO TO TR16]

REFUSED		-7	[GO TO TR16]

DON’T KNOW		-8	[GO TO TR16]

**TR15b**.	Does the driver or aide help {you/him/her} get into or out of the van or bus?

**(GETBHELP)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**TR16**.	{Do you/Does NAME OF PARTICIPANT} use {your/his/her} transportation service to get to: **(TRACTA TO TRACTK)**

PROGRAMMER NOTE:  IF ALL OF TR16 A-J AND 91 ARE 2, -7, AND/OR -8, AUTOCODE TR16K “1.”  IF ANY OF TR16 A-J AND/OR 91 ARE 1, AUTOCODE TR16K “2.”

# FENCEPOST

**TR17.**	Next, how would {you/ NAME OF PARTICIPANT} rate the transportation service that {you/s/he} received? Would {you/ s/he} say...

**(TRRATE)**

Excellent		1 

Very good,		2

Good,		3

Fair, or		4

Poor?		5

REFUSED		-7 

DON’T KNOW		-8 

# FENCEPOST

**TR18.**	{Do you/ Does NAME OF PARTICIPANT} get around more than {you/s/he} did before {you/s/he} had this service? Would {you/s/he} say...

**(AROUND)**

YES		1

NO		2

REFUSED		-7 

DON’T KNOW		-8 

**TRINTRO3**.****Please tell me:

**FENCEPOST**

**TRINTRO4.**Now, I would like to ask if {you have/s/he has} a car or personal motor vehicle.

**TR21.**	Is there a car or personal motor vehicle****in working condition in {your/NAME OF PARTICIPANT’s} household?

**(TRISCAR)**

YES		1

NO		2 			[SKIP TR22]

REFUSED		-7	 	[SKIP TR22]

DON’T KNOW		-8			[SKIP TR22]	

**TR22.**	{Do you/Does NAME OF PARTICIPANT} ever drive that car or personal motor vehicle?

**(TRDRIVE)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**GO TO THE FOLLOWING MODULES AND COMPLETE THE QUESTIONS IN THIS SEQUENCE:**

**ADDITIONAL SERVICE LIST MODULE;**

**PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE;**

**DEMOGRAPHIC INTAKE MODULE.**

Transportation 		Page 36

Transportation		Page 43

**FAMILY CAREGIVER SURVEY**

**(VERSION: JANUARY 2008)**

**CGINTRO [CAREGIVER/PARTICIPANT].** My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find out how we can help meet the needs of caregivers and seniors being served by {PROVIDER NAME/AGENCY NAME}. We show you have received caregiver support services from {PROVIDER NAME/AGENCY NAME} to help you take care of {CARE RECIPIENT}. We would like to know if these caregiver support services have been helpful. 

This survey will take about 30 minutes to complete. Your participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual.  We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  Your and {CARE RECIPIENT}’s eligibility for services will not be affected by your decision to participate or by any answers you give.

**CGINTROINT [INTERPRETER].** My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’. Administration on Aging, We are conducting a survey to find out how we can help meet the needs of caregivers and seniors being served by {PROVIDER NAME/AGENCY NAME}. We show {NAME OF CAREGIVER} has received caregiver support services from {PROVIDER NAME/AGENCY NAME} to help {him/her} take care of {CARE RECIPIENT}. We would like to know if these caregiver support services have been helpful. 

We would like {NAME OF CAREGIVER} to answer the questions as independently as possible. We want to be sure that, wherever possible, we are getting {NAME OF CAREGIVER}’s actual opinions and responses. 

This survey will take about 30 minutes to complete. {NAME OF CAREGIVER’s} participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual.  We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  {His/Her} and {CARE RECIPIENT}’s eligibility for services will not be affected by {NAME OF CAREGIVER’s} decision to participate or by any answers {s/he} gives

**IF NEEDED:** We were given your name as the interpreter for {NAME OF CAREGIVER}.

**CGINTROPRX [PROXY].**My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S. Department of Health and Human Services’. Administration on Aging, We are conducting a survey to find out how we can help meet the needs of caregivers and seniors being served by {PROVIDER NAME/AGENCY NAME}. We got {NAME OF CAREGIVER} information from {PROVIDER NAME/AGENCY NAME}. 

We want to be sure that, wherever possible, we are getting {NAME OF CAREGIVER}’s actual opinions and responses. For the remainder of the survey, I would like you to answer as though you were {NAME OF CAREGIVER}. All of the following questions pertain to {him/her} Please provide your best estimate as to {his/her} own response or opinion.

This survey will take about 30 minutes to complete. {His/Her} participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual.  We will not provide information that identifies individuals to anyone outside the study team, except as required by law.  {His/Her} and {CARE RECIPIENT}’s eligibility for services will not be affected by {NAME OF CAREGIVER}’s decision to participate or by any answers {s/he} gives.

**IF NEEDED:** We were given your name as the proxy for {NAME OF CAREGIVER}. 

SKIP TO CGB IF NO CARE RECIPIENT NAME

**CGA.**	{You are/NAME OF CAREGIVER is} listed as someone who currently provides care for {CARE RECIPIENT}.  {Are you/Is s/he} still the caregiver for {CARE RECIPIENT}?

**(CGSTLCR)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**IF NO, RECORD ANY COMMENTS RESPONDENT MADE ABOUT FORMER CARE RECIPIENT (E.G., RESPONDENT IN NURSING HOME, DECEASED, ETC):**

**PROGRAMMER NOTE:  IF CGA IS NO, RF, OR DK,  GO TO CLOSING AND END INTERVIEW AFTER INTERVIEWER ENTERS ANY COMMENTS.**

**CGB.**Is {CARE RECIPIENT} 60 years of age or older?

**(CGAGE60)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**PROGRAMMER NOTE:  IF CGB IS NO, RF, OR DK, GO TO CLOSING AND END INTERVIEW.**

**PROGRAMMER NOTE:  IF INTERPRETER WILL NOT DO INTERVIEW, GO TO CGALTCON. OTHERWISE, GO TO CGINTRO1.**

**PROGRAMMER NOTE:  IF PROXY WILL NOT DO INTERVIEW, CONTINUE WITH CGALTCON. OTHERWISE CONTINUE WITH CGINTRO1.**

**CGALTCON.**May I have the name and telephone number of someone else to contact?

	_________________	____________________

	FIRST NAME	LAST NAME

	(|___|___|___|)	|___|___|___| - |___|___|___|___|

	(AREA CODE)	(TELEPHONE NUMBER)

REFERRED BACK TO CAREGIVER		1		[GO TO CGINTRO]

REFUSED		-7	[GO TO THANK YOU]

DON’T KNOW		-8	[GO TO THANK YOU]

**THANK-YOU. Thank you for the information. END INTERVIEW.**

**CGINTRO1.**This survey typically takes 30 minutes. {You/NAME OF CAREGIVER} may be more comfortable answering these questions if {you are/s/he is} not in the presence of the person {you are/s/he is} caring for. Is this a good time for {you/him/her}? 

YES		1

NO		2	[GO TO APPOINTMENT]

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**CGINTRO2.**  Now, let’s begin the caregiver survey.  {Your/NAME OF CAREGIVER’s} participation is voluntary and very important to the success of this study.

**PROGRAMMER NOTE:  IF CAREGIVER IS FEMALE OR GENDER IS UNKNOWN, USE FIRST DISPLAY IN SECOND SENTENCE OF CG1 (E.G.: WIFE OR DAUGHTER).  IF CAREGIVER IS MALE, USE SECOND DISPLAY (E.G. HUSBAND OR SON).  IF CARE RECIPIENT’S NAME IS NOT ON FILE, REFER TO THE CARE RECIPIENT AS “THE PERSON YOU CARE FOR” IN THE FIRST DISPLAY AND “THEIR” IN THE SECOND DISPLAY.**

**CG1.**	What is {your/his/her} relationship to {CARE RECIPIENT/the person you care for}?   Are you {Is he/she} his/her...  

**[INTERVIEWER NOTE:  READ CATEGORIES IF NEEDED]**

**(CGREL)**

HUSBAND,		1

WIFE,		2

SON,		3

SON-IN-LAW,		4

DAUGHTER,	    	5

DAUGHTER-IN-LAW,		6

FATHER,		7

MOTHER,		8

BROTHER,		9

SISTER,		10

GRANDDAUGHTER,		11

GRANDSON, 		12

NIECE,		13

NEPHEW, 		14

A FRIEND OR NEIGHBOR OR ANOTHER PERSON, OR		15

OTHER RELATIVE		91

(SPECIFY: _______________________________________)

REFUSED		-7 

DON’T KNOW		-8

**FENCEPOST**

**PROGRAMMER NOTE:  IF CARE RECIPIENT’S NAME IS NOT ON FILE FROM AREA AGENCY, ASK CGC.  ELSE, GO TO CG2.**

**CGC.**	[DON’T ASK IF OBVIOUS] What is {CARE RECIPIENT’s} gender?

**(CGPMF)**

MALE		1 	

FEMALE		2 	

REFUSED		-7 	

DON’T KNOW		-8 	

**IF RELATIONSHIP IN CG1 = NIECE OR NEPHEW, INSERT “{YOUR/HIS/HER} RELATIVE” IN PLACE OF CARE RECIPIENT NAME IN THE REST OF THE INTERVIEW AND SKIP TO CG2**

**IF RELATIONSHIP IN CG1 = OTHER RELATIVE, INSERT “{YOUR/HIS/HER} {CGRELOS}” IN PLACE OF CARE RECIPIENT NAME IN THE REST OF THE INTERVIEW AND SKIP TO CG2**

**IF RELATIONSHIP IN CG1 = FRIEND, DK, OR RF, CONTINUE TO SHOW “THE PERSON YOU CARE FOR” IN PLACE OF CARE RECIPIENT NAME IN THE REST OF THE INTERVIEW AND SKIP TO CG2**

**G2.**	I’m going to read several activities that some people need help with. {Do you/Does NAME OF CAREGIVER} help {CARE RECIPIENT} with ...

**(CGACTI01 TO CGACTI06)**

**FENCEPOST**

**CG2B.**	What kind of care {do you/ does NAME OF CAREGIVER} provide for {CARE RECIPIENT}?

**(COMM.COMMTEXT)**

NONE		1	[GO TO CLOSING]

REFUSED		-7		[GO TO CLOSING]  

DON’T KNOW		-8	[GO TO CLOSING]

OPEN-ENDED RESPONSES: 

A.	

