Form CMS-P-0015A Background Questionnaire

BQ. BACKGROUND QUESTIONNAIRE

2006 Facility Interview
(Baseline Only)

BQ. BACKGROUND QUESTIONNAIRE
(BASELINE ONLY)

BOX BQ1

If first time through BQ for this respondent, continue; else, go to BQ1PRE2.

BQ1PRE1
The following questions are about {SP's} background including {her/his} life-time use of long-term care, demographics,
and {her/his} immediate family. In answering some of these questions, you might find it useful to refer to various
records. Some of these questions refer to specific points in time while others are more general in nature. I'd like to
begin by asking a few questions about prior use of long-term care.
PRESS ENTER TO CONTINUE.

BOX BQ2

Go to BQ1.

BQ1
The first question is about the time before {SP} was a resident of {FACILITY/ELIGIBLE UNIT} {on or about {REF
DATE}}. Before that, had {she/he} ever been in a nursing home, residential care facility including personal care
home, or some other kind of long-term care facility?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

1
0
-8
-7

(BOX BQ3A)
(BOX BQ3A)
(BOX BQ3A)

BQ2
What type of facility was that?
PROBE: Which of these was the first one?
NURSING HOME.........................................................................
PERSONAL CARE HOME/RESIDENTIAL CARE FACILITY.......
OTHER LONG-TERM CARE FACILITY ......................................

1
2
3

PRESS F1 FOR DEFINITIONS.

BQ3
When was the first time that {SP} ever entered {a nursing home {,}/a residential care facility including a personal care
home {or}/some other kind of long-term care facility}?
MONTH (

) YEAR (

)

DK ...............................................................................................
RF ................................................................................................

1

-8
-7

BQ. BACKGROUND QUESTIONNAIRE

BOX BQ3

2006 Facility Interview
(Baseline Only)

If DK to YR, go to BQ4.
If YR = RF, go to BQ5.
If FLU YR = REF DATE YR, go to BOX BQ3A, otherwise go to BQ5.

BQ4
About how long ago was it? Would you say...
about 1 year, ................................................................................
about 2 years, ..............................................................................
about 5 years, or ..........................................................................
10 or more years? ........................................................................

1
2
3
4

BQ5
How many different nursing homes, personal care homes, or other long-term care facilities had {SP} been in prior to
{FACILITY/ELIGIBLE UNIT} {in which {he/she} was a resident on or about {REF DATE}}?

NUMBER OF LTC FACILITIES

BQ6
Between {her/his} first use of long-term care {in {FLU YR}} and when {she/he} entered a nursing home or personal
care home {on or about {REF DATE}}, how much of that time did {SP} spend in a nursing home, personal care
home, or other long-term care facility? Would you say ...
all, ................................................................................................
more than half, or .........................................................................
half or less than half? ...................................................................
DK ................................................................................................
RF ................................................................................................

1
2
3
-8
-7

(BOX BQ3A)
(BQ8)
(BOX BQ3A)
(BOX BQ3A)

1
2
-8
-7

(BOX BQ3A)
(BOX BQ3A)
(BOX BQ3A)
(BOX BQ3A)

BQ7
Would you say more or less than three-fourths of {her/his} time?
MORE ..........................................................................................
LESS............................................................................................
DK ................................................................................................
RF ................................................................................................

BQ8
Would you say more or less than one-fourth of {her/his} time?
MORE ..........................................................................................
LESS............................................................................................

BOX
BQ3A

If SP type is SSM1 or CFC, continue.
Else, go to BQ9PRE.

2

1
2

BQ. BACKGROUND QUESTIONNAIRE

2006 Facility Interview
(Baseline Only)

RH22A
Please look at this card and tell me what kind of place {SP} was in just before being admitted
here on {ADMISSION DATE}.

OTHER NURSING HOME/REHAB CENTER ................................
PERSONAL CARE HOME/RESIDENTIAL CARE FACILITY .........
CCRC/RETIREMENT HOME/CENTER .........................................
HOSPITAL .....................................................................................
PRIVATE HOME OR APARTMENT...............................................
OTHER LTC FACILITY ..................................................................
OTHER (SPECIFY: _____________________) ...........................

SHOW
CARD
RH1

1
2
3
4
5
7
91

PRESS F1 FOR DEFINITIONS.

BOX
BQ3B

If RH22A = 5 or 91, continue.
Else, go to BQ9PRE.

RH30A
Who lived with {her/him} there?
SELECT ALL THAT APPLY.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
91.
92.
93.

