**Form Approved**

OMB No.: XXXX-XXXX

Expiration Date: XX/XX/2017

**Form Approved**

OMB No.: XXXX-XXXX

Expiration Date: XX/XX/2017

Evaluation of the ACL Title VI Programs

Title VI Tribal Elder Interview Guide

**Introduction and Informed Consent Statement**

Hi. My name is __________. 

As you may remember, I work for ICF and we are helping the Administration on Aging find out how well the elders’ programs in our country are serving their communities. ICF will be talking to program leaders, elders, and caregivers to learn how the services in their communities help to make their lives better. We will also be looking for ideas to share with programs all over the country.

You have been asked to participate because your tribal elders program told us you are an elder who received some services from them. This discussion should take no more than 60 minutes of your time. We will do our best to stay on track.  

There are no right or wrong answers. You are the expert on your experiences, and your opinions and thoughts are really important to us. You can choose not to answer any question for any reason. Your answers will not give you any benefits or change any benefits that you currently may be receiving. Your input will be used to help improve programs in tribal communities.

This interview is strictly confidential; meaning information that identifies you will not be shared with anyone but study staff. To help with our notes, we also will audio tape the interview. We will keep the notes and tape records in locked files and only study staff will be allowed to see them. The information that we report will be grouped together with the results from all tribes and will not contain any information about you or your community.

Participation in the interview is completely voluntary. You can refuse to participate with no penalty or negative results. You do not have to answer questions that you do not want to answer. You may choose to end the interview at any time, for any reason.  

Do you have any questions before we get started? 

Do you agree to participate in this interview?

· Yes  *Thank-you. I am confirming you are willing to answer questions during this interview and will note your verbal consent. We also would like to record the discussion to make sure we don’t miss anything.*

· No  *Thank participant for their time.*

Do I have your permission to turn on the audio recorder?

· Yes  Thank-you. *Turn on recorder.*****

· No  *Thank-you. I will refrain from recording the interview.*

**First, I want to ask you a couple of questions to get a better understanding of the services you receive from your Title VI Program.**

1. How long have you been receiving Title VI services?

2. Can you tell me a little bit about the services you get through the program? (*Probe for: meals, transportation, supportive services such as home care and legal assistance, nutrition education, exercise services, chore services*)

3. What do you like best about the services you receive through the program? (*e.g., don’t have to cook; don’t have to worry about having enough money for food; feel more independent; someone to talk to/ask for help; helps me to feel safe in my home, a place to practice my culture*)

4. Which service is the most helpful to you?

a. Does that service make it easier for you to live in your home?

5. What else do you wish the program had?

6. If you could change something about the program, what would that be?

**Now we’re going to shift the conversation to talk more about the impact the program has for you.**

7. Can you talk a little bit about the different ways the program helps you?

a. How has the program helped you stay connected to traditional American Indian, Alaska Native, Native Hawaiian (AI/AN/NH) ways of life (e.g., foods, spirituality, language, music)?

b. Are there other ways that the program helps you feel connected to your community?

c. How does the program help you get around your house or community? 

d. How does the program help with your day-to-day activities? 

e. How does the program help you to stay in the community?

f. How does the program help you to be healthier?

g. How does the program help contribute to your quality of life?

8. What is the best/most important thing the program has done for you?

a. If you were telling someone else about the program, what would be the first thing you would tell them about?

b. Do you think the program makes a difference in people’s lives? Can you share an example?

9. What would happen if you didn’t have this program? Probe for:

a. Meals—have fewer meals/cold meals

b. Nutrition—eat less healthy meals

c. Chances to socialize/visit with others—feel isolated/lonely

d. Getting out of the house—feel isolated/lonely

e. Transportation to places I couldn’t otherwise get to

f. Chore services

g. Mental/Emotional—more depressed/anxious/worried

**That wraps up my list of questions for you at this time. Do you have any questions for me? [ADDRESS ANY QUESTIONS]**

· **If no questions “Thank you again for taking the time to speak with me. We sincerely appreciate and value your input!”**

· **If you think of anything else after we get off the phone, please call me or email me.**

*Public Burden Statement: 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 project is xxxx-xxxx. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, per year, including the time to review instructions. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to [title], [address, city, state, zip].*

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