B.	

C.	

D.	

E.	

F.	

**FENCEPOST**

**CGINTRO3.**I'd like to ask {you/NAME OF CAREGIVER} some questions about the Family Caregiver services that are provided by {PROVIDER NAME/AGENCY'S NAME}. We are interested in {your/his/her} experiences with services during the last year.

**CG3.**{Have you/Has NAME OF CAREGIVER} received Respite Care, which allows {you, the caregiver/NAME OF CAREGIVER}, a brief period of rest or relief while temporary care is provided to {CARE RECIPIENT} either in {your/his/her} home or someplace else? 

**(CGRSPT)**

YES		1	

NO		2		[GO TO CG4]

REFUSED		-7		[GO TO CG4]

DON’T KNOW		-8		[GO TO CG4]

**CG3A.**What type of respite care {have you/has NAME OF CAREGIVER} received? {Have you/Has NAME OF CAREGIVER} received...

**(CGRSP01 TO CGRSP05 AND CGRSPOS)**

**PROGRAMMER NOTE:  SOFT RANGE FOR CG3B= 0 TO 24; HARD RANGE = 0 TO 168.**

**CG3B.**How many hours per week of respite care {do you/does NAME OF CAREGIVER} usually receive?

**(CGHRWK)**

NUMBER OF HOURS PER WEEK			|__|__|

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**CG4.**Has someone, such as {your/NAME OF CAREGIVER’s} caseworker, case manager or other AAA staff person, helped {you/him her} or given {you/him/her} information to connect {you/him/her} to other available services and resources? 

**(CGINFO)**

YES		1	

NO		2	[GO TO CG5]

REFUSED		-7	[GO TO CG5]  

DON’T KNOW		-8	[GO TO CG5] 

**CG4A.**Has the **help or information** {you have/NAME OF CAREGIVER has} received helped {you/him/her} connect to other services and resources?  

**(CGINFOHP)**

YES,		1	

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**CG5.**{Have you/Has NAME OF CAREGIVER} received caregiver training or education, including counseling or support groups, to help {you/him/her} make decisions and solve problems in {your/his/her} role as a caregiver?   

**(CGEDU)**

YES		1	

NO		2	[GO TO CG6] 

REFUSED		-7		[GO TO CG6] 

DON’T KNOW		-8	[GO TO CG6]

**CG5A.**	{Have you/Has NAME OF CAREGIVER} attended...

**(CGEDKD01 TO CGEDK04 AND CGEDKDOS)**

**CG6.**	Have the Family Caregiver services provided any other **Supplemental Services** to complement the care {you provide/s/he provides}, such as: 

**(CGSUPA TO CGSUPG AND CGSUPOS)**

**PROGRAMMER NOTE:  IF RESPONDENT RECEIVES ANY OF THE ABOVE SERVICES (I.E. “YES” TO Q. CG3, CG4, CG5, OR CG6), CONTINUE INTERVIEW.  OTHERWISE, GO TO CLOSING.**

**IF ONLY ONE OF QCG3, CG4, CG5 OR CG6 A-G IS YES, DO NOT ASK CG7.  GO TO CG8 INSTEAD.**

ONLY **ASK** CG7 ABOUT THE SERVICES RESPONDENT SAID THEY RECEIVED: IF YES TO QCG3, ASK 1 (Respite Care Services), IF YES TO CG4, ASK 2-Help or Information connecting {you/him/her} to available services or resources. IF ANY OF CG6 A-E AND/OR G ARE YES, ASK 5 (Other Support Services or Assistance).  IF CG6-F IS YES, ASK 4, “Money or a Stipend.”

**FENCEPOST**

**CG7.**Of the services {you have/NAME OF CAREGIVER has} received**,**which service was the most helpful? Would {you/s/he} say...

**(CGMSTHLP)**

Respite care services,		1

Help or information connecting {you/him/her} to available services or resources,		2

Caregiver training or education, including counseling or a support group,		3

Other support services or assistance?		4

REFUSED		-7

DON’T KNOW		-8

**CG8.**	Where did {you/NAME OF CAREGIVER} first hear about these services for caregivers? Would {you/s/he} say {you/s/he} heard about the services from...

**(CGHEAR AND CGHEAROS)**

Family,		 1

Friends,		2

A physician or other healthcare provider,		3

A community organization,		4

The media,		5

A social worker or case manager,		6

The hospital,		7

The state or local office for the aging, or		8

Someplace else?		91

(SPECIFY: _______________________________________)

REFUSED		-7 

DON’T KNOW		-8

**CG9.**As a result of the caregiver services {you have/NAME OF CAREGIVER has} received, {do you/does s/he}...

**(CGAFECA-CGAFECE)**

**FENCEPOST**

**CG9A.**  	{Do you/Does NAME OF CAREGIVER} think that {CARE RECIPIENT} benefits from the caregiver services {you receive/NAME OF CAREGIVER receives}? 

**(CGAFECF)**

YES	1

NO	2

REFUSED	-7

DON’T KNOW	-8

**CG10.**	Have these caregiver services helped {you/her/him} to be a better caregiver? 

**(CGHELP)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CG11.**	Have these caregiver services enabled {you/NAME OF CAREGIVER} to provide care for {CARE RECIPIENT} for a longer time than would have been possible without these services? 

**(CGCARLG)**

YES,		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CG12.**	Overall, how would {you/ NAME OF CAREGIVER} rate the caregiver support services {you have/s/he has} received? Would {you/ NAME OF CAREGIVER} say...

**(CGRATE)**

Excellent,		1 

Very good,		2

Good,		3

Fair, or		4

Poor?		5

REFUSED		-7 

DON’T KNOW		-8 

**FENCEPOST**

**CG13.**	Has it been difficult for {you/ NAME OF CAREGIVER} to get services from agencies for {CARE RECIPIENT}? 

**(CGDIFF)**

YES		1

NO		2

REFUSED		-7	

DON’T KNOW		-8	

**CGINTRO4.** Now, I would like to ask some questions about {your/NAME OF CAREGIVER’s} employment.

**CG14.**What is {your/NAME OF CAREGIVER’S} current employment status? {Are you/Is s/he}...

**(CGWORK)**

Working full time,		1	[GO TO CG14B]

Working part time,		2	[GO TO CG14B]

Retired **[INTERVIEWER NOTE: Includes not working**

**due to permanent disability]**, or		3	[GO TO 14A]

Not working?		4	[GO TO 14A]

REFUSED		-7	[GO TO CGINTRO5] 

DON’T KNOW		-8	[GO TO CGINTRO5] 

**CG14A.**	Did {your/his/her} caregiving responsibilities cause {you/him/her} to quit work or retire early?

**(CGQUIT)**

YES		1	[GO TO CGINTRO5]

NO		2	[GO TO CG14B.]		 

REFUSED		-7		[GO TO CGINTRO5]

DON’T KNOW		-8	[GO TO CGINTRO5]

**CG14B.**Has providing care for {CARE RECIPIENT} interfered with {your/NAME OF CAREGIVER’s} job?

**(CGINTRFR)**

YES		1	

NO		2		[GO TO CGINTRO5]

REFUSED		-7		[GO TO CGINTRO5]

DON’T KNOW		-8		[GO TO CGINTRO5]

**CG15.**	How frequently has providing care for {CARE RECIPIENT} interfered with {your/NAME OF CAREGIVER’s} job?  Would {you/s/he} say...

**(CGINTJB)**

Always,		1

Often, 		2

Sometimes, 		3

Rarely,		4

Never?		5	

REFUSED		-7	[GO TO CGINTRO5]     

DON’T KNOW		-8	[GO TO CGINTRO5]

**CG16.**Have the caregiver support services helped {you/NAME OF CAREGIVER} deal with these work difficulties? 

**(CGSRVHLP)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**CGINTRO5.**  Next, I would like to ask {you/NAME OF CAREGIVER} about different aspects of caregiving.

**PROGRAMMER NOTE:  ALLOW 6 LINES OF TEXT, 60 CHARACTERS EACH, IN CG17.**

**CG17.**In {your/NAME OF CAREGIVER’S} experience as a caregiver, what would {you/s/he} say is the most positive aspect of caregiving? 

**(COMM.COMMTEXT)**

REFUSED		-7	

DON’T KNOW............................................................    -8	

OPEN-ENDED RESPONSES:

	A.	

	B.	

	C.	

	D.	

	E.	

	F.	

**FENCEPOST**

**CG18.**	Think of a scale from 1 to 5, where 1 is “not a strain at all” and 5 is “very much of a strain.”  How much of a physical strain would {you/NAME OF CAREGIVER} say that caring for {CARE RECIPIENT} is for {you/him/her}?

**(CGPSTRN)**

NOT A STRAIN AT ALL 		 1 

TWO		 2 

THREE		3 

FOUR		 4 

VERY MUCH OF A STRAIN.		5 

REFUSED		-7 

DON’T KNOW	 	-8

**CG19.**Again****using a scale from 1 to 5, where 1 is “not at all stressful” and 5 is “very stressful”, how emotionally stressful would {you/NAME OF CAREGIVER} say that caring for****{CARE RECIPIENT} is for {you/him/her}?

**(CGEMSTRS)**

NOT AT ALL STRESSFUL		 1 

TWO		 2 

THREE		3 

FOUR		 4 

VERY STRESSFUL		 5 

REFUSED		-7 

DON’T KNOW		-8

**CG20.**Overall, again using a scale from 1 to 5, where 1 is no financial hardship at all and 5 is a great financial hardship, how much of a financial hardship has caring for {CARE RECIPIENT’S NAME} been?

**(CGHDSHP)**

NO HARDSHIP AT ALL		1 

TWO		 2 

THREE		3 

FOUR		4 

A GREAT HARDSHIP		5 

REFUSED		-7

DON’T KNOW		-8

**CG21.**	Which of the following has been the biggest difficulty {you have/s/he has} faced in caring for {CARE RECIPIENT}?  Would {you/s/he} say...