ALONE
SPOUSE
DAUGHTER
SON
MOTHER
FATHER
SISTER
BROTHER
DAUGHTER-IN-LAW
SON-IN-LAW
GRANDDAUGHTER
GRANDSON
NIECE
NEPHEW
FRIEND
NURSE/AIDE
BOARDER
GUARDIAN
OTHER FEMALE RELATIVE, SPECIFY
OTHER MALE RELATIVE, SPECIFY
OTHER NONRELATIVE, SPECIFY

{How many {PLURAL FORM OF RELATIONSHIP CODE} {live/lived} there? (

)}

DEMOGRAPHICS
BQ9PRE
The next few questions are about {SP's} {level of education,} race, ethnicity, and military service.
PRESS ENTER TO CONTINUE.

3

BQ. BACKGROUND QUESTIONNAIRE

BOX BQ4

2006 Facility Interview
(Baseline Only)

If HA51 of Health Status is -8 (DK), -7 (RF), or -1, go to BQ9; else go to BQ10A.

4

BQ. BACKGROUND QUESTIONNAIRE

2006 Facility Interview
(Baseline Only)

BQ9
As far as you know, what {is/was} the highest level of schooling {SP} completed?
IF DK, USE CATEGORIES AS PROBES.
EDLEVELF
SPDEGRCV

NO FORMAL SCHOOLING .........................................................
ELEMENTARY (1ST-8TH GRADES)...........................................
SOME HIGH SCHOOL (9TH-12TH GRADES) ............................
COMPLETED HIGH SCHOOL, NO COLLEGE ...........................
TECHNICAL OR TRADE SCHOOL .............................................
SOME COLLEGE ........................................................................
COLLEGE GRADUATE ..............................................................
GRADUATE DEGREE ................................................................
DK ...............................................................................................
RF ...............................................................................................

1
2
3
4
5
6
7
8
-8
-7

BQ10 omitted in Round 22.

BQ10A
{Is/Was} {SP} of Hispanic or Latino origin?
HISPORIG
D_ETHNIC

YES..............................................................................................
NO................................................................................................

1
0

BQ11 omitted in Round 22.

BQ11A
Please look at this card and tell me what {is/was} {SP}'s race.
SELECT ALL THAT APPLY.
SHOW
CARD
BQ1A

RACEAI
RACEAS
RACEAA
RACENH
RACEWH
RACEOTH
D_RACE
D_RACE2

BOX BQ5

AMERICAN INDIAN OR ALASKA NATIVE
ASIAN
BLACK OR AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
WHITE
ANOTHER RACE (SPECIFY) _________________________

If SP < 15 years old, go to BQ18PRE; else, continue.

BQ12
Did {SP} ever serve on active duty in the Armed Forces?
D_AFEVER

YES .............................................................................................
NO................................................................................................
DK ...............................................................................................
RF ...............................................................................................

5

1
0
-8
-7

(BQ12B)
(BQ12B)
(BQ12B)

BQ. BACKGROUND QUESTIONNAIRE

2006 Facility Interview
(Baseline Only)

BQ12A
Looking at this card, which time periods best describe when {SP} served in the Armed Forces?
SELECT ALL THAT APPLY.
SHOW
CARD
BQ1

D_AFIRAF
D_AFGULF
D_AFVIET
D_AFKORE
D_AFWWII
D_AFWWI
D_AFPEAC

IRAQ OR AFGHANISTAN CONFLICT (2001 - Present)
PERSIAN GULF WAR (Aug 1990 – March 1991)
VIETNAM ERA (Aug. 1964 - May 1975)
KOREAN CONFLICT (June 1950 - Jan. 1955)
WORLD WAR II (Sept. 1940 - July 1947)
WORLD WAR I (1917 - 1918)
PEACE TIME ONLY (ALL OTHER TIMES)
DON'T KNOW

BQ12B
Was {SP} ever an active member of a National Guard or military reserve unit of the United States?
D_NGEVER

YES .............................................................................................
NO................................................................................................
DK ...............................................................................................
RF ...............................................................................................

1
0
-8
-7

(BOX BQ5A)
(BOX BQ5A)
(BOX BQ5A)

BQ12C
Was all of {SP's} active duty related to National Guard or military reserve training?
D_NGALL

BOX
BQ5A

YES .............................................................................................
NO................................................................................................

1
0

(BQ12D)
(BQ12D)

If BQ12 = 1, continue; else, go to BQ13PRE.

BQ12D
Does {SP} have a disability related to (his/her) service in the Armed Forces of the United States?
D_NGDSBL

YES .............................................................................................
NO................................................................................................
DK ...............................................................................................
RF ...............................................................................................

