**CONTENTS**

**Section NamePage**

**PROGRAMMING CONVENTIONS						  i**

**INTRODUCTION AND PARTICIPANT VERIFICATION				iii**

**INDIVIDUAL SERVICE MODULES:**

**CASE MANAGEMENT							  1**

**CONGREGATE MEALS						  6**

**HOME-DELIVERED MEALS						12**

**HOMEMAKER								20**

**TRANSPORTATION							25**

**FAMILY CAREGIVER							33**

**ADDITIONAL SERVICE LIST MODULE						68**

**USDA MODULE								74**

**FALLS MODULE								75**

**LIFE CHANGES MODULE							77**

**SOCIAL INTEGRATION MODULE						78**

**PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE		79**

**EMERGENCY PREPAREDNESS						96**

**DEMOGRAPHIC INTAKE MODULE						100**

**CLOSING									107**

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 25 minutes to 45 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. Susan Jenkins, (888) 204-0271.

**PROGRAMMING CONVENTIONS**

The SAMP 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 SAMP.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 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 i

SURVEY MODULES

CASE MANAGEMENT Service (VERSION: december 2018)

**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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

**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 SECOND PERSON PRONOUN (E.G., “do you” OR “have you”) IN QUESTIONS. IF PROXY, DISPLAY THIRD PERSON PRONOUN  (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; USDA; FALLS; LIFE CHANGES; SOCIAL INTEGRATION; PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE;**

**DEMOGRAPHIC INTAKE MODULE.**

CASE MANAGEMENT		Page 1

CASE MANAGEMENT		Page 5

CONGREGATE Meals (Version: DECEMBER 2018)

**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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

[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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

**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. 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

**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 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 of a typical day {you/NAME OF PARTICIPANT} eat a meal from the Senior Center or meal site. . Of all {you/NAME OF PARTICIPANT} ate that day, 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

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**

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

**CNR29.**	Within the last 12 months, have you {he/she} noticed any changes in the amount or quality of the food in your lunch program?

**(CMFQYN)**

YES	..	     1      [GO TO CNR29A]

NO		2	   [GO TO CNR20]

REFUSED		-7		[GO TO CNR20]

DON’T KNOW		-8	   [GO TO CNR20]

**CNR29A.**	How has the lunch program changed?

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

[PROBE:  Anything else?]

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

**(CMFQ1-11; CMFQOT)**

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 

THE QUALITY OF THE FOOD IMPROVED			11

OTHER			91

(SPECIFY:_____________________________________)

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

**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.**	Does the meal program help {you/NAME OF PARTICIPANT} to continue to live at 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	

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

**ADDITIONAL SERVICE LIST MODULE; USDA; FALLS; LIFE CHANGES; SOCIAL INTEGRATION;**

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

**DEMOGRAPHIC INTAKE MODULE.**

CONGREGATE MEALS 		Page 6

CONGREGATE MEALS		Page 11

Home-delivered Meals (Version: DECEMBER 2018)

**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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

[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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

**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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

**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 home delivered-meals {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 home-delivered meals?  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

**HNR2a.**	Has knowing that you will receive regular visits by the home delivered meals or Meals-on-Wheels" volunteer/driver made you feel safer at home?

**(NEW.SAFER)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

****

**HNR2b[49b].**	Other than the person who delivers the meals how many times a week do {you have/ NAME OF PARTICIPANT has} personal contact (face-to-face) with a friend, family member, or other visitor**?**

**(NEW.PERSONALCONTACT)**

NONE		1

ONE TIME		 2

TWO TIMES		 3

THREE TIMES		 4

FOUR TIMES		5

FIVE TIMES		6

SIX TIMES		7

EVERYDAY		 8

REFUSED		-7	

DON’T KNOW		-8	

**HNRINTRO2.**Now, I am going to ask about the days {you receive/NAME OF PARTICIPANT receive} 	home-delivered meals.

**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} home-delivered meals? 

**(HMATTENA)**

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

OTHER		91

(Please Specify: 	)

REFUSED		-7

DON’T KNOW		-8

**HNR3a [A15.1]** 	How long ago did {you/ NAME OF PARTICIPANT} first receive a home-delivered meal? PROBE: You may answer in days, weeks, months, or years. Your best estimate is fine.

|___|  (0-999)

DAYS AGO (RANGE 0-45)		1

WEEKS AGO (RANGE 1-30)		2

MONTHS AGO (RANGE 1-13)		3

YEARS AGO (RANGE 1-40)		4

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?

**(HMDAYPST)**

NUMBER OF DAYS	|___|___|

REFUSED		-7

DON’T KNOW		-8

**HARD CHECK:** IF DAYS PER WEEK GT 7; I want to be sure I recorded your answer correctly.

**HNR5.**		Think of a typical day {you eat/NAME OF PARTICIPANT eats} a meal from home-delivered meals. Of all {you ate/s/he ate} that day, what portion of all the foods {you eat/s/he eats} does the 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

**HNR20.**How would {you/NAME OF PARTICIPANT} rate the home-delivered meals 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 home-delivered meals 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 home-delivered meals 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/NAME OF PARTICIPANT} noticed any changes in the amount or quality of the food in your home-delivered meals?