**(CGDIF AND CGDIFOS)**

The financial burden,		1	

Not enough time for {yourself/NAME OF CAREGIVER},		2

Not enough time for {your/NAME OF CAREGIVER’S} family,		3

Interferes with {your/NAME OF CAREGIVER’S} work,		4

Affects {your/NAME OF CAREGIVER’S} family relationships,		5

Interferes with {your/NAME OF CAREGIVER’S} privacy,		6

Conflicts with {your/NAME OF CAREGIVER’S} social life,		7

Creates stress, or		8

Something else?		91

(SPECIFY:	)

NONE		9

ALL OF THE ABOVE		10

REFUSED		-7	

DON’T KNOW		-8	

**IF ALL OF CG18, CG19, AND CG20 ARE 1, AND CG21 IS NONE, RF OR DK, SKIP TO CG23.**

**CG22.**Have the Caregiver Support Services helped {you/NAME OF CAREGIVER} deal with the difficulties that result from caregiving? 

**(CGALLEV)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CGINTRO6.** Now, we would like to ask a few questions about {you/NAME OF CAREGIVER} and {your/his/her} experiences as a caregiver.

**CG23.**	In general, would {you/ NAME OF CAREGIVER} say {your/his/her} health is:

**(CGHEALTH)**

Excellent,		1

Very good,		2

Good,		3

Fair, or		4

Poor?		5

REFUSED		-7

DON’T KNOW		-8

**CG24.**	{Do you/Does NAME OF CAREGIVER} have any kind of health problems, or a physical condition or disability that affects the kind or amount of care that {you/s/he} can provide for {CARE RECIPIENT}?

**(CGDISAB)**

YES		1

NO		2	 	[GO TO CGINTRO7]  

REFUSED		-7	 [GO TO CGINTRO7]  

DON’T KNOW		-8	 	[GO TO CGINTRO7]  

**CG24A.**	What is that problem, condition, or disability?  **[INTERVIEWER NOTE: CODE ALL THAT APPLY.  PROBE: Anything else?  CTRL/P TO EXIT]**

**(CGDISBB AND CGDISBOS)**

**PHYSICAL**

BACK PROBLEMS AND OTHER JOINT PROBLEMS/ARTHRITIS		1

INJURIES (BROKEN BONES/HIP REPLACEMENT) 		2

WEAKNESS/LACK OF STRENGTH, 		3

**ILLNESS**

HEART PROBLEMS/HIGH BLOOD PRESSURE/HYPERTENSION/STROKE		4

DIABETES.		5

ALLERGIES/ASTHMA/OTHER BREATHING AND LUNG PROBLEMS		6

CANCER AND TUMORS		7

**MENTAL HEALTH (ALL)**		8

**EYE PROBLEMS [INTERVIEWER NOTE: THIS DOES NOT INCLUDE ONLY WEARS GLASSES OR CONTACTS]**		9

**OTHER**		91

(SPECIFY: ___________________________________)

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**CG25.**	{Have your/Has NAME OF CAREGIVER’S} caregiving activities created or worsened any of these conditions or problems or disabilities? 

**(CGHLTH)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**CGINTRO7.**  Next, I would like to ask some questions about the amount of care {you provide/NAME OF CAREGIVER provides}.

**CG26.**For how long {have you/has s/he} been providing help to {CARE RECIPIENT NAME}?  {YOUR/HIS/HER} best guess is fine.  Would {YOU/HE/SHE} say:

**(CGHLONG)**

6 months or less,		1 	

More than 6 months, but less than 1 year,		2 	

At least 1 year, but less than 2 years,		3 	

2 to 5 years, 		4 	

5 to 10 years,		5

11 to 20 years, or		6

More than 20 years?		7

REFUSED		-7	

DON’T KNOW		-8	

**CG27.**	How far away {do you/does NAME OF CAREGIVER} live from {CARE RECIPIENT}? Would {you/s/he} say....

**(CGMINUT)**

In the same house,		1	[GO TO CG29]

Less than 20 minutes away,		2

Between 20 and 60 minutes away,		3

Between 1 and 2 hours away, or		4

More than 2 hours away?		5

REFUSED		-7	

DON’T KNOW		-8	

**CG27A.**	On average, how often {do you/does s/he} visit {CARE RECIPIENT}? Would {you/s/he} say...

**(VISTIMES)**

Every day,		1

Two or more times per week, 		2

Once a week,		3

A few times a month,		4

Once a month,		5

A few times a year, or		6

Less often?		7

REFUSED		-7

DON’T KNOW		-8

**CG28.**Does {CARE RECIPIENT} live alone?

**(CGALONE)**

YES		1	

NO		2

REFUSED		-7

DON’T KNOW 		-8

**CG29.**	How long can {CARE RECIPIENT} be left alone? Would {you/NAME OF CAREGIVER} say...

**(CGLFTLN)**

S/He can be left alone for over a day at a time, 		 1

{S/He} can be left alone for an entire day, but then needs

	 to be checked on,		 2 

{S/He} needs someone there at least part of the day, or 		 3

{S/He} needs someone there all or nearly all the time?		 4

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PROGRAMMER NOTE:  FOR ANALYSIS PURPOSES, WE WANT HOURS PER WEEK, SO THE HOURS IN QCG30 WILL BE MULTIPLIED BY 7 (CGHRS7). WE ALSO WANT TO PRESERVE THE ORIGINAL RESPONSES (CGHRS)**

**CG30.**	In {your/NAME OF CAREGIVER’s} judgment, how many hours per day of help, care, or supervision does {CARE RECIPIENT} need?

**(CGHRS AND CGHRS7)**

NUMBER OF HOURS PER DAY		 |___|___| **HARD RANGE = 0-24 HRS**

REFUSED		-7

DON’T KNOW		-8

**PROGRAMMER NOTE:  FOR ANALYSIS PURPOSES, WE WANT HOURS PER WEEK, SO THE HOURS IN QCG31 WILL BE MULTIPLIED BY 5 (CGHRSWK5) AND THE HOURS IN Q. CG32 WILL BE MULTIPLIED BY 2 (CGHRSWD2), THEN WE WILL ADD THOSE TWO PRODUCTS TOGETHER TO GET THE TOTAL HOURS PER WEEK. (CGHRSWK7).  WE ALSO WANT TO PRESERVE THE ORIGINAL RESPONSES (CGHRSWK AND CGHRSWD)**

**CG31.**	In a typical 24-hour week******day, how many hours {do you/does NAME OF CAREGIVER} provide help, care or supervision for {CARE RECIPIENT} in person?

**(CGHRSWK AND CGHRSWK5)**

NUMBER OF HOURS/DAY	 	|___|___|	 **HARD****RANGE = 0-24 HRS**

REFUSED		-7

DON’T KNOW		-8

**CG32.**	In a typical 24-hour weekend day, how many hours {do you/does NAME OF CAREGIVER} provide help, care or supervision for {CARE RECIPIENT} in person?

**(CGHRSWD AND CGHRSWD2)**

NUMBER OF HOURS/DAY	 	|___|___|	 **HARD****RANGE = 0-24 HRS**

REFUSED		-7

DON’T KNOW		-8

**CG33.**Some care recipients also receive help from other places.  Does {CARE RECIPIENT} receive help...

**(CGOTHLPA – CGOTHLPE AND CGOTHLPOS)**

**IN CG33, IF RECEIVED HELP FROM ONE OR MORE OTHER PLACES (CG33-1 THROUGH CG33-5 = “1” OR “YES”), GO TO CG34.**

**IF DID NOT RECEIVE, REFUSED, OR DON’T KNOW HELP FROM ANY OTHER PLACE ( -7, OR -8), GO TO CG35.**

**CG34.** 	Who provides most of the care for {CARE RECIPIENT}?

**(CGCARE)**

{You/NAME OF CAREGIVER},		1

Other family members or friends, 		2

{PROVIDER NAME/AGENCY NAME}, 		3

Other community agencies such as a local non-profit agency, a place of worship, or a government agency		4

Help paid for by {CARE RECIPIENT} or {his/her} family, or 		5

Someplace else?		6

(Please Specify: 	)

REFUSED		-7

DON’T KNOW		-8

**IF ANSWERED “YES” TO MORE THAN ONE OTHER PLACE IN CG33-1 THROUGH CG33-5, ASK CG34B.****IN    CG34B, DO NOT ASK THE RESPONSE SELECTED IN CG34.**

**CG34B.**After {INSERT RESPONSE FROM CG34}, who provides most of the care?

**(CGOTHLP2)**

{You/NAME OF CAREGIVER}		1

Other family members or friends? 		2

{PROVIDER NAME/AGENCY NAME}? 		3

Other community agencies such as a local non-profit agency, a place of worship or a government agency,		4

Help paid for by {CARE RECIPIENT} or {his/her} family? 		5

Someplace else		6

(Please Specify: 	)

REFUSED		-7

DON’T KNOW		-8

**CG35.**{Are you/Is NAME OF CAREGIVER} paid by {CARE RECIPIENT} or a community agency to provide care for {him/her}?

**(CGPAID)**

YES		1

NO		2	[GO TO CG36]

REFUSED		-7	[GO TO CG36]  

DON’T KNOW		-8	[GO TO CG36]

**CG35B.**Who pays {you/him/her}?****

**(CGWHOPAY AND CGWHPYOS)**

{CARE RECIPIENT}		1

COMMUNITY AGENCY		2

OTHER		91

(PLEASE SPECIFY: 	)

REFUSED		-7

DON’T KNOW		-8

**CGINTRO8.**Now, we would like to ask about information {you/s/he} may need.

**CG36.**	In addition to the kinds of information that {you already have/NAME OF CAREGIVER already has}, what additional new kinds of information would be valuable to {you/her/him} as a caregiver?  How about...

**(CGINF01 TO CGINF08 AND CGINF91 AND CGINFOS)**

**PROGRAMMER NOTE:  IF ALL OF CG36-1 THROUGH CG36-8 AND 91 ARE ALL 2, -7 AND/OR -8, AUTOCODE CG36-9 “1.”  ELSE, AUTOCODE CG36-9 “2.”**

**FENCEPOST**

**PROGRAMMER NOTE:  GO TO ADDITIONAL SERVICE LIST MODULE**

**CG37.**In {your/NAME OF CAREGIVER’s} judgment, if the services that {you/NAME OF CAREGIVER} and {CARE RECIPIENT} have received had not been available, would {CARE RECIPIENT} be able to continue to live in the same residence?  