1
0
-8
-7

(BQ13PRE)
(BQ13PRE)
(BQ13PRE)

BQ12E
What is {SP's} current VA disability rating?
D_VARATE

RATING = __________________________%
IMMEDIATE FAMILY

BQ13PRE
Next I am going to ask you some questions about {SP's} marital status and immediate family.
PRESS ENTER TO CONTINUE.

6

BQ. BACKGROUND QUESTIONNAIRE

BOX
BQ5B

2006 Facility Interview
(Baseline Only)

If CFC or SSM2, go to BQ14.
Else, go to BQ13.

7

BQ. BACKGROUND QUESTIONNAIRE

2006 Facility Interview
(Baseline Only)

BQ13
On January 1, {SAMPLE YEAR}, was {SP} married, widowed, divorced, separated, or never married?
SPMARSTA

BOX BQ6

MARRIED ....................................................................................
WIDOWED...................................................................................
DIVORCED ..................................................................................
SEPARATED ...............................................................................
NEVER MARRIED .......................................................................
DK ................................................................................................
RF ................................................................................................

1
2
3
4
5
-8
-7

(BQ15)

(BQ18PRE)

If SP type is SSM1, go to BQ18PRE.
Else, continue.

BQ14
When {SP} was admitted to {FACILITY/ELIGIBLE UNIT} on {FAD}, was {he/she} married, widowed, divorced,
separated, or never married?
MARRIED ....................................................................................
WIDOWED...................................................................................
DIVORCED ..................................................................................
SEPARATED ...............................................................................
NEVER MARRIED .......................................................................
DK ................................................................................................
RF ................................................................................................

1
2
3
4
5
-8
-7

(BQ18PRE)
(BQ18PRE)
(BQ18PRE)
(BQ18PRE)
(BQ18PRE)
(BQ18PRE)

BQ15
Please look at this card and tell me where {SP's} {husband/wife} lives now.
IN THIS FACILITY ......................................................................... 1
OTHER NURSING HOME/REHAB CENTER ................................ 2
PERSONAL CARE HOME/RESIDENTIAL CARE FACILITY.......... 3
CCRC/RETIREMENT HOME/CENTER ......................................... 4
HOSPITAL ...................................................................................... 5
PRIVATE HOME OR APARTMENT .............................................. 6
SPOUSE DECEASED .................................................................... 7
OTHER LTC FACILITY .................................................................. 8
OTHER (SPECIFY:______________________) ............................ 91

SHOW
CARD
BQ2

BOX BQ7

If BQ15 = 1 and FACILITY has more than one part, go to BQ15a; else if BQ15 = 6, go
to BQ16; otherwise go to BOX BQ9.

BQ15a
In which part of {LARGER FACILITY} does {he/she} live? PROBE: Is it [READ NAMES FROM PLACE ROSTER]?
USE ARROW KEYS. TO SELECT/DESELECT, PRESS ENTER.
TO EXIT, PRESS ESC.

BOX BQ8

Go to BOX BQ9.

8

BQ. BACKGROUND QUESTIONNAIRE

2006 Facility Interview
(Baseline Only)

BQ16
Who owns that home or apartment, {SP} and/or {her/his} spouse, a relative, or does someone else, such as a
landlord, own it?
SP/SPOUSE OWNS HOME/APARTMENT.................................
RELATIVE OWNS HOME/APARTMENT ....................................
SOMEONE ELSE OWNS HOME/APARTMENT.........................

BOX BQ9

1
2
3

If BQ15 = "7" go to BQ18PRE; else go to BQ17.

BQ17
In general, compared to other people of {her/his} age would you say {SP's} {husband's/wife's} health is excellent,
very good, good, fair, or poor?
EXCELLENT ...........................................
VERY GOOD ..........................................
GOOD ....................................................
FAIR........................................................
POOR ...................................................

1
2
3
4
5

BQ18PRE
The next few questions are about {SP's} immediate family.
PRESS ENTER TO CONTINUE.

BOX
BQ10

If SP < 15 years old, go to BQ20; else, continue.

BQ18-21
How many {VARIABLE TEXT} altogether does {SP} have, including any who may live far away?

BQ18
Living daughters?

(

) SPCHNLNM

(

) SPCHNLNM

PRESS F1 FOR DEFINITION OF DAUGHTER.

BQ19
Living sons?
PRESS F1 FOR DEFINITION OF SON.

BQ20
Living sisters?