**(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/s/he} home-delivered meals service changed?

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

**[PROBE:  Anything else?]**

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

**(HNRFQ1-11; HNRFQOT)**

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 

THE QUALITY OF THE FOOD HAS IMPROVED		11  

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 home-delivered meals 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 home-delivered meals 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 home-delivered meals improve (your/NAME OF PARTICIPANT’S) health?

**(HMFLBTR)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**HNR28.**	Do the home-delivered meals help (you/NAME OF PARTICIPANT) continue to live at home?

**(HMSTAYHM)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**HNR29.**	As a result of receiving home-delivered meals, {do you/does NAME OF PARTICIPANT} feel better?

**(HMFLBR2)**

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; USDA; FALLS; LIFE CHANGES; SOCIAL INTEGRATION;**

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

**DEMOGRAPHIC INTAKE MODULE.**

HOME DELIVERED-MEALS 		Page 13

HOME DELIVERED MEALS		Page 13

HomeMaker Service (VERSION: DECEMBER 2018)

**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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can. 

[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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

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 SECOND PERSON pronoun (E.G., “do you” OR “have you”) in questions. If proxy, display THIRD person pronoun (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;**

**USDA MODULE;**

**FALLS;**

**LIFE CHANGES;**

**SOCIAL INTEGRATION;**

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

**DEMOGRAPHIC INTAKE MODULE.**

HOMEMAKER 		Page 21

HOMEMAKER		Page 24

Transportation SERVICES (Version: DECEMBER 2018)

**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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

[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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

**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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

**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 second person pronoun (E.G., “do you” OR “have you”) IN QUESTIONS. IF PROXY, DISPLAY third person pronoun (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; USDA; FALLS; LIFE CHANGES; SOCIAL INTEGRATION;**

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

**DEMOGRAPHIC INTAKE MODULE.**

TRANSPORTATION 		Page 26

TRANSPORTATION		Page 32

**FAMILY CAREGIVER SURVEY**(VERSION: MARCH 2019)

**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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

**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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

**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 information provided by participants 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. You may skip any question that you do not want to answer, or stop the interview at any time, but we would really appreciate your answering all the questions you can.

**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.**	[ASK OF ALL] What is {CARE RECIPIENT’s} sex?

**(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**

****

The first few questions are about your caregiving experiences.

**CG3.**	What prompted you to contact [AGENCY NAME]?  

**(CGAGNAME)**

MEDICAL OR HEALTH ISSUE OR HOSPITALIZATION		1

SPOUSE, SON/DAUGHTER, SIBLING, FRIEND 

  NO LONGER ABLE TO HELP		2

PAID CAREGIVER QUIT		3

RECENTLY MOVED TO THE AREA		4

NEED TRANSPORTATION		5

JUST WANTED INFORMATION		6

WAITING LIST		7

INFORMATION AND ASSISTANCE (I&A)		8

DON’T REMEMBER		9

REFUSED		-7

DON’T KNOW		-8

**CG4.**	Please think about all of the health care professionals or service providers who give care or treatment to [CARE RECIPIENT’S NAME]. How easy or difficult is it for {you/him/her} to coordinate care between those providers?   

**(CGCOORD)**

Very easy		1

Somewhat easy		2

Somewhat difficult		3

Very difficult		4

REFUSED		-7

DON’T KNOW		-8

NOT APPLICABLE		-9

**CG5.**	If [CARE RECIPIENT’S NAME] needed a greater amount of care would you be able to increase your caregiving responsibilities? 

**(CGMORE)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

****

**CG6.**	How long have you been receiving caregiver support services? 

**(CGHOWLNG)**

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

**CG7.**	Do you know where to go to ask for respite care, which allows you a brief period of rest or relief while temporary care is provided to [CARE RECIPIENT’S NAME] either in your home or his/her home or someplace else? 

**(KNOWRSPT)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CG8.** 	Have you attended caregiver education or training such as classroom or on-line courses? 

**(ATTNDTRN)**

YES		1		**GO TO CG9**

NO		2		**GO TO CG8a**

REFUSED		-7		**GO TO CG9**

DON’T KNOW		-8		**GO TO CG9**

**FENCEPOST**

**CG8a.**	IF NO, do you have a need for caregiver education or training, such as classroom or on-line courses? 

**(NEEDEDU)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

****

**CG9.**	Have you attended counseling to assist with your specific caregiving situation?  

**(ATTNDCON)**

YES		1		**GO TO CG10**

NO		2		**GO TO CG9a**

REFUSED		-7		**GO TO CG10**

DON’T KNOW		-8		**GO TO CG10**

**CG9a.**	IF NO, do you have a need for counseling to assist with his/her specific caregiving situation? 

**(NEEDCON**)

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CG10.**	Have you attended caregiver support groups? 

**(ATTNDSUP)**

YES		1		**GO TO CG11**

NO		2		**GO TO CG10a**

REFUSED		-7		**GO TO CG11**

DON’T KNOW		-8		**GO TO CG11**

**CG10a.**	IF NO, do you have a need for attending caregiver support groups? 

**(NEEDSUP)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CG11.**	In the last year, have you found financial help for {CARE RECIPIENT} including helping him/her apply for Medicaid? 