**(CGDFPLC)**

YES		1	[GO TO CGPF1]

NO		2	[GO TO CG37A]  

REFUSED		-7		[GO TO CG37A]  

DON’T KNOW		 -8	[GO TO CG37A]  

**CG37A.**Where would {CARE RECIPIENT} be living?****

**(CGWHER AND CGWHEROS)**

**[INTERVIEWER NOTE: CHOOSE ONLY ONE ANSWER, DO NOT READ LIST]**

IN CAREGIVER’S HOME	1

IN THE HOME OF ANOTHER FAMILY MEMBER OR FRIEND	2

IN AN ASSISTED LIVING FACILITY	3

IN A NURSING HOME	4

CARE RECIPIENT WOULD HAVE DIED	5

OTHER	91

(SPECIFY: _____________________________ )

REFUSED	-7

DON’T KNOW	-8

**CGINTRO9.**  The next few questions are about {CARE RECIPIENT’s} health.

**CGPF1.**	In general, would {you/NAME OF CAREGIVER} say {CARE RECIPIENT}’s health is...

**(CGCRHL)**

Excellent,		1

Very Good,		2

Good,		3

Fair, or		4

Poor?		5

REFUSED		-7

DON’T KNOW		-8

**CGPF1B.**Has a doctor ever told {you/NAME OF CAREGIVER} that {CARE RECIPIENT} has:

**FENCEPOST**

****

**CGOHINTRO.**Now we would like to ask about the care recipient’s oral or dental health (that is, the health of the care recipient’s teeth and gums)... 

CGOHQ.030	About how long has it been since the care recipient **last** visited a dentist? Include all types of dentists, such as, orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

6 MONTHS OR LESS	......	            1

MORE THAN 6 MONTHS, BUT NOT MORE THAN 1 YEAR AGO		2

MORE THAN 1 YEAR, BUT NOT MORE THAN 2 YEARS AGO			3

MORE THAN 2 YEARS, BUT NOT MORE THAN 3 YEARS AGO		4

MORE THAN 3 YEARS, BUT NOT MORE THAN 5 YEARS AGO		5

MORE THAN 5 YEARS AGO		             6

NEVER HAVE BEEN		             7 

REFUSED		-7

DON'T KNOW		-8

	HELP SCREEN:

****Dentist: Medical persons whose primary occupation is caring for teeth, gums, and jaws. Dental care includes general work such as fillings, cleaning, extractions, and also specialized work such as root canals, fittings for braces, etc. 

CGOHQ.770	During the past 12 months, was there a time when the care recipient needed dental care but could not get it at that time? 

YES		1 

NO		 2

REFUSED		-7	

DON'T KNOW		-8	

CGOHQ.780	What were the reasons that the care recipient could not get the dental care he/she needed? 

	CODE ALL THAT APPLY 

COULD NOT AFFORD THE COST					10 

DID NOT WANT TO SPEND THE MONEY					11 

INSURANCE DID NOT COVER RECOMMENDED PROCEDURES		12 

DENTAL OFFICE IS TOO FAR AWAY					13 

DENTAL OFFICE IS NOT OPEN AT CONVENIENT TIMES					14 

ANOTHER DENTIST RECOMMENDED NOT DOING IT					15 

AFRAID OR DO NOT LIKE DENTISTS					16 

UNABLE TO TAKE TIME OFF FROM WORK					17 

TOO BUSY					18 

DID NOT THINK ANYTHING SERIOUS WAS WRONG/EXPECTED DENTAL PROBLEMS TO GO AWAY					19 

DID NOT HAVE TRANSPORTATION..................................				20

OTHER					21 

REFUSED		....				 -7 

DON'T KNOW						 -8

CGOHQ.845	Overall, how would you rate the health of the care recipient’s teeth and gums?

EXCELLENT		1

VERY GOOD		2

GOOD,		3

FAIR		4

POOR		5

REFUSED		-7

DON’T KNOW		-8

FENCEPOST

**CGINTRO10.**We would like to ask about {CARE RECIPIENT’s} abilities to perform some common activities of everyday life and whether {CARE RECIPIENT} needs assistance performing these activities.  We are only interested in long-term conditions, not temporary conditions. 

**PF1CG.**Does {CARE RECIPIENT} have difficulty getting around inside the home?

**(PFDFINC)**

YES		1 

NO		2		[GO TO PF2CG]  

REFUSED		-7		[GO TO PF2CG]  

DON’T KNOW		-8		[GO TO PF2CG]  

**PF1BCG.**{Does s/he} need the help of another person to perform this activity?

**(PFDFINBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF2CG.**Does {s/he} have difficulty going outside the home, for example to shop or visit a doctor’s office?

**(PFDFOUC)**

YES		1

NO		2	[GO TO PF3CG] 

REFUSED		-7		[GO TO PF3CG] 

DON’T KNOW		-8	[GO TO PF3CG]

**PF2BCG.**Does {s/he} need the help of another person to perform this activity?

**(PFDFOUBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF3CG.**Does {CARE RECIPIENT} have difficulty getting in or out of bed or a chair?

**(PFBEDC)**

YES		1 

NO		2	[GO TO PF4CG]

REFUSED		-7		[GO TO PF4CG]

DON’T KNOW		-8	[GO TO PF4CG]

**PF3BCG.**Does {s/he} need the help of another person to perform this activity?

**(PFBEDBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF4CG.**Does {s/he} have difficulty when taking a bath or shower?

**(PFBATHC)**

YES		1 

NO		2	[GO TO PF5CG]  

REFUSED		-7		[GO TO PF5CG]  

DON’T KNOW		-8	[GO TO PF5CG]  

**PF4BCG.**Does {s/he} need the help of another person to perform this activity?

**(PFBATHBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF5CG.**Does {CARE RECIPIENT} have difficulty when dressing?

**(PFDRESC)**

YES		1 

NO		2	[GO TO PF6CG]

REFUSED		-7		[GO TO PF6CG]

DON’T KNOW		-8	[GO TO PF6CG]

**PF5BCG.**Does {s/he} need the help of another person to perform this activity?

**(PFDRESBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF6CG.**Does {s/he} have difficulty when walking?

**(PFWALKC)**

YES		1 

NO		2		[GO TO PF7CG]

REFUSED		-7		[GO TO PF7CG]

DON’T KNOW		-8		[GO TO PF7CG]

**PF6BCG.**Does {s/he} need the help of another person to perform this activity?

**(PFWALKBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF7CG.**Does {CARE RECIPIENT} have difficulty eating?

**(PFEATC)**

YES		1 

NO		2		[GO TO PF8CG]

REFUSED		-7		[GO TO PF8CG]

DON’T KNOW		-8		[GO TO PF8CG]

****

**PF7BCG.** Does {s/he} need the help of another person to perform this activity?

**(PFEATBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF8CG.**Does {s/he} have difficulty using the toilet or getting to the toilet?

**(PFWCC)**

YES		1 

NO		2	[GO TO PF9CG]

REFUSED		-7	[GO TO PF9CG]

DON’T KNOW		-8	[GO TO PF9CG]

**PF8BCG.**Does {s/he} need the help of another person to perform this activity?

**(PFWCBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF9CG.**Does {CARE RECIPIENT} have difficulty keeping track of money or bills?

**(PFDLRC)**

YES		1

NO		2	[GO TO PF10CG]

REFUSED		-7		[GO TO PF10CG]

DON’T KNOW		-8	[GO TO PF10CG]

**PF9BCG.**Does {s/he} need the help of another person to perform this activity?

**(PFDLRBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF10CG.** 	Does {s/he} have difficulty preparing meals?

**(PFMEALC)**

YES		1 	

NO		2		[GO TO PF11CG]

REFUSED		-7		[GO TO PF11CG]

DON’T KNOW		-8		[GO TO PF11CG]

**PF10BCG.**Does {s/he} need the help of another person to perform this activity?

**(PFMEALBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF11CG.**Does {CARE RECIPIENT} have difficulty doing light housework, such as washing dishes or sweeping a floor?

**(PFCLENC)**

YES		1 	

NO		2 	[GO TO PF11ACG]

REFUSED		-7		[GO TO PF11ACG]

DON’T KNOW		-8 	[GO TO PF11ACG]

**PF11BCG.**Does {s/he} need the help of another person to perform this activity?

**(PFCLENBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF11ACG.**Does {s/he} have difficulty doing heavy housework, such as scrubbing floors or washing windows?

**(PFHCLNC)**

YES		1 	

NO		2 		[GO TO PF12CG]

REFUSED		-7		[GO TO PF12CG]

DON’T KNOW		-8		[GO TO PF12CG]

**PF11ABCG.**Does {s/he} need the help of another person to perform this activity?

**(PFHCLNBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF12CG.**	Does {s/he} have difficulty taking the right amount of prescribed medicine at the right time?

**(PFTKDGC)**

YES		1 	

NO		2		[GO TO PF13CG]

REFUSED		-7		[GO TO PF13CG]

DON’T KNOW		-8		[GO TO PF13CG]

**PF12BCG.**Does {s/he} need the help of another person to perform this activity?

**(PFTKDGBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**PF13CG.**Does {CARE RECIPIENT} have difficulty using the telephone?

**(PFFONEC)**

YES		1 	

NO		2 	[GO TO PF14CG]

REFUSED		-7		[GO TO PF14CG] 

DON’T KNOW		-8 	[GO TO PF14CG]

**PF13BCG.**Does {s/he} need the help of another person to perform this activity?

**(PFFONEBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

PF14CG-new.    Is there a car or personal motor vehicle in working condition in {CARE RECIPIENT’s}   household?

(CGISCAR)

YES		1

NO		2 		[GO TO PFCG15]

REFUSED		-7		[GO TO PFCG15]

DON’T KNOW		-8		[GO TO PFCG15]

**PF14CG-old.**	Does {s/he} have difficulty driving a car or other personal motor vehicle?

**(PFDRIVEC)**

YES		1 	

NO		2	

REFUSED		-7	

DON’T KNOW		-8 	

**PF15CG.**Is there a public bus or transit stop within three-quarters of a mile from {his/her} home?

**(PFBUSC)**

YES		1 	

NO		2	

REFUSED		-7		[GO TO CGINTRO10]

DON’T KNOW		-8	

**PF15BCG.**	Does {s/he} have difficulty using this transportation?

**(PFUSBSC)**

YES		1 	

NO		2	

REFUSED		-7		[GO TO CGINTRO10]

DON’T KNOW		-8	 

**PF15CCG.** Does {s/he} need the help of another person to perform this activity?

**(PFUSBSBC)**

YES		1 

NO		2 

REFUSED		-7 

DON’T KNOW		-8 

FENCEPOST

****

**CGINTRO10.**  We are interested in knowing more about the demographic characteristics of people receiving services. All this information will be kept confidential to the extent allowed by law.