(

)

(

)

PRESS F1 FOR DEFINITION OF SISTER.

BQ21
Living brothers?
PRESS F1 FOR DEFINITION OF BROTHER.

9

BQ. BACKGROUND QUESTIONNAIRE

BOX
BQ11

2006 Facility Interview
(Baseline Only)

Check SP date of birth or age from Residence History.
If SP AGE > 65, go to BQ24; else go to BQ22-23.

BQ22-23
Is {SP's} {VARIABLE TEXT} still living?

BQ22
YES = 1, NO = 0
(
)

Mother?

BQ23
Father?

(

)

PRESS F1 FOR DEFINITIONS OF MOTHER AND FATHER.

BQ24
In studies like this, people are sometimes grouped together according to income.
Looking at this card, please tell me what {is/was} the total yearly income for {SP} {and (his/her) spouse} received
from jobs, businesses, interest, Social Security, Railroad Retirement, Supplemental Security Income (SSI),
pensions, and any other sources of income, before taxes or any deductions.
SHOW
CARD
BQ3

AMOUNT $_______________________ .................................... (BQ28)
DK ............................................................................................... (BQ25)
RF ............................................................................................... (BQ25)

BQ25
{Is/Was} it less than $25,000?
YES.........................................................
NO ..........................................................
DK...........................................................
REFUSED...............................................

1
0
-8
-7

Less than $5,000; ...................................
$5,000 to $9,999; ....................................
$10,000 to $14,999; ...............................
$15,000 to $19,999; or ............................
$20,000 to $24,999? ...............................
DK...........................................................
REFUSED...............................................

1
2
3
4
5
-8
-7

(BQ27)
(BQ28)
(BQ28)

BQ26
Would you say it {is/was}...

10

(BQ28)

BQ. BACKGROUND QUESTIONNAIRE

2006 Facility Interview
(Baseline Only)

BQ27
Would you say it {is/was}...
$25,000 to $29,999; ................................
$30,000 to $34,999; ................................
$35,000 to $39,999; ................................
$40,000 to $44,999; ................................
$45,000 to $49,999; or............................
$50,000 or more?....................................

1
2
3
4
5
6

BQ28
DID YOU ABSTRACT?
ALL...............................................................................................
MAJORITY...................................................................................
HALF............................................................................................
SOME ..........................................................................................
NONE...........................................................................................

1
2
3
4
5

BQ29
WHY DID YOU ABSTRACT?
NO KNOWLEDGEABLE RESPONDENT AVAILABLE ................ 1
NO TIME/STAFF BURDEN TOO GREAT ................................... 2
REFUSAL--UNWILLING TO COOPERATE................................. 3
OTHER (SPECIFY:_____________________) .......................... 91

BQEND
YOU HAVE COMPLETED THE BACKGROUND SECTION FOR THIS SP.
PRESS ENTER TO RETURN TO NAVIGATION SCREEN.

11

(BQEND)

BQ. BACKGROUND QUESTIONNAIRE

2006 Facility Interview
(Baseline Only)

12

BQ. BACKGROUND QUESTIONNAIRE

2006 Facility Interview
(Baseline Only)
BQ HELP (F1) SCREENS

BQ2
NURSING HOME
Nursing homes are licensed or certified facilities that provide nursing services 24-hours a day to the resident.
PERSONAL CARE HOME/RESIDENTIAL CARE FACILITY
Assisted living facilities, board and care homes, domiciliary care homes, personal care homes, and rest homes are
various terms for residential care facilities: places that offer residents help with activities such as bathing and
dressing, but do not provide 24-hour nursing services. (Some residents at a residential care facility may not require
such assistance, but it must be available to them.)
Some other common terms for residential care facilities are: (IL) shelter care facilities, community living facilities;
community residential alternatives; home individualized programs.
(MD) group home for the mentally disabled; group senior-assisted housing for the elderly.
(MO) residential care centers; group care homes; group homes (adult); foster care homes; group homes.
(VA) homes for adults; residential facilities.
LONG-TERM CARE FACILITY
A place that provides a residence and some surveillance and available living assistance for persons no longer willing
or able to live on their own for the long term.

BQ18
"Living daughters" includes natural, adopted, and step-children.

BQ19
"Living sons" includes natural, adopted, and step-children.

BQ20
"Living sisters" includes siblings related to the sampled person by blood, adoption, or marriage.

BQ21
"Living brothers" includes siblings related to the sampled person by blood, adoption, or marriage.

BQ22
"Mother" refers to natural or step-mother.

BQ23
"Father refers to natural or step-father.

13