**(HELPFIN)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CG12.**	Have the Family Caregiver services provided S**upplemental Services** such as: 

**(CGSUPA – CGSUPD , SUPPSVE, CGUSPF-CGSUPG)**

**FENCEPOST**

**CG13.**As a result of the caregiver services {you have/NAME OF CAREGIVER has} received, {do you/does s/he}...

**(CGAFECA-CGAFECE)**

**CG14.**	Have these caregiver services helped you to be a better caregiver? 

**(CGHELP)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**FENCEPOST**

**CG15.**	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

**CG16.**	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**

**CG17.**	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 you a few questions about {your/NAME OF CAREGIVER’s} employment.

**CG18.**	Are you currently employed?

**(CAREMP)**

YES		1		**GO TO CG18a**

NO		2		**GO TO CG19**

REFUSED		-7		**GO TO CG19**

DON’T KNOW		-8		**GO TO CG19**

**CG18a**.	Has providing care for {CARE RECIPIENT} interfered with {your/NAME OF CAREGIVER’s} job?

(CGINTER)

YES		1	

NO		2		[GO TO CGINTRO5]

REFUSED		-7		[GO TO CGINTRO5]

DON’T KNOW		-8		[GO TO CGINTRO5]

**CG19.**	Because of providing care for [NAME OF CARE RECIPIENT] care for, did you...  

**(CRPROBA-CRPROBI)**

****

**CG19a.**	(IF YES, TO ANY OF THE ABOVE)  Did the caregiver support services helped you deal with these work difficulties? 

(**CAREHLP)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**IF NO TO ALL CG19 a to g GO TO CG21.**

**CG20.**	As a result of caregiving-related changes in your employment or expenses, have you had to... 

**(CGFINCLA-CGFINCLJ)**

****

**CGINTRO5.**  The following questions are about {your/his/her} situation as a caregiver.

**CG21.**	I gain “no,” “some,” or “a lot” of satisfaction from performing my care tasks.  Please select the response that that best fits your situation.  Would you say**...**

**(CGSATISA-CGSATISC)**

**CG22.**	In the last year have you paid for [CARE RECIPIENT’S NAME]... 

**(CGPAIDA-CGPAIDF)**

Now, I am going to ask you about how you feel these days.  

**CG23.**	How much of the time during the past four weeks have you... 

**(CGFEELA-CGFEELC)**

Now, I am going to ask you about how caregiving fits in with your other activities. Please select the situation that best fits your answer.

**CG24.**	Regarding your present social activities, do you feel that you are doing... 

**(CGACT)**

About enough		1

Too much		2

Would like to be doing more		3

REFUSED		-7

DON’T KNOW		-8

**CG25.**	Have your social opportunities increased since you became involved with [PROVIDER AGENCY NAME] services?  

**(CGOPPINC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CG26.**	How often does caregiving prevent you from having enough time for yourself?  

**(CGTIME)**

Always		1

Usually		2

Sometimes		3

Rarely		4

Never		5

REFUSED		-7

DON’T KNOW		-8

**CG27.**	How often does caregiving prevent you from having enough time for your family?  

**(CGFAMILY)**

Always		1

Usually		2

Sometimes		3

Rarely		4

Never		5

REFUSED		-7

DON’T KNOW		-8

****

**CG28.**	How often does caregiving conflict with your social life? 

**(CGSOCIAL)**

Always		1

Usually		2

Sometimes		3

Rarely		4

Never		5

REFUSED		-7

DON’T KNOW		-8

**CG29.**	How often does being a caregiver for the person you care for give you the joy of spending time with someone you care about? 

**(CGJOY)**

Always		1

Usually		2

Sometimes		3

Rarely		4

Never		5

REFUSED		-7

DON’T KNOW		-8

**CG30.**	How often does being a caregiver provide you with a sense of accomplishment? 

**(CGACOMP)**

Always		1

Usually		2

Sometimes		3

Rarely		4

Never		5

REFUSED		-7

DON’T KNOW		-8

**CG31.**	How often does providing care for the person you care for give you the satisfaction of knowing that they are receiving the care and attention they need? 

**(CGATTION)**

Always		1

Usually		2

Sometimes		3

Rarely		4

Never		5

REFUSED		-7

DON’T KNOW		-8

****

**CG32.**	How often do you feel that the person you care for appreciates the care that you are providing to [CARE RECIPIENT’S NAME]? 

**(CRAPREC)**

Always		1

Usually		2

Sometimes		3

Rarely		4

Never		5

REFUSED		-7

DON’T KNOW		-8

**CG33.**	As a caregiver, how often do you feel you are fulfilling your duty by caring for the [CARE RECIPIENTS NAME]?  

**(CGDUTY)**

Always		1

Usually		2

Sometimes		3

Rarely		4

Never		5

REFUSED		-7

DON’T KNOW		-8

For the next set of questions, I will ask you how true the statement is for you.