**CGDE1.**	What is {CARE RECIPIENT’s} date of birth?

**(CGPMM, CGPDD, CGPYYYY)**

_____/____/________

 MM     DD   YYYY

REFUSED		-7 	

DON’T KNOW		-8

**PROGRAMMER NOTE:   PLEASE COMPUTE AGE BASED ON DATE OF INTERVIEW AND STORE AS CONSTRUCTED VARIABLE NAME: CGPAGE**

**IF CGC ASKED AND RESPONSE IS 1, MALE OR 2, FEMALE, AUTOCODE CGDE2 AS 1, MALE OR 2, FEMALE—MATCH TO CGC-- AND SKIP TO CGDE3.**

**CGDE2.**	[DON’T ASK IF OBVIOUS] What is {CARE RECIPIENT’s} gender?

**(CGPMF)**

MALE		1 	

FEMALE		2 	

REFUSED		-7 	

DON’T KNOW		-8 	

**CGDE3.**	How many persons total {are you/is NAME OF CAREGIVER} caring for not counting {CARE RECIPIENT}?

**(CGMANY)**

NUMBER 		|___|___| 

REFUSED		-7 

DON’T KNOW		-8 

**CGDE4.**	Who are those people?  **[INTERVIEWER NOTE: CODE ALL THAT APPLY.  PROBE: Anyone else?  CTRL/P TO EXIT]**

**(CGWHO1-8, CGWHO01-08 AND CGWHOOS)**

HUSBAND OR WIFE		1

SON(S) OR DAUGHTER(S)		2

FATHER		3

MOTHER		4

BROTHER(S) OR SISTER(S)		5

GRANDSON(S) OR GRANDDAUGHTER(S)		6

OTHER RELATIVE(S) NOT MENTIONED ABOVE		7

FRIEND(S) OR NEIGHBOR(S)		8

OTHER PERSONS NOT MENTIONED ABOVE (SPECIFY:______________________)		91

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**GO TO DEMOGRAPHIC INTAKE MODULE**

Family Caregiver 		Page 44

Family Caregiver		Page 75

ADDITIONAL SERVICE LIST MODULE (Version: JANUARY 2008)

**CASE MANAGEMENT IS CS16 (CSKNOW).**

**CONGREGATE MEALS IS CNR29 (CMENUF).**

**HOME DELIVERED MEALS QUESTION JUST PRIOR TO THIS MODULE IS HNR33 (HMSKP).**

**HOMEMAKER IS HC9 (HCSTAYHM).**

**TRANSPORTATION QUESTION JUST PRIOR TO THIS MODULE IS TR22 (TRDRIVE).**

**FAMILY CAREGIVER QUESTION JUST PRIOR TO THIS MODULE IS CG36 (CGINF09).**

**PROGRAMMER NOTE:  FOR QUESTION SVC1,**

**SKIP QUESTION A FOR CONGREGATE MEALS.**

**SKIP QUESTION B FOR HOME DELIVERED MEALS RESPONDENTS.**

**SKIP QUESTION C FOR HOMEMAKER.**

**SKIP QUESTION D FOR CASE MANAGEMENT RESPONDENTS.**

**SKIP QUESTION E FOR TRANSPORTATION RESPONDENTS.**

**FOR HOME DELIVERED MEALS, CONGREGATE MEALS, HOMEMAKER, CASE MANAGEMENT AND TRANSPORTATION CLIENTS, USE FIRST DISPLAY.**

**FOR FAMILY CAREGIVER RESPONDENTS, USE CARE RECIPIENT NAME (OR RELATION) DISPLAY IN SVC1, SVC2, SVC3 AND SVC4. WE ARE NOT INTERESTED IN INFORMATION ON SERVICES THE CAREGIVER RECEIVES.  FOR CAREGIVERS, WE WANT TO KNOW ONLY ABOUT THE SERVICES THEIR CARE RECIPIENT RECEIVES.**

**SVC1.**	I’d like to ask about additional help {you/NAME OF PARTICIPANT} {CARE RECIPIENT} may have received from {PROVIDER NAME} or {AGENCY NAME}.  

PROGRAMMER NOTE: DO NOT ASK SVC2 IF ALL OF SVC1a THROUGH SVC1Q ARE ALL 2, -7 AND/OR -8. SKIP TO SVC3.

**SVC2.**	Overall, how would {you/s/he} {you/s/he} rate the group of services {you receive/s/he receives} {CARE RECIPIENT RECEIVES}? Would {you/NAME OF PARTICIPANT} {you/NAME OF CAREGIVER} say...

**(SVCRATE)**

Excellent,		1 

Very good,		2

Good,		3

Fair, or		4

Poor?		5

REFUSED		-7 

DON’T KNOW		-8 

**PROGRAMMER NOTE: FOR CAREGIVER, SKIP TO SVC4**

INTRO: Now, I would like to ask about how these services help {you/him/her}.

**SVC3.**	Thinking about {your/NAME OF PARTICIPANT’s} {CARE RECIPIENT’s} services in general, {do you/does s/he} {do you/does s/he} agree or disagree with these statements?  

**SVC4.**	Thinking about {your/NAME OF PARTICIPANT’s} {CARE RECIPIENT’s} services in general, {do you/does s/he} {do you/does s/he} agree or disagree with these statements?  

FENCEPOST

**SVC5.**	{Are you/Is NAME OF PARTICIPANT/Is CARE RECIPIENT} receiving any other types of assistance, such as...

**SVC6.** 	{Do your/his/her} family or friends help arrange for the services {you receive/s/he receives}?

**(CSARRNG)**

YES		1 

NO		2

REFUSED		-7

DON’T KNOW		-8

**SVC7.** 	{Do your/his/her} family or friends provide assistance that helps {you/NAME OF PARTICIPANT} stay at home?

**(CSHOME)**

YES		1 

NO		2

REFUSED		-7

DON’T KNOW		-8

FENCEPOST

**PROGRAMMER NOTE:**

**IF CASE MANAGEMENT, GO TO PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE.**

**IF CONGREGATE MEALS, GO TO PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE**

**IF HOME-DELIVERED MEALS, GO TO PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE**

**IF HOMEMAKER, GO TO PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE**

**IF TRANSPORTATION, GO TO PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE**

**THEN GO TO DEMOGRAPHIC INTAKE MODULE.**

**NEED TO ASK UNLESS:**

**IF HMDAYS=5, GO TO DEMOGRAPHIC INTAKE MODULE.**

**IF HCDAYS=5 AND/OR HCMOFT=L, GO DEMOGRAPHIC INTAKE MODULE.**

**IF TROFTEN=6 AND/OR TRDAYS=5, GO TO DEMOGRAPHIC INTAKE MODULE.**

**IF CMDAYS=5, GO TO DEMOGRAPHIC INTAKE MODULE.**

**IF FAMILY CAREGIVER, GO TO CGDFPLC.**

Additional Service List 		Page 76

Additional Service List		Page 81

**PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE (VERSION: SEPTEMBER 2013)**

**PROGRAMMER NOTE:  THIS MODULE IS FOR CASE****MANAGEMENT, CONGREGATE MEALS, HOME-DELIVERED MEALS, HOMEMAKER, AND TRANSPORTATION RESPONDENTS.**

**UNLESS:**

**IF HMDAYS=5, GO TO MODULE 4, DEMOGRAPHIC INTAKE.**

**IF CMDAYS=5, GO TO MODUULE 4, DEMOGRAPHIC INTAKE.**

**IF HCDAYS=5 AND/OR HCMOFT=L, GO TO MODULE 4, DEMOGRAPHIC INTAKE.**

**IF TROFTEN=6 AND/OR TRDAYS=5, GO TO MODULE 4, DEMOGRAPHIC INTAKE.**

**PROGRAMMER NOTE:  IF PARTICIPANT OR INTERPRETER/TRANSLATOR, DISPLAY FIRST PERSON TENSE (E.G., “DO YOU” OR “HAVE YOU”) INTO QUESTIONS. IF PROXY, DISPLAY SECOND PERSON TENSE (E.G., “DOES S/HE” OR “HAS S/HE”) WHERE INDICATED IN THIS MODULE.**

**PFINTRO1.**  The next question is about {your/PARTICPANT’S NAME} health.  Please try to answer as accurately as you can.

**SF1.**In general, would you say {your/his/her} health is . . .****[READ RESPONSE OPTIONS]

**(PFHLTH)**

Excellent		1

Very good		2

Good		3

Fair, or		4

Poor?		5

REFUSED		-7

DON’T KNOW		-8

Now I’m going to read a list of activities that {you/s/he} might do during a typical day. As I read each item, please tell me if {your/his/her} health now limits {you/him/her} you a lot, limits {you/him/her} a little, or does not limit {you/him/her} at all in these activities.  

How about...

**SF2a.**. . .  moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf. Does {your/his/her} health now limit {you/him/her} a lot, limit {you/him/her} a little, or not limit {you/him/her} at all?  [READ RESPONSE OPTIONS]

**(SFMODACT)**

Yes, limited a lot		1

Yes, limited a little or		2

No, not limited at all?		3

REFUSED		-7

DON’T KNOW		-8

How about...

**SF2b.**. . . climbing several flights of stairs. Does {your/his/her} health now limit {you/him/her} a lot, limit {you/him/her} a little, or not limit {you/him/her} at all?****[READ RESPONSE OPTIONS]

**(SFCLIMB)**

   Yes, limited a lot		1

Yes, limited a little or		2

No, not limited at all?		3

REFUSED		-7

DON’T KNOW		-8

The following two questions ask you about {your/his/her} physical health and {your/his/her} daily activities.

**SF3a.**During the past four weeks, how much of the time {have you/has s/he} accomplished less than {you/s/he} would like as a result of {your/his/her} physical health? [READ RESPONSE OPTIONS]

**(SFACCOMP)**

All of the time		1

Most of the time		2

Some of the time		3

A little of the time, or		4

None of the time?		5

REFUSED		-7

DON’T KNOW		-8

**SF3b.**During the past four weeks, how much of the time {were you/was s/he} limited in the kind of work or other regular daily activities {you/she/he} did as a result of your physical health?

