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EXHIBIT D: POST INTERVENTION QUESTIONS 

IDENTIFIERS 

1. Code Name #: _______________ 

2. Interviewer: ________________ 

3. Date of Post Interview/Decision to Close: __mm/dd/yyyy_________ 

4. Study Participant? 

1☐ Yes 0☐ No 2☐ Unable to locate 

Hello, I am from AgeOptions, the Suburban Area Agency on Aging. As you may 

remember about eight (8) weeks ago, you agreed to answer some follow-up 

questions regarding food. Is this a good time for us to ask you these questions? 

Many of these questions may sound familiar to you, but we would like to ask 

them again. 

At this time, 

(Food Insecurity Trigger Questions) 

1. Are you worried that your food will run out before you have money to buy more? 

1☐ Yes 0 ☐ No 2☐ Declined to Answer 

2. In the last 2 months, have you run out of food that you bought, and didn't have money 

to get more? 

1☐ Yes 0 ☐ No 2☐ Declined to Answer 

3. I am not always physically able to: 

1. Shop 3 Cook 4 Feed Myself 5

2. 0☐ No difficulty with these ADL/IADLs 

3. 2☐ Declined to Answer 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________________________ 

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4. Do you have enough money to pay for food each month? 

1☐ Yes 0 ☐ No 

5. Thinking about what money you have for food, what applies? 

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I ask family for food 

2 I ask friends for food 

3 I ask strangers for money for food 

4 I go to the food pantry for food 

5 Other, please specify: ______________________________________* 

6. Have you eaten today or last evening in the last 12 hours? 

1☐ Yes 0☐ No 

6a. If No, how many hours is it since you last ate? ____# hours 

6b. If Yes or No? 

Where did you obtain food for you most recent meal? 

1 ☐

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I bought it at a grocery 

2 I bought it at a convenience store 

3 I was given this food at a food pantry 

4 My family provided me with food 

5 A friend provided me with food 

6 I attended a group congregate meal site 

7 I receive home delivered meals 

8 Other, Please Specify_________________________________________* 

6d. If No, how many hours is it since you last ate? ____ hours 

6e. Where did you obtain food for your most recent meal? 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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7. If food obtained in grocery or convenience or food pantry, did someone help you? 

1☐ Yes 0☐ No – I was able to get it myself 

7a. If yes, who helped you? ______________________________ 

8. Regarding the food that you do eat, which of the following statements is most true: 

1.___ I can eat whatever I want, I am not on any special kind of diet 

2.___ My doctor has told me that there are things that I should not eat and I am able to 

keep the diet that my doctor wants me to be on 

3.___ My doctor has told me that there are things that I should not eat, but I am unable 

to be keep the diet that my doctor wants me to be on. 

4.___ I do not know what I should or should not eat 

9. As to shopping for food, which of the following statements is most true: 

1.___ I am able to go to the store or food pantry and obtain my food 

2.___ Sometimes, I can go to the store or food pantry and other times, I must rely on 

others 

to shop for my food 

3.___ I am not able to go to the store or food pantry and obtain my food and must rely 

on others to shop for my food 

10. As to cooking food, which of the following statements is most true: 

1.___ I am able to cook food 

2.___ Sometimes, I am able to cook food and other times, I must rely on others 

to cook my food 

3.___ I am not able to cook food and must rely on others to cook my food 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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11. When we last spoke to help determine what types of food programs you might be 

eligible to participate or receive, we needed to know about your living situation. Has 

there been a change in the last six to eight weeks in your living situation? 

1___Yes 0___No 

Ask only if (YES) there has been a change, 

12. Since there has been a change, please tell me which of the following describes where 

you live. 

1___I live in a home or apartment 

2___I live in an apartment in a senior building 

3___I live in a supportive or assisted living residence 

4___I live with friends 

5___ I stay with friends 

6___ I live with family 

7___ I do not have a permanent place to stay 

8___ I am homeless 

9___ Other, specify: ______________________* 

These next set of questions focus on your feelings about your health. 

(Questions taken from the PROMIS Global Health Tool) 

13. In general, would you say your health is: 

5___Excellent 4___Very Good 3____Good 2___Fair 1 ___Poor 

14. In general, how would you rate your physical health? 

5___Excellent 4___Very Good 3____Good 2___Fair 1 ___Poor 

15. In general, how would you rate your mood and your ability to think? 

5___Excellent 4___Very Good 3____Good 2___Fair 1 ___Poor 

(Question from the UCLA Loneliness Scale (R-UCLA) – Three Item Loneliness Scale) 

16. How often do you feel that you lack companionship? 

1___Hardly ever 2___Some of the Time 3___Often 

17. How often do you feel left out? 

1___Hardly ever 2___Some of the Time 3 ___Often 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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18. How often do you feel isolated from others? 

1___Hardly ever 2 ___Some of the Time 3___Often 

(N-4-A Questions) 

19. On a weekly basis do you participate in social activities or attend organized groups, such 

as choirs, support groups, cultural performances, group meals, exercise classes? 