**CG34.**	You can always manage to solve difficult problems if you try hard enough. Would you say... 

**(CGSOLV)**

Not at all true		1

Hardly true		2

Moderately true		3

Exactly true		4

REFUSED		-7

DON’T KNOW		-8

**CG35.**	It is easy for you to stick to your aims and accomplish your goals. Would you... 

**(CGAIMS)**

Not at all true		1

Hardly true		2

Moderately true		3

Exactly true		4

REFUSED		-7

DON’T KNOW		-8

****

**CG36.**		You are confident that you could deal efficiently with unexpected events. Would you say... 

**(CGEFF)**

Not at all true		1

Hardly true		2

Moderately true		3

Exactly true		4

REFUSED		-7

DON’T KNOW		-8

**CG37.**	Thanks to your resourcefulness, you know how to handle unforeseen situations. Would you say... 

**(CGRESORC)**

Not at all true		1

Hardly true		2

Moderately true		3

Exactly true		4

REFUSED		-7

DON’T KNOW		-8

**CG38.**	You can solve most problems if you invest the necessary effort. Would you say...

**(CGSOLVE)**

Not at all true		1

Hardly true		2

Moderately true		3

Exactly true		4

REFUSED		-7

DON’T KNOW		-8

**CG39.**	You can remain calm when facing difficulties because you can rely on your coping abilities. Would you say...

**(CGRELY)**

Not at all true		1

Hardly true		2

Moderately true		3

Exactly true		4

REFUSED		-7

DON’T KNOW		-8

****

**CG40.**	When you are confronted with a problem you can usually find several solutions. Would you say... 

**(CGCONFRNT)**

Not at all true		1

Hardly true		2

Moderately true		3

Exactly true		4

REFUSED		-7

DON’T KNOW		-8

**CG41.**	If someone opposes you, you can find the means and ways to get what you want.  Would you say...

**(CGWANT)**

Not at all true		1

Hardly true		2

Moderately true		3

Exactly true		4

REFUSED		-7

DON’T KNOW		-8

**CG42.**	If you are in trouble, you can usually think of a solution. Would you say...

**(CGTRBL)**

Not at all true		1

Hardly true		2

Moderately true		3

Exactly true		4

REFUSED		-7

DON’T KNOW		-8

**CG43.**	You can usually handle whatever comes your way. Would you say...

**(CGHANDL)**

Not at all true		1

Hardly true		2

Moderately true		3

Exactly true		4

REFUSED		-7

DON’T KNOW		-8

****

**CGINTRO6.** The next set of questions are about {your/NAME OF CAREGIVER’s} health.

**CG44.**	Compared to one year ago, how would {you/ NAME OF CAREGIVER} rate your health in general now? Would {you/s/he} say:

**(CGHEALTH)**

Much better,		1

Somewhat better,		2

About the same,		3

Somewhat worse		4

Much worse		5

REFUSED		-7

DON’T KNOW		-8

**CG45.**	In the past month, have you been bothered by pain? 

**(CGPAIN)**

YES		1		**GO TO CG45a**

NO		2		**GO TO CG46**

REFUSED		-7		**GO TO CG46**

DON’T KNOW		-8		**GO TO CG46**

**CG45a**.	IF YES, in the last month how often has pain limited your activities? 

                     (**CGLIMIT)**

Every day		1

Most days		2

Some days		3

Rarely		4

Never		5

REFUSED		-7

DON’T KNOW		-8

**CG46.**	In the past 12 months, have you been to see a doctor?  Do not include going to the hospital emergency department. 

**(CGDOCTOR)**

**INTERVIEWER NOTE:**

**DOCTOR INCLUDES PHYSICIANS ASSISTANT OR NURSE PRACTITIONER**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

****

**CG47.**	In the past 12 months, have you been to an urgent care center? Do not include going to the hospital or to the hospital emergency department. 

**(CGURGNT)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CG48.**	In the past 12, months, have you been to a hospital emergency department? 

**(CGER)**

YES		1		**GO TO CG48a**

NO		2		**GO TO CG49**

REFUSED		-7		**GO TO CG49**

DON’T KNOW		-8		**GO TO CG49**

**CG48a.**	In the past 12 months, how many times did you go to a hospital emergency department?  

**(CGERNUMB)**

|___|___|___| TIMES

REFUSED		-7

DON’T KNOW		-8

**CG49.**	In the past 12 months did you have to stay overnight in a hospital? 

**(CGHOSP)**

YES		1		**GO TO CG49a**

NO		2		**GO TO CG50**

REFUSED		-7		**GO TO CG50**

DON’T KNOW		-8		**GO TO CG50**

**CG49a.**	If YES, in the past 12 months, how many times were you hospitalized for one night or longer?  

**(CGHOSPN)**

|___|___|___| TIMES

REFUSED		-7

DON’T KNOW		-8

****

**CG49b.**	If YES, how many total nights did you spend in the hospital? 

**(CGHOSPNN)**

|___|___|___| NIGHTS

REFUSED		-7

DON’T KNOW		-8

**CG50.**	In the past 12 months, did you have to stay overnight in a nursing home or rehabilitation center? 

**(CGREHAB)**

YES		1		**GO TO CG50a**

NO		2		**GO TO CG51**

REFUSED		-7		**GO TO CG51**

DON’T KNOW		-8		**GO TO CG51**

**CG50a.**	IF YES, in the past 12 months, how many times have you stayed in a nursing home or live in a rehabilitation center?   