**(SFLIMITD)**

All of the time		1

Most of the time		2

Some of the time		3

A little of the time, or		4

None of the time?		5

REFUSED		-7

DON’T KNOW		-8

**SF4a.**During the past four weeks, how much of the time (have you/has s/he} accomplished less than {you/he/she} would like as a result of any emotional problems, such as feeling depressed or anxious?  [READ RESPONSE OPTIONS]

**(SFEMOT)**

All of the time		1

Most of the time		2

Some of the time		3

A little of the time, or		4

None of the time?		5

REFUSED		-7

DON’T KNOW		-8

**SF4b.**During the past four weeks, how much of the time did {you/he/she} do work or other regular daily activities less carefully than usual as a result of any emotional problems, such as feeling depressed or anxious? ****[READ RESPONSE OPTIONS]

**(SFCAREFL)**

All of the time		1

Most of the time		2

Some of the time		3

A little of the time, or		4

None of the time?		5

REFUSED		-7

DON’T KNOW		-8

**SF5a.**During the past four weeks, how much did pain interfere with (your/his/her} normal work (including both work outside the home and housework)? ****[READ RESPONSE OPTIONS]

**(SFPAIN)**

Not at all		1

A little bit		2

Moderately		3

Quite a bit, or		4

Extremely?		5

REFUSED		-7

DON’T KNOW		-8

The next few questions are about how {you feel/he feels/she feels} and how things have been with {you/ him/her} during the past four weeks.

As I read each statement, please give me the one answer that comes closest to the way {you have/he has/she has} been feeling; is it all of the time, most of the time, some of the time, a little of the time, or none of the time?

**SF6a.**How much of the time during the past four weeks . . . {have you/has s/he} felt calm and peaceful?  [READ RESPONSE OPTIONS]

**(SFCALM)**

All of the time		1

Most of the time		2

Some of the time		3

A little of the time, or		4

None of the time?		5

REFUSED		-7

DON’T KNOW		-8

**SF6b.**How much of the time during the past four weeks . . . did {you/s/he} have a lot of energy?  [READ RESPONSE OPTIONS]

**(SFENERGY)**

All of the time		1

Most of the time		2

Some of the time		3

A little of the time, or		4

None of the time?		5

REFUSED		-7

DON’T KNOW		-8

**SF6c.**How much of the time during the past four weeks . . . {have you/has he/has she} felt downhearted and depressed?  [READ RESPONSE OPTIONS]

**(SFDOWN)**

All of the time		1

Most of the time		2

Some of the time		3

A little of the time, or		4

None of the time?		5

REFUSED		-7

DON’T KNOW		-8

**SF7.**During the past four weeks, how much of the time has {your/his/her} physical health or emotional problems interfered with {your/his/her} social activities (like visiting friends, relatives, etc.)?  [READ RESPONSE OPTIONS]

**(SFINTERF)**

All of the time		1

Most of the time		2

Some of the time		3

A little of the time, or		4

None of the time?		5

REFUSED		-7

DON’T KNOW		-8

**SF8.**	Compared with {your/his/her} health one year ago, would you say {your/his/her} health is ...

**(SFHEALTH)**

Much better than one year ago,		1

A little better than one year ago,		2

About the same as one year ago,		3

A little worse than one, or		4

Worse than one year ago?		5

REFUSED		-7

DON’T KNOW		-8

**SF9.**Regarding {your/ NAME OF PARTICIPANT’s} present social activities, {do you/does s/he} feel that {you are/s/he is} doing... 

**(SFACTIVE)**

About enough,		1

Too much, or		2

{You/ NAME OF PARTICIPANT} would like to be doing more?	3

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

**SF10.**	Have {your/NAME OF PARTICIPANT’s} social opportunities increased since {you/s/he} became involved with {PROVIDER NAME’s/AGENCY NAME’s} services?

**(SFSOCIAL)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

FENCEPOST

# PF1a6.  	Now I would like to ask about medical conditions {you/NAME OF PARTICIPANT} may have. Has a doctor ever told {you/NAME OF PARTICIPANT} that {you have/s/he has} had:

**FENCEPOST**

**PF1a6-1.**  	During the last 12 months, have you learned how to take care of {any or all of} your chronic {illness/illnesses} or medical {condition/conditions}?

(PFTKCARE)

YES		     1   [Go to PF1a6-2]

NO		2	[GO TO PF1a6-3]

REFUSED		-7	[GO TO PF1a6-3]

DON’T KNOW		-8	[GO TO PF1a6-3]

# PF1a6-2.  	During the last 12 months, how did you learn about taking care of {your/any or all of your} chronic {illness/illnesses} or medical {condition/conditions}?  Did you...[CHECK ALL THAT APPLY]

**PF1a6-3.**Having **{an illness/one or more illnesses}**often means doing different tasks and activities to manage your **{condition/conditions}**. How confident are you that you can do all the things necessary to manage your **chronic {illness/illnesses} or medical {condition/conditions}**on a regular basis? **Would you say you are...** [READ RESPONSE OPTIONS]

**(PFCONF)**

Not at all confident,		1

A little confident,		2

Moderately confident, or		3

Very confident?		4

REFUSED		-7

DON’T KNOW		-8

# 

PF1a7.	Because of a physical, mental or emotional condition lasting 6 months or more, {do you/does NAME OF PARTICIPANT} have any difficulty learning, remembering, or concentrating?

**(PFLEARN)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**PROGRAMMER NOTE:  SOFT RANGE FOR HLM4 = 0 TO 10.  IF MORE THAN 10, HAVE INTERVIEWER PROBE:  You told me {you take/s/he takes} {INSERT NUMBER OVER 10} prescription medications per day.  Is that correct?**

**HLM1.**About how many different prescription medications {do you/does s/he} take every day? 

**(HLMDRUGS)**

**[INTERVIEWER NOTE:  IF NONE, ENTER 0]**

NUMBER OF PRESCRIPTION MEDICINES 

PER DAY	|__|__| 

REFUSED	-7

DON’T KNOW	-8

**HLM1-OV.**You told me {you take/NAME OF PARTICIPANT takes} {INSERT NUMBER OVER 10} prescription medications per day. Is that correct? 

**(HMDRCHK)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**HLM2.**In the past 12 months, did {you/NAME OF PARTICIPANT} have to stay overnight in a hospital?

**(HLMHOSP)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**HLM3.**	In the past 12 months, did {you/NAME OF PARTICIPANT} have to stay overnight in a nursing home or rehabilitation center?

**(HLMNH)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

****

**OHINTRO.**Now we would like to ask about your oral or dental health (that is, the health of your teeth and gums)... 

OHQ.030	About how long has it been since you **last** visited a dentist? Include all types of dentists, such as, orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.

6 MONTHS OR LESS	......	            1

MORE THAN 6 MONTHS, BUT NOT MORE THAN 1 YEAR AGO		2

MORE THAN 1 YEAR, BUT NOT MORE THAN 2 YEARS AGO		      3

MORE THAN 2 YEARS, BUT NOT MORE THAN 3 YEARS AGO		4

MORE THAN 3 YEARS, BUT NOT MORE THAN 5 YEARS AGO		5

MORE THAN 5 YEARS AGO		             6

NEVER HAVE BEEN		             7 

REFUSED		.-7

DON'T KNOW		-8

	HELP SCREEN:

****Dentist: Medical persons whose primary occupation is caring for teeth, gums, and jaws. Dental care includes general work such as fillings, cleaning, extractions, and also specialized work such as root canals, fittings for braces, etc. 

OHQ.770	During the past 12 months, was there a time when you needed dental care but could not get it at that time? 

YES		1 

NO		 2 	

REFUSED		-7	 

DON'T KNOW		-8	 	

OHQ.780	What were the reasons that you could not get the dental care you needed? 

	CODE ALL THAT APPLY 

COULD NOT AFFORD THE COST					10 

DID NOT WANT TO SPEND THE MONEY					11 

INSURANCE DID NOT COVER RECOMMENDED PROCEDURES		12 

DENTAL OFFICE IS TOO FAR AWAY					13 

DENTAL OFFICE IS NOT OPEN AT CONVENIENT TIMES					14 

ANOTHER DENTIST RECOMMENDED NOT DOING IT					15 

AFRAID OR DO NOT LIKE DENTISTS					16 

UNABLE TO TAKE TIME OFF FROM WORK					17 

TOO BUSY					18 

DID NOT THINK ANYTHING SERIOUS WAS WRONG/EXPECTED DENTAL PROBLEMS TO GO AWAY					19 

DID NOT HAVE TRANSPORTATION..................................				20

OTHER					21 

REFUSED		....				-7 

DON'T KNOW						-8

OHQ.845	Overall, how would you rate the health of your teeth and gums?

EXCELLENT		1

VERY GOOD		2

GOOD,		3

FAIR		4

POOR		5

REFUSED		-7

DON’T KNOW		-8

FENCEPOST

**PFINTRO2.**We would like to ask about difficulties with some common activities of everyday life and whether {you need /NAME OF PARTICIPANT needs} assistance performing these activities. Please exclude the effects of temporary conditions. 

**PF1.**	{Do you/Does NAME OF PARTICIPANT} have difficulty getting around inside the home?

**(PFDFIN)**

YES		1 

NO		2	[GO TO PF2]

REFUSED		-7	[GO TO PF2]

DON’T KNOW		-8	[GO TO PF2]

**PROGRAMMER NOTE; INSERT MONTH AND DAY 30 DAYS PRIOR TO INTERVIEW DATE IN IF NEEDED IN PF1c, PF2c, PF3c, PF4c, pF5c, PF7c, PF8c, PF10c, PF11c.**

**PF1b.**	{Do you/Does s/he} need the help of another person to perform this activity?

**(PFDFINB)**

YES		1 

NO		2	

REFUSED		-7	

DON’T KNOW		-8	

FENCEPOST

**PF2.**	{Do you/Does s/he} have difficulty going outside the home, for example to shop or visit a doctor’s office?

**(PFDFOU)**

YES		1 

NO		2	[GO TO PF3]

REFUSED		-7	[GO TO PF3]

DON’T KNOW		-8	[GO TO PF3]

**PF2b.**	{Do you/Does s/he} need the help of another person to perform this activity?

**(PFDFOUB)**

YES		1 

NO		2

REFUSED		-7

DON’T KNOW		-8

FENCEPOST

PF3.	{Do you/Does name of participant} have difficulty getting in or out of bed or a chair?

