Form B

Resident Name: ____________________________________
(Black out or erase after completion, ID check)

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/2010

Collaborative Studies of Long-Term Care:
Falls Prevention Program in Assisted Living
B. Resident Interview
(RES)
7-31-2007

Date
completed:
M

M

D

D

Y

Y

Facility
ID:
Resident
ID:
Interviewer
ID:

Developed / adapted for the Collaborative Studies of Long-Term Care
Cecil G. Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
Do not use without permission

Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to
complete the survey. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX)
AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

I. Demographics
I like to start by asking you a few questions about yourself.

1. What is your highest level of education completed?

…1 Junior high or middle school
…2 Some high school
…3 High school grad or GED
…3 2-year college or associate’s degree
…4 Some college (no degree)
…5 4-year college degree or higher

2. Are you Hispanic or Latino/Latina?
[code 7 for don’t know; 8 for refusal]

3. What is your race? Please select one or more?
[record all that the respondent identifies with;
code 7 for don’t know; 8 for refusal]

…0 No …1 Yes

…1 American Indian or Alaska Native
…2 Asian
…3 Native Hawaiian or Other Pacific Islander
…4 Black or African American
…5 White

4. What is your gender? (DO NOT ASK)

…1 Male
…2

5. What is your marital status?
[code 7 for don’t know; 8 for refusal]

Female

…1 Never Married
…2 Married
…3 Widowed
…4 Separated
…5 Divorced