**(CGREHABN)**

|___|___|___| TIMES

REFUSED		-7

DON’T KNOW		-8

**CG51.**	Thinking about all the family members or friends who provide help, care, or supervision for [NAME OF CARE RECIPIENT], what proportion of the care do you provide during a typical week? Would you say... 

**(CGPORT)**

Less than one-quarter		1

About one-quarter		2

About one-half		3

About three-quarters		4

All or almost all of the care		5

REFUSED		-7

DON’T KNOW		-8

The next questions ask about any thoughts you have had about alternative types of care.

**CG52.**	In the past six months, have you ever considered a nursing home, boarding home, or assisted living for [NAME OF CARE RECIPIENT]?

**(CGNH)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CG53.**	In the past six months, have you felt that [NAME OF CARE RECIPIENT] would be better off in a nursing home, boarding home, or assisted living facility? 

**(CGNHBTR)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CG54.**	In the past six months, have you discussed the possibility of a nursing home, boarding home, or assisted living with family members or others excluding [NAME OF CARE RECIPIENT]? 

**(NHCRDIS)**

YES		1		**GO TO CG54a**

NO		2		**GO TO CG55**

REFUSED		-7		**GO TO CG55**

DON’T KNOW		-8		**GO TO CG55**

**CG54a.**If YES, in the past six months have you discussed that possibility with the [NAME OF CARE RECIPIENT]? 

**(NHDISCR)**

YES		1		**GO TO CG54b**

NO		2		**GO TO CG55**

REFUSED		-7		**GO TO CG55**

DON’T KNOW		-8		**GO TO CG55**

**CG54b.**	If YES, in the past six months, have you taken any steps toward placement? 

**(CGNHSTPS)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

****

**CG55.**	Are you responsible for providing help or supervision to [NAME OF CARE RECIPIENT] on a 24-hour basis? 

**(CGBASIS)**

YES		1		**GO TO CG55a**

NO		2		**GO TO CG56**

REFUSED		-7		**GO TO CG56**

DON’T KNOW		-8		**GO TO CG56**

**CG55a.**	If YES, since you say you provide 24-hour care, let me ask you a question about the intensity of care provided.  On a scale from 1 to 5 where 1 is not very intense and 5 is very intense, how intense is the care you provide? 

**(CGINSTY)**

	Not Very Intense							Very Intense

				1			2		3		4		5

**CG56.**	Would you recommend the caregiving support services to a friend?  

**(CGREMND)**

YES		1	

NO		2

REFUSED		-7

DON’T KNOW		-8

**CG57.**	Do you have any recommendations to improve the caregiver support service?  

**(CGRECMND)**

YES		1		**GO TO CG57a**

NO		2		**GO TO CG58**

REFUSED		-7		**GO TO CG58**

DON’T KNOW		-8		**GO TO CG58**

**CG57a.**	IF YES, what recommendations do you have for improving the service? 

**(IMPRVSVC)**

****

**CG58.**	Overall, do you feel like you have enough support? 

**(CGSUPP)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**PROGRAMMER NOTE:**

**GO TO ADDITIONAL SERVICE LIST MODULE.**

**CG59.**In your judgment, if the services that you 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 CG59a**

REFUSED		-7		**GO TO CG59a**

DON’T KNOW		-8	 	**GO TO CG59a**

**CG59a.**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.

**CG60.**	In general, would you 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

**CG60a.**Has a doctor ever told you 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)... 

**CG61**	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.

            (**CGOHQ1)**

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. 

**CG62**	During the past 12 months, was there a time when the care recipient needed dental care but could not get it at that time? 

****

         (**CGOHQ2)**

YES		1 

NO		 2		[skip to CG64?]

REFUSED		-7

DON’T KNOW		-8

**CG63**	What were the reasons that the care recipient could not get the dental care he/she needed? 

           (**CGOHQ301** - **CGOHQ312)**

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

CG64	Overall, how would you rate the health of the care recipient’s teeth and gums?

            (**CGOHQ4)**

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. 

**CG65.**Does {CARE RECIPIENT} have difficulty getting around inside the home?

**(PFDFINC)**

YES		1 

NO		2		[GO TO CG67]  

REFUSED		-7		[GO TO CG67]  

DON’T KNOW		-8		[GO TO CG67]  

****

**CG66.**{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**

**CG67.**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 CG68] 

REFUSED		-7		[GO TO CG68] 

DON’T KNOW		-8	[GO TO CG68

**CG67a.**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**

**CG68.**Does {CARE RECIPIENT} have difficulty getting in or out of bed or a chair?

**(PFBEDC)**

YES		1 

NO		2	[GO TO CG69]

REFUSED		-7		[GO TO CG69]

DON’T KNOW		-8	[GO TO CG69]

**CG68a.**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**

**CG69.**Does {s/he} have difficulty when taking a bath or shower?

**(PFBATHC)**

YES		1 

NO		2	[GO TO CG70]  

REFUSED		-7		[GO TO CG70]  

DON’T KNOW		-8	[GO TO CG70]  

**CG69a.**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**

**CG70.**Does {CARE RECIPIENT} have difficulty when dressing?

**(PFDRESC)**

YES		1 

NO		2	[GO TO CG71]

REFUSED		-7		[GO TO CG71]

DON’T KNOW		-8	[GO TO CG71]

