For the remainder of the survey I would like you to answer as though you were {Name of Participant}. All of the following questions pertain to {him/her}. Please provide your best estimate as to {his/her} own response or opinion. This survey will take about 30 minutes to complete. Your participation is voluntary and very important to the success of this study. Responses to this data collection will be used only for purposes of this research. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific individual. We will not provide information that identifies individuals to anyone outside the study team, except as required by law. {His/Her} eligibility for services will not be affected by your decision to participate or by any answers you give. IF NEEDED: We were given your name as the proxy for {NAME OF PARTICIPANT}. [IF NEEDED: Home Delivered Meals also called Meals- on-Wheels are meals that are usually delivered to eat at home.] PROGRAMMER NOTE: If proxy will not do interview, continue with NRALTCON. Otherwise go to NRSERVERF. 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 HNRINTRO1 REFUSED -7 DON’T KNOW -8 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 GO TO NRINTRO1 NO 2 GO TO OTHER SERVICES MODULE REFUSED -7 Thank you for your time DON’T KNOW -8 you for your time PROGRAMMER NOTE: IF PARTICIPANT OR INTERPRETER/TRANSLATOR, DISPLAY FIRST PERSON TENSE (E.G., “do you” OR “have you”) IN QUESTIONS. IF PROXY, DISPLAY SECOND PERSON TENSE (E.G., “does s/he” OR “has s/he”) WHERE INDICATED.
DON’T KNOW -8 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 REFUSED -7 GO TO TR16 DON’T KNOW -8 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 TR16. {Do you/Does NAME OF PARTICIPANT} use {your/his/her} transportation service to get to: (TRACTA TO TRACTK) Yes No RF DK A. Doctors and health care providers? 1 2 -7 -8 B. Shopping? [INTERVIEWER NOTE: INCLUDES HAIRDRESSER] 1 2 -7 -8 C. Volunteer activities? 1 2 -7 -8 D. Senior center? 1 2 -7 -8 E. Lunch program? 1 2 -7 -8 F. Friends, neighbors, and relatives? 1 2 -7 -8 G. Social events and recreation activities? 1 2 -7 -8 H. Clubs and meetings? 1 2 -7 -8
TR21. Is there a car or personal motor vehicle in working condition in {your/NAME OF PARTICIPANT’S} household? (TRISCAR) YES 1 NO 2 REFUSED -7 SKIP TR22 DON’T KNOW -8 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 FOOD SECURITY, FALLS, LIFE CHANGES, SOCIAL INTEGRATION, FALLS, PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE; DEMOGRAPHIC INTAKE MODULE.
CG70. Does {CARE RECIPIENT} have difficulty eating? (PFEATC) YES 1 NO 2 REFUSED -7 GO TO CG71 DON’T KNOW -8 CG70a. Does {s/he} need the help of another person to perform this activity? (PFEATBC) YES 1 NO 2 REFUSED -7 DON’T KNOW -8 CG71. Does {s/he} have difficulty using the toilet or getting to the toilet? (PFWCC) YES 1 NO 2 REFUSED -7 GO TO CG72 DON’T KNOW -8 CG71a. Does {s/he} need the help of another person to perform this activity? (PFWCBC) YES 1 NO 2 REFUSED -7 DON’T KNOW -8 CG72. Does {CARE RECIPIENT} have difficulty keeping track of money or bills? (PFDLRC) YES 1 NO 2 REFUSED -7 GO TO CG73 DON’T KNOW -8 CG72a. Does {s/he} need the help of another person to perform this activity? (PFDLRBC) YES 1 NO 2