1___Yes 0___No 2____Declined to answer 

19a. If Yes, what activity (ies) do you participate? _________________________ 

20. Would you say that you often feel that a lack of companionship? 

0___Yes 1___No 2____Declined to answer 

21. Is it difficult or impossible for you to leave your home without assistance? 

0___Yes 1___No 2____Declined to answer 

22. Do you see or talk to friends at least once a week? 

1___Yes 0___No 2____Declined to answer 

(Question from the Diener Satisfaction with Life Scale) 

For these next three (3) statements, think about a scale of one (1) to seven (7), 

with one (1) being that you strongly agree and seven (7) being that you strongly 

disagree with the statement. I will now read each of these statements and tell me 

a number between one (1) to seven (7). 

23. The conditions of my life are excellent 

What number would you give it? ____ 

1_____Strongly Agree 2_____ Somewhat Strongly Agree 3_____Agree 4____Neither Agree or Disagree 

5_____Disagree 6______Somewhat Strongly Disagree 7____ Strongly Disagree 

24. I am satisfied with my life 

What number would you give it? ____ 

1_____Strongly Agree 2_____ Somewhat Strongly Agree 3_____Agree 4____Neither Agree 

or Disagree 

5_____Disagree 6______Somewhat Strongly Disagree 7____ Strongly Disagree 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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25. So far, I have gotten the important things I want in life 

What number would you give it? ____ 

1_____Strongly Agree 2_____ Somewhat Strongly Agree 3_____Agree 4____Neither Agree 

or Disagree 

5_____Disagree 6______Somewhat Strongly Disagree 7____ Strongly Disagree 

26. Approximately eight (8) weeks ago, we asked you how many appointments you had 

scheduled with your primary care physician or doctor, clinic or with a specialist or with a 

physical or occupational therapist or for counseling. At that time, you stated that you 

had #_________ appointments scheduled. (Interviewer: Look to pre-test question #25 

for # of appointments.) 

 How many of those appointments did you attend? #_____ 

27. Of the appointment(s) you were unable to attend, what were the reasons for not 

attending your appointment(s)? 

1___ I was a patient in the hospital 

2___ I was a patient the Emergency Room or urgent care center 

3___ I was unable to obtain a ride to go to my appointment 

4___ I was not feeling well enough to go to go to my appointment 

5___ I needed to take care of someone else, so I could not go 

6___ Other, please specify: __________________________________________* 

28. If you were in a patient in the hospital or an Emergency Room or urgent care center, what 

did the doctor tell you what was wrong with you? Please Specify:____________________ 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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In checking our records, AgeOptions referred or provided you with information. 

Depending upon what services or programs, ask one or more of the following questions. 

(Interviewer: See pre-test question #26 to determine type(s) of referral received. Ask only 

about those referrals.) 

29. Did you visit the food pantry? 

1___Yes 2___No 

29a. If No, why not? 

1___ I no longer need help with obtaining food 

2___ I no longer need help with cooking food 

3___ I was in the hospital 

4___ I was unable to obtain a ride 

5___ I was not feeling well enough to go 

6___ I needed to take care of someone else, so I could not go to the appointment 

7___ Other, please specify: _____________________________________________* 

30. Are you attending a group congregate dining site? 

1___Yes 0___No 

30a. If No, why not? 

1___ I no longer need help with obtaining food 

2___ I no longer need help with cooking food 

3___ I was in the hospital 

4___ I was unable to obtain a ride 

5___ I was not feeling well enough to go 

6___ I needed to take care of someone else, so I could not go to the appointment 

7___ Other: _____________________________________________________* 

31. Did you receive or are you currently receiving home delivered meals? 

1___Yes 0___No 

31a. If No, why not? 

1___ Not found eligible 

2___ No longer need home delivered meals 

3___ Did not like the food 

4___ Other, please specify: _____________________________________________* 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

___________________________________________________________________ 

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32. Have you participated in MatherLifeWays Telephone Topics where you call-in and listen 

to a conversation on the telephone? 

1___Yes 0___No 

32a. If yes, how satisfied were you with the information you received? Would you say 

you were: 

5___Highly Satisfied 4___Satisfied 3___Neither Satisfied or Not 

Satisfied 

2___Not Satisfied 1___Highly Unsatisfied 

32b. If you were less than satisfied, can you tell us why? Please be specific: 

33. Similarly, when we last spoke, to determine if you were eligible for various programs 

from AgeOptions. Have you participated in any programs from AgeOptions? 

1 ___Yes 0___No 

Ask only if a participant responses with a “yes”

33a. Of the following, what programs or services did you receive from AgeOptions? 

1___ Accessing Information and Resources 

2___ Caring Together, Living Better 

3___ Illinois Financial Abuse 

4___ Make Medicare Work 

5___ Senior Medicare Patrol 

6___ Take Charge of your Health 

7___ Other, please specify: ______________________________________* 

34. Have you applied for any government programs besides a program helping you with 

food? 

1___Yes 0___No 

34a. If yes, of the following, what programs or services did you apply? 

1___ LHEAP 

2___ Medicaid 

3___ Medicare 

4___ SNAP, Food Stamps 

5___ Other, please specify: _______________________________________* 

Thank you very much. Please do not hesitate to give us a call here at 

AgeOptions at 800-699-9043 if you have any questions.