**PF5BCG70a.**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**

**PF6CG71.**Does {s/he} have difficulty when walking?

**(PFWALKC)**

YES		1 

NO		2		[GO TO CG72]

REFUSED		-7		[GO TO CG72]

DON’T KNOW		-8		[GO TO CG72]

****

**PF6BCG71a.**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**

**CG72.**Does {CARE RECIPIENT} have difficulty eating?

**(PFEATC)**

YES		1 

NO		2		[GO TO CG73]

REFUSED		-7		[GO TO CG73]

DON’T KNOW		-8		[GO TO CG73]

**CG72a.** 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**

**CG73.**Does {s/he} have difficulty using the toilet or getting to the toilet?

**(PFWCC)**

YES		1 

NO		2	[GO TO CG74]

REFUSED		-7	[GO TO CG74]

DON’T KNOW		-8	[GO TO CG74]

**CG73a.**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**

****

**CG74.**Does {CARE RECIPIENT} have difficulty keeping track of money or bills?

**(PFDLRC)**

YES		1

NO		2	[GO TO CG75]

REFUSED		-7		[GO TO CG75]

DON’T KNOW		-8	[GO TO CG75]

**CG74a.**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**

**CG75.** 	Does {s/he} have difficulty preparing meals?

**(PFMEALC)**

YES		1 	

NO		2		[GO TO CG76]

REFUSED		-7		[GO TO CG76]

DON’T KNOW		-8		[GO TO CG76]

**CG75a.**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**

**CG76.**Does {CARE RECIPIENT} have difficulty doing light housework, such as washing dishes or sweeping a floor?

**(PFCLENC)**

YES		1 	

NO		2 	[GO TO CG77]

REFUSED		-7		[GO TO CG77]

DON’T KNOW		-8 	[GO TO CG77]

****

**CG76a.**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**

**CG77.**Does {s/he} have difficulty doing heavy housework, such as scrubbing floors or washing windows?

**(PFHCLNC)**

YES		1 	

NO		2 		[GO TO CG78]

REFUSED		-7		[GO TO CG78]

DON’T KNOW		-8		[GO TO CG78]

**CG77a.**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**

**CG78.**	Does {s/he} have difficulty taking the right amount of prescribed medicine at the right time?

**(PFTKDGC)**

YES		1 	

NO		2		[GO TO CG79]

REFUSED		-7		[GO TO CG79]

DON’T KNOW		-8		[GO TO CG79]

**CG78a.**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**

**CG79.**Does {CARE RECIPIENT} have difficulty using the telephone?

**(PFFONEC)**

YES		1 	

NO		2 	[GO TO CG80]

REFUSED		-7		[GO TO CG80] 

DON’T KNOW		-8 	[GO TO CG80]

**CG79a.**Does {s/he} need the help of another person to perform this activity?

**(PFFONEBC)**

YES		1

NO		2

REFUSED		-7

DON’T KNOW		-8

**CG80**.	Is there a car or personal motor vehicle in working condition in {CARE RECIPIENT’s}   household?

**(CGISCAR)**

YES		1

NO		2 		[GO TO CG81]

REFUSED		-7		[GO TO CG81]

DON’T KNOW		-8		[GO TO CG81]

**CG80a.**	Does {s/he} have difficulty driving a car or other personal motor vehicle?

**(PFDRIVEC)**

YES		1 	

NO		2	

REFUSED		-7	

DON’T KNOW		-8 	

**CG81.**Is there a public bus or transit stop within three-quarters of a mile from {his/her} home?

**(PFBUSC)**

YES		1 	

NO		2		[GO TO CGINTRO10]

REFUSED		-7		[GO TO CGINTRO10]

DON’T KNOW		-8		[GO TO CGINTRO10]

**CG81a.**	Does {s/he} have difficulty using this transportation?

**(PFUSBSC)**

YES		1 	

NO		2		[GO TO CGINTRO10

REFUSED		-7		[GO TO CGINTRO10]

DON’T KNOW		-8		[GO TO CGINTRO10

**CCG81b.** 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.

**CG82.**	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**

**CG83.**	What is {CARE RECIPIENT’s} sex?

**(CGPMF)**

MALE		1 	

FEMALE		2 	

REFUSED		-7 	

DON’T KNOW		-8 	

**CG84.**	How many persons total {are you/is NAME OF CAREGIVER} caring for not counting {CARE RECIPIENT}?

**(CGMANY)**

NUMBER 		|___|___| 

REFUSED		-7 

DON’T KNOW		-8 

**CG85.**	Who are those people?  

**INTERVIEWER NOTE: CODE ALL THAT APPLY.  PROBE: Anyone else?**

**(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**

ADDITIONAL SERVICE LIST 		Page 70

FAMILY CAREGIVER		Page 33

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.**

LIFE CHANGES 		Page 82

ADDITIONAL SERVICE LIST		Page 73

USDA Module

**HH3.**	I’m going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for you in the last 12 months—that is, since last (name of current month).

The first statement is, “The food that I bought just didn’t last, and I didn’t have money to get more.”  Was that often, sometimes, or never true for you in the last 12 months? 