 (PFBED)

YES		1 

NO		2	[GO TO PF4]

REFUSED		-7	[GO TO PF4]

DON’T KNOW		-8	[GO TO PF4]

**PF3b.**	{Do you/Does s/he} need the help of another person to perform this activity?

**(PFBEDB)**

YES		1 

NO		2

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

**PF4.**	{Do you/Does s/he} have difficulty when taking a bath or shower?

**(PFBATH)**

YES		1 

NO		2	[GO TO PF5]

REFUSED		-7	[GO TO PF5]

DON’T KNOW		-8	[GO TO PF5]

**PF4b.**	{Do you/Does s/he} need the help of another person to perform this activity?

**(PFBATHB)**

YES		1 

NO		2

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

**PF5.**	{Do you/Does NAME OF PARTICIPANT} have difficulty when dressing?

**(PFDRES)**

YES		1 

NO		2	[GO TO PF6]

REFUSED		-7	[GO TO PF6]

DON’T KNOW		-8	[GO TO PF6]

**PF5b.**	{Do you/Does s/he} need the help of another person to perform this activity?

**(PFDRESB)**

YES		1 

NO		2

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

**PF6.**	{Do you/Does s/he} have difficulty when walking?

**(PFWALK)**

YES		1 

NO		2	[GO TO PF7]

REFUSED		-7	[GO TO PF7]

DON’T KNOW		-8	[GO TO PF7]

**PF6b.**	{Do you/Does s/he} need the help of another person to perform this activity?

**(PFWALKB)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

**PF7.**	{Do you/Does NAME OF PARTICIPANT} have difficulty eating?

**(PFEAT)**

YES		1 

NO		2	[GO TO PF8]

REFUSED		-7	[GO TO PF8]

DON’T KNOW		-8	[GO TO PF8]

**PF7b.**	{Do you/does s/he} need the help of another person to perform this activity?

**(PFEATB)**

YES		1 

NO		2

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

**PF8.**	{Do you/Does s/he} have difficulty using the toilet or getting to the toilet?

**(PFWC)**

YES		1 

NO		2	[GO TO PF9]

REFUSED		-7	[GO TO PF9]

DON’T KNOW		-8	[GO TO PF9]

**PF8b.**	{Do you/Does s/he} need the help of another person to perform this activity?

**(PFWCB)**

YES		1 

NO		2	

REFUSED		-7	

DON’T KNOW		-8	

# FENCEPOST

**PF9.**	{Do you/Does NAME OF PARTICIPANT} have difficulty keeping track of money or bills?

**(PFDLR)**

YES		1	

NO		2	[GO TO PF10]

REFUSED		-7	[GO TO PF10]

DON’T KNOW		-8 	[GO TO PF10]

**PF9b.**	{Do you/Does s/he} need the help of another person to perform this activity?

**(PFDLRB)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

**PF10.** 	{Do you/Does s/he} have difficulty preparing meals?

**(PFMEAL)**

YES		1 	

NO		2	[GO TO PF11]

REFUSED		-7	[GO TO PF11]

DON’T KNOW		-8 	[GO TO PF11]

**PF10b.**	{Do you/Does s/he} need the help of another person to perform this activity?

**(PFMEALB)**

YES		1 	

NO		2	

REFUSED		-7	

DON’T KNOW		-8 	

# FENCEPOST

**PF11.**	{Do you/Does NAME OF PARTICIPANT} have difficulty doing light housework, such as washing dishes or sweeping a floor?

**(PFCLEN)**

YES		1 	

NO		2 	[GO TO PF12]

REFUSED		-7	[GO TO PF12]

DON’T KNOW		-8 	[GO TO PF12]

**PF11b.**	{Do you/Does s/he} need the help of another person to perform this activity?

**(PFCLENB)**

YES		1 	

NO		2 

REFUSED		-7

DON’T KNOW		-8 

# FENCEPOST

**PF12.**	{Do you/Does NAME OF PARTICIPANT} have difficulty doing heavy housework, such as scrubbing floors or washing windows?

**(PFHCLEN)**

YES		1 	

NO		2 	[GO TO PF13]

REFUSED		-7	[GO TO PF13]

DON’T KNOW		-8 	[GO TO PF13]

**PF12b.**	{Do you/Does s/he} need the help of another person to perform this activity?

**(PFHCLENB)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

**PF13.** 	{Do you/Does s/he} have difficulty taking the right amount of prescribed medicine at the right time?

**(PFTKDG)**

YES		1 	

NO		2 	[SKIP PF13b]

REFUSED		-7	[SKIP PF13b]

DON’T KNOW		-8	[SKIP PF13b]

**PF13b.**	{Do you/Does s/he} need the help of another person to perform this activity?

**(PFTKDGB)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

**PROGRAMMER NOTE:  ASK PF14 ONLY IF PROXY OR INTERPRETER INTERVIEW. IF RESPONDENT ON PHONE, DO NOT ASK. IF RESPONDENT ON PHONE, AUTOCODE AS 2 (NO).**

**PF14.**	{Does NAME OF PARTICIPANT} have difficulty using the telephone?

**(PFFONE)**

YES		1

NO		2	[GO TO PF15]

REFUSED		-7	[GO TO PF15]

DON’T KNOW		-8 	[GO TO PF15]

****

**PF14b.**	{Does s/he} need the help of another person to perform this activity?

**(PFFONEB)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**PF15-A**   Is there a car or personal motor vehicle in working condition in your {his/her}   household?

**(PFISCAR)**

YES		1

NO		2 		[GO TO PF16]

REFUSED		-7	[GO TO PF16]

DON’T KNOW		-8	[GO TO PF16]

**PF15-B.**	{Do you/Does s/he} have difficulty driving a car or personal motor vehicle?

**(PFDRIVE)**

YES		1 	

NO		2	

REFUSED		-7	

DON’T KNOW		-8 	

**PF16.**Is there a public bus or transit stop within three-quarters of a mile from {your/his/her} home?

**(PFBUS)**

YES		1	

NO		2 	[GO TO DEMOG. MOD.]

REFUSED		-7	[GO TO DEMOG. MOD.]

DON’T KNOW		-8	[GO TO DEMOG. MOD.]

**PF16B.**	{Do you/Does s/he} have difficulty using this transportation?

**(PFUSEBUS)**

YES		1 	

NO		2 	[GO TO DEMOG. MOD.]

NEVER USES BUS......................................................    3	[GO TO DEMOG. MOD.]

REFUSED		-7	

DON’T KNOW		-8 	

**PF16BOV.**{Do you/Does s/he} need the help of another person to perform this activity?

**(PFBUSEB)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

**PROGRAMMER NOTE:  IF RESPONDENT HAS ANSWERED YES TO QUESTIONS THAT ASK IF ANOTHER PERSON HELPS THEM (PF1B, PF2B, PF3B, PF4B, PF5B, PF6B, PF7B, PF8B, PF9B, PF10B, PF11B, PF12B, PF13B, PF14B AND/OR PF16C, GO TO PF17A.**

**DISPLAY YES RESPONSES ON CATI SCREEN FOR PF16A. WE WANT TO DISPLAY THE ACTUAL CATEGORIES FOR WHICH THE RESPONDENT SAID THEY RECEIVE HELP, SO DISPLAY THE PREVIOUS QUESTIONS WHERE THE RESPONDENT SAID “YES, THEY HAVE DIFFICULTY...” (NUMBERED QUESTIONS 1,2,3,4,5,6,7,8,9,10,11,11A, 12,13,15B)  AND ‘YES, THEY RECEIVE HELP.” (PF1B, PF2B, PF3B, PF4B, PF5B, PF6B, PF7B, PF8B, PF9B, PF10B, PF11B, PF13B, PF13B, PF14B AND/OR PF16C).  DISPLAY APPROPRIATE CATEGORIES LIKE THIS:**

**PF1	DIFFICULTY GETTING AROUND INSIDE THE HOME**

**PF2	DIFFICULTY GOING OUTSIDE THE HOME, FOR EXAMPLE TO SHOP OR VISIT A**

**DOCTOR’S OFFICE**

**PF3	DIFFICULTY GETTING IN OR OUT OF BED OR A CHAIR**

**PF4	DIFFICULTY WHEN TAKING A BATH OR SHOWER**

**PF5	DIFFICULTY WHEN DRESSING**

**PF6	DIFFICULTY WHEN WALKING**

**PF7	DIFFICULTY EATING**

**PF8	DIFFICULTY USING THE TOILET OR GETTING TO THE TOILET**

**PF9	DIFFICULTY KEEPING TRACK OF MONEY OR BILLS**

**PF10	DIFFICULTY PREPARING MEALS**

**PF11	DIFFICULTY DOING LIGHT HOUSEWORK, SUCH AS WASHING DISHES OR SWEEPING A**

**FLOOR**

**PF12B	DIFFICULTY DOING HEAVY HOUSEWORK, SUCH AS SCRUBBING FLOORS OR**

**WASHING WINDOWS**

**PF13	DIFFICULTY TAKING THE RIGHT AMOUNT OF PRESCRIBED MEDICINE AT THE RIGHT**

**TIME**

**PF14	DIFFICULTY USING THE TELEPHONE**

**PF16B	DIFFICULTY USING PUBLIC TRANSPORTATION**

**IF NOT, GO TO DEMOGRAPHIC INTAKE MODULE.**

**PF17A.**You have said that {you need/NAME OF PARTICIPANT needs} the help of another person with ... **[READ LIST OF ACTIVITIES PARTICULAR TO THIS CLIENT]**.  

**PF17B.**We would like to know if family or friends provide help with these activities.  If so, who provides the most help with these activities? Was it...

**(FAMFRND)**

FAMILY, OR		1

SOMEONE ELSE, LIKE A FRIEND, NEIGHBOR OR OTHER PERSON?		2

DID NOT RECEIVE HELP FROM FAMILY/FRIENDS		3

**PF17C.**	         Which family member helps the most with these activities? [INTERVIEWER NOTE: MARK

                          ONLY ONE]

**(WHOHELPS)**

HUSBAND		1

WIFE		2

SON,		3

SON-IN-LAW 		4

DAUGHTER,	    	5

DAUGHTER-IN-LAW		6

FATHER,		7

MOTHER,		8

BROTHER,		9

SISTER,		10

GRANDSON,		11

GRANDDAUGHTER, 		12

NEPHEW,		13

NIECE, 		14

OTHER RELATIVE		91

REFUSED		-7 

DON’T KNOW		-8

**GO TO DEMOGRAPHIC INTAKE MODULE**

Physical, Social, and Emotional Well-Being 		Page 82

Physical, Social, and Emotional Well-Being		Page 100

**DEMOGRAPHIC INTAKE MODULE (VERSION: NOVEMBER 2013)**

**NOTE: THIS MODULE IS FOR CASE MANAGEMENT, CONGREGATE MEALS, HOME-DELIVERED MEALS, HOMEMAKER, TRANSPORTATION, AND FAMILY CAREGIVER.**

**PROGRAMMER NOTE: SKIP DEINTRO IF CAREGIVER.  REPEATS CGINTRO1.**

**DEINTRO.**    We are interested in knowing more about the demographic characteristics of our clients. We would appreciate it if you would answer the following questions. Your answers will be used only for the purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual. We will not provide information that identifies any individuals to anyone outside the study team, except as required by law. Remember your answers are confidential and you don't have to answer any question you don't want to.