**(USDAHH3)**

Often true		1

Sometimes true		2

Never true		3

REFUSED		-7	

DON’T KNOW		-8	

**HH4.**	“I couldn’t afford to eat balanced meals.”  Was that often, sometimes, or never true for you in the last 12 months?

**(USDAHH4)**

Often true		1

Sometimes true		2

Never true		3

REFUSED		-7	

DON’T KNOW		-8	

**AD1.**	In the last 12 months, since last (name of current month), did you ever cut the size of your meals or skip meals because there wasn't enough money for food? 

**(USDAAD1)**

YES		 1

NO		 2	

REFUSED		-7	

DON’T KNOW		-8	

USDA 		Page 76

USDA		Page 74

Falls

The next few questions are about falling down.  By falling down, we mean any fall, slip, or trip in which you lose your balance and land on the floor or ground or at a lower level.

**HC14.**	In the last month, have you fallen down?  

**(NHATSHC14)**

YES		 1	

NO		 2

REFUSED		-7

DON’T KNOW		-8

**HC15.**	In the last month, did you worry about falling down? 

**(NHATSHC15)**

YES		 1

NO		 2	GO TO HC17.

REFUSED		-7	GO TO HC17.

DON’T KNOW		-8	GO TO HC17.

**HC16.**	In the last month, did this worry ever limit your activities? 

**(NHATSHC16)**

YES		 1

NO		 2

REFUSED		-7	

DON’T KNOW		-8	

**PROGRAMMER NOTE:  IF HC14=YES; GO TO HC18.**

**HC17.**	In the last 12 months, since {MONTH, YEAR}, have you fallen down?  

IF NEEDED: By falling down we mean any fall, slip, or trip in which you lose your balance and land on the floor or ground or at a lower level.

**(NHATSHC17)**

YES		1

NO		2 		**GO TO LIFECHNG1**

REFUSED		-7		**GO TO LIFECHNG1**

DON’T KNOW		-8		**GO TO LIFECHNG1**

****

**HC18.**	In the last 12 months/Since {LAST INT MONTH AND YEAR}, have you fallen down more than one time? 

**(NHATSHC18)**

YES		1

NO		2 

REFUSED		-7	

DON’T KNOW		-8	

FALLS 		Page 77

FALLS		Page 76

**LIFE CHANGES**

We are interested in why you initially sought services from [NAME OF AGENCY]

**LIFECHNG1.**	What was going on in your life that led you to seek services?

**(LIFECHANGE)**

ILLNESS		1		

ILLNESS OF A PERSON CLOSE TO YOU		2 		

DEATH OF A SPOUSE		3		

PROBLEMS WITH MOBILITY		4		

COULD NO LONGER TAKE CARE OF MYSELF		5		

COULD NO LONGER TAKE CARE OF MY HOME 		6		

OTHER		91

(SPECIFY:	)

REFUSED		-7

DON’T KNOW		-8	

LIFE CHANGES 		Page 79

LIFE CHANGES		Page 77

Social integration

The next few questions are about your contact with other people.

**UCLA1.**	First, how often do you feel that you lack companionship? Hardly ever, some of the time, or often?

**(SIUCLA1)**

Hardly ever		 1

Some of the time		 2

Often		3

REFUSED		-7	

DON’T KNOW		-8	

**UCLA2.**	How often do you feel left out: Hardly ever, some of the time, or often?

**(SIUCLA2)**

Hardly ever		 1

Some of the time		 2

Often		3

REFUSED		-7	

DON’T KNOW		-8	

**UCLA3.**	How often do you feel isolated from others? Hardly ever, some of the time, or often?

**(SIUCLA3)**

Hardly ever		 1

Some of the time		 2

Often		3

REFUSED		-7	

DON’T KNOW		-8	

**HRS1.**	How often do you feel alone?  Is it hardly ever, some of the time, or often?

**(SIHRS1)**

Hardly ever		 1

Some of the time		 2

Often		3

REFUSED		-7	

DON’T KNOW		-8	

SOCIAL INTEGRATION 		Page 80

SOCIAL INTEGRATION		Page 78

**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 MODULE 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/PARTICIPANT’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.  

**SF2a.**How about  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.**How about 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} have:

**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.

                     (**OHQ030)**

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? 

          (**OHQ770)**

YES		1 

NO		 2 	GO TO OHQ.845

REFUSED		-7	GO TO OHQ.845	 

DON'T KNOW		-8	GO TO OHQ.845	 	

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

            (**OHQ78001 - OHQ78012**)

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?

                   (**OHQ845)**

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]

****

**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 PF17A.]

NEVER USES BUS....................................        3	[GO TO PF17A]

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		**GO TO DEINTRO**

DID NOT RECEIVE HELP FROM FAMILY/FRIENDS		3		**GO TO DEINTRO**

**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 EMERGENCY PREPAREDNESS MODULE**

DEMOGRAPHIC INTAKE MODULE 		Page 100

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING	Page 95

**EMERGENCY PREPAREDNESS ROTATING MODULE**

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

**EPINTRO1.**  These questions are about how prepared you {s/he} are {is} for a disaster that might happen in your community, such as an earthquake, fire, flood, tornado, hurricane or other natural or man-made disasters. The questions refer to both you and other members of your household.

# EP1.	Have you ever experienced any of the following situations? 

**EP2.**Has anyone either in your household or someone close to you prepared a specific disaster plan written or otherwise on what to do in case of a disaster, such as a fire, flood, tornado, hurricane, or earthquake? 

**(EP2)**

YES		1 

NO		2	

REFUSED		-7	

DON’T KNOW		-8	

**EP3.**Do you {Does s/he} have a list of family, friends, and others who can help you {him/her} in case of a disaster? 

**(EP3)**

YES		1 

NO		2	

REFUSED		-7	

DON’T KNOW		-8	

****

**EP4.**If there were no power or working telephones, would you {s/he} have a way to receive communications about disasters in your residence, such as with a battery-operated radio? 

**(EP4)**

YES		1 

NO		2	

REFUSED		-7	

DON’T KNOW		-8	

# EP5.	Do you {s/he} currently have you any of the following ready in the event of a disaster or emergency? 

**EP6a.**If public authorities announced a mandatory evacuation from your {his/her} community due to a large-scale disaster or emergency, would you {s/he} evacuate? 

**(EP6a)**

YES		1 

NO		2	

REFUSED		-7	

DON’T KNOW		-8	

# EP6b.	What would be the reason you {s/he} might not evacuate if asked to do so? 

OTHER 		91

(SPECIFY:_____________________________________)

# 

# EP6c.	From the reasons for not evacuating that you just mentioned, what are the top three reason(s) you {s/he} might not evacuate if asked to do so? 

**[INTERVIEWER, CODE ALL THAT APPLY WHILE RANKING PRIORITY1, PRIORITY2, PRIORITY3]**

**(EP6c1-EP6c9; EP6c91)**

LACK OF TRANSPORTATION 		1

HEALTH PROBLEMS (COULD NOT BE MOVED) 		 2 

CONCERN ABOUT LEAVING PETS 		3 

CONCERN ABOUT LEAVING PROPERTY BEHIND		4

CONCERN ABOUT PERSONAL OR FAMILY SAFETY 		 5

LACK OF TRUST IN PUBLIC OFFICIALS		 6 

CONCERN ABOUT TRAFFIC JAMS AND INABILITY TO 

GET OUT		7 

CONCERN ABOUT PHYSICAL ACCESSIBILITY OF 

SHELTERS		8

CONCERN ABOUT LOSS OF INDEPENDENCE		 9

OTHER 		91

(SPECIFY:_____________________________________)

****

**EP7.**In the past few years, have you {s/he} or other members of your {his/her} household talked to a service provider, doctor, or health care worker, or read any materials about how to prepare for disasters? 

**(EP7)**

YES		1 

NO		2	

REFUSED		-7	

DON’T KNOW		-8	

**EP8.**Do you****{Does s/he} or does anyone in your [the/this] {his/her} household have any medical devices in your [the] {his/her} home that are important to health that require electrical power to operate? 

**(EP8)**

YES		    1 [GO TO EP8a]

NO		2	

REFUSED		-7	

DON’T KNOW		-8	

**EP8a.	[ONLY ASK IF THE RESPONSE TO EP8 IS “YES”]**Do you****{Does s/he} or does anyone in your [the/this] {his/her} household have an alternative power source for those devices? [IF NEEDED: EXAMPLES OF ALTERNATIVE POWER SOURCES INCLUDE GAS GENERATORS, SOLAR GENERATORS, SOLAR CHARGERS, CAR CHARGER ADAPTER.]

**(EP8A)**

YES		    1 

NO		2	

REFUSED		-7	

DON’T KNOW		-8	

**GO TO DEMOGRAPHIC INTAKE MODULE**

EMERGENCY PREPAREDNESS		Page 99

**DEMOGRAPHIC INTAKE MODULE**(VERSION: DECEMBER 2018)

**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 information provided by participants 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 private and you don't have to answer any question you don't want to.

**DE1.**	[ASK OF ALL]: What is {your/NAME OF PARTICIPANT’s/NAME OF CAREGIVER’s} sex?

**(DEGENDR)**

MALE		1

FEMALE		2

REFUSED		-7	

DON’T KNOW		-8	

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

**(DETHINK)**

Lesbian or gay*		1	

Straight, that is, not lesbian or gay**		2	

Bisexual		3	

Something else		4	

REFUSED		-7	

DON’T KNOW		-8	

*For men, the category reads “gay” 

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

**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 PARTICIPANT’s} race? Would (you/s/he) say...  (CODE ALL THAT APPLY. CTRL/P TO EXIT)

**(DERAC01-06 DERACOS)**

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 DE8a.]

NO		2	[GO TO DE8b.]

REFUSED		-7	[GO TO DE8a ]

DON’T KNOW		-8	[GO TO DE8a]

**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

Living with a partner,		2

Widowed,		3

Divorced,		4

Separated, or		5

Never Married?		6

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 2020 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 2020? Would {you/s(he)} say...

**(INCOMEC)**

$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 2019? Would {you/NAME OF PARTICIPANT/NAME OF CAREGIVER} say...

**(DEINABOV)**

$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 106

cLOSING (Version: december 2018)

**CLOSE1.**That concludes our interview. Thank you very much for your help with this important national survey. We appreciate your time.

CLOSING		Page 103

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