**DE1.**	ASK IF NOT OBVIOUS: What is {your/NAME OF PARTICIPANT’s/NAME OF CAREGIVER’s} gender?

**(DEGENDR)**

MALE		1

FEMALE		2

REFUSED		-7	

DON’T KNOW		-8	

**DE1a.**	Which of the following best represents how you think of yourself?

**(ACISIM)**OR **(ACISIF)**

Lesbian or gay*		1	[GO TO DE2]

Straight, that is, not lesbian or gay**		2	[GO TO DE2]

Bisexual		3	[GO TO DE2]

Something else		4	[GO TO DE2]

REFUSED		-7	[GO TO DE2]

DON’T KNOW		-8	[GO TO DE2]

*For men, the category reads “gay” **(ACISIM)**

**For men, the category reads “straight, that is, not gay” **(ACISIF)**

****

**DE2.**We have {your/NAME OF PARTICIPANT/ NAME OF CAREGIVER’s} date of birth as {DISPLAY DATE}, is that correct?

**(DEBDAY1)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**DE2UPDT.**	What is {your/NAME OF PARTICIPANT/NAME OF CAREGIVER} date of birth?

**(DEBMM-DEBDD-DEBYYYY)**

_____/____/________

 MM     DD     YYYY

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

PROGRAMMER NOTE: CONSTRUCTED VARIABLE-AGEC — PLEASE CONVERT DATE OF BIRTH TO AGE AS OF INTERVIEW DATE.  KEEP ORIGINAL RESPAGE AS WELL.

**DE3.**	What is {your/ NAME OF PARTICIPANT’s/NAME OF CAREGIVER’s} highest level of education? Would {you/s/he} say...

**(DEEDUC)**

Less than high school diploma,		1

High school diploma or GED,		2

Some college, including Associate’s degree {INCLUDES BUSINESS SCHOOL AND VOCATIONAL 

   OR TECHNICAL SCHOOL}, 		3

Bachelor’s degree, or		4

Some post-graduate work or advanced degree?		5

REFUSED		-7

DON’T KNOW		-8

****

**DE4.**	{Are you/Is NAME OF PARTICIPANT/NAME OF CAREGIVER} Hispanic or Latino?

**(DEHISP)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

# FENCEPOST

**DE5.**	Which one or more of the following best describes {your/NAME OF PARTICPANT’s} race? Would (you/s/he) say...  (CODE ALL THAT APPLY. CTRL/P TO EXIT)

**(DERACE1-6 DERAOS)**

White,		1

Black or African-American,		2

Asian,		3

American Indian or Alaskan Native, or		4

Native Hawaiian or other Pacific Islander		5

REFUSED		-7

DON’T KNOW		-8

FENCEPOST

**DE5a.**	{Have you/Did NAME OF PARTICIPANT/NAME OF CAREGIVER} previously served on active duty in the U.S. Armed Forces, military Reserves or National Guard? 

**(DEVET)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

****

**DE6**.	Is {your/ his/her} home located in...

**(DELOC)**

The city,		1

The suburbs, or		2

A rural area?		3

REFUSED		-7	

DON’T KNOW		-8	

**FENCEPOST**

**DE5.**	Which one or more of the following best describes {your/NAME OF PARTICPANT’s} race? Would (you/s/he) say...  (CODE ALL THAT APPLY. CTRL/P TO EXIT)

**(DERACE1-6 DERAOS)**

White,		1

Black or African-American,		2

Asian,		3

American Indian or Alaskan Native, or		4

Native Hawaiian or other Pacific Islander		5

REFUSED		-7

DON’T KNOW		-8

FENCEPOST

**DE5a.**	{Have you/Did NAME OF PARTICIPANT/NAME OF CAREGIVER} previously served on active duty in the U.S. Armed Forces, military Reserves or National Guard? 

**(DEVET)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

****

**DE6**.	Is {your/ his/her} home located in...

**(DELOC)**

The city,		1

The suburbs, or		2

A rural area?		3

REFUSED		-7	

DON’T KNOW		-8	

**DE7.**	What is {your/ NAME OF PARTICIPANT’s/NAME OF CAREGIVER’s} home ZIP code?

**(DEZIP)**

HOME ZIP CODE		|___|___|___|___|___| 

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

PROGRAMMER NOTE: IF CAREGIVER ANSWERS CG21—CGMINUT—1-Lives in same house, AUTOCODE DE8 “2,” AND GO TO DE8A.

**DE8.**We’d like to ask about the persons who live in this household. Does anyone else live with {you/NAME OF PARTICIPANT/NAME OF CAREGIVER}?

**(DELIVWI)**

YES		1	[GO TO PROGRAMMER NOTE BEFORE DE8B]

NO		2	

REFUSED		-7	[GO TO PROGRAMMER NOTE BEFORE DE8B]

DON’T KNOW		-8	[GO TO PROGRAMMER NOTE BEFORE DE8B]

**DE8a.**	Do you/Does {NAME OF PARTICIPANT/NAME OF CAREGIVER} 

PROGRAMMER NOTE:  Soft range for DE8b is 1 to 10; hard range 1-20. If DE8 = 2 (NO), autocode DE8b 1 and go to DE9.

PROGRAMMER NOTE: IF ALL OF DE8a IS NO, PROMPT "YOU TOLD ME YOU LIVE WITH SOMEONE ELSE.  WHO DO YOU LIVE WITH?"  THEN ALLOW THE INTERVIEWER TO GO BACK AND CODE THE RESPONSE "YES" THAT APPLIES.

If the respondent has indicated in DE8 that he or she lives with someone else (ANY OF DE8 1-4 is YES OR CAREGIVER ANSWERS CG21—CGMINUT—1-Lives in same house), if interviewer enters 0 in de8b, give a prompt that says, “the system will not accept zero, because this question asks you to include yourself.” If interviewer enters one, AND DE8 IS YES (1) theN GIVE  a prompt that says, “you told me you live with other people. Please include yourself when telling me how many people live in your household.” IF DE8 IS REFUSED OR DON’T KNOW, THEN ACCEPT 1.

IF CAREGIVER AND CGMINUT=1, AND INTERVIEWER ENTERS 0 OR 1 IN DE8B, PROMPT, “You told me {you live/s/he lives} with {CARE RECIPIENT}. Please include {him/her} when you tell me how many live in the household.”

Variables:

# FENCEPOST

**DE8b.**Including {yourself/himself/herself}, how many people live in {your/NAME OF PARTICIPANT’S/NAME OF CAREGIVER’S} household? 

**(DEHHM)**

NUMBER OF HOUSEHOLD MEMBERS		 |__|__|

REFUSED		-7 

DON’T KNOW		-8

**FENCEPOST**

**DE9.**	What is {your/his/her} marital status? Would {you/NAME OF PARTICIPANT/NAME OF CAREGIVER} say {you are/s/he is}...

**(DEMARST)**

Married,		1

Widowed,		2

Divorced,		3

Separated, or		4

Never Married?		5

REFUSED		-7	

DON’T KNOW		-8	

FENCEPOST

Programmer note: IF de8b (dehhm) = 1, IN DE10, DE10A AND DE10B, use first displAy (your/NAME OF PARTICIPANT’s/NAME of caregiver’s). if dehhm is greater than 1, use 2nd display, “Your/NAME OF PARTICIPANT’s/NAME of caregiver’s total Combined family” display.

ASK ALL RESPONDENTS THE INCOME QUESTIONS.

**DE10.**	Thinking about the total combined income from all sources for all persons in this household, including income from jobs, Social Security, retirement income, public assistance, and all other sources was {your/ NAME OF PARTICIPANT’s/NAME OF CAREGIVER’S} total household annual income during the year 2016 above or below $20,000?

**(DEINAB)**

At or below $20,000 {$1,666 PER MONTH OR LESS}, or		1	[GO TO DE10A (SEE PROGRAMMER NOTE, ABOVE)] 

Above $20,000 {$1,667 PER MONTH OR MORE}?		2	[GO TO DE10B (SEE PROGRAMMER NOTE ABOVE)]

REFUSED		-7	[GO TO CLOSING]

DON’T KNOW		-8	[GO TO CLOSING]

**DE10A.**	Which category best describes {your/NAME OF PARTICIPANT’s/NAME OF CAREGIVER’s} total household annual income during the year 2016? Would {you/s(he)} say...

**(DEINBEL)**

$5,000 or less [$417 OR LESS PER MONTH],	 ................... 1

$5,001 - $10,000 [$418 - $833 PER MONTH], 	.................... 2

$10,001 - $15,000, [$834 TO $1,250 PER MONTH]  ,..........  3

$15,001 - $20,000, [$1,251 TO $1,666 PER MONTH]? .......... 4

REFUSED................................................................    -7

DON’T KNOW	..............	       	  -8

**GO TO CLOSING**

**DE10B.**Which category best describes {your/NAME OF PARTICIPANT’s/NAME OF CAREGIVER’s} total household annual income during the year 2016? Would {you/NAME OF PARTICIPANT/NAME OF CAREGIVER} say...

**(DEINABOVB)**

$20,001 -$25,000 [$1,667 TO $2,083 PER MONTH]	..................... 	1

$25,001 - $30,000 [$2,084 TO $2,500 PER MONTH]...................  2

$30,001 - $35,000 [$2,501 TO $2,917]....................................... 3

$35,001 - 40,000 [$2,918 TO $3,333]......................................... 4

$40,001 - $50,000, or $3,334 TO $4,167 PER MONTH], or	.........   5

Over $50,000? [$4,168 PER MONTH OR MORE]?	..................	 6

REFUSED	......................................................				-7

DON’T KNOW					-8

**GO TO CLOSING**

Demographic 		Page 101

Demographic		Page 108

Closing		Page 108

# image1.jpeg