Form D Form D Chart Abstract Demo 2007

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
D. Chart Abstract
(ABS)
7-31-2007

Facility ID:

Resident ID:

Interviewer ID:
Date
completed:
M

M

D

D

Y

Y

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. Resident Demographic Information
1. Date resident admitted to facility?

2. Resident date of birth?

____ ____

____ ____

____ ____ ____ ____

Month

Day

Year

____ ____

____ ____

____ ____ ____ ____

Month

Day

Year

Complete questions 3-7 for residents unable to provide the information themselves [proxy consent].
3. What is the resident’s 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

4. Is the resident Hispanic or Latino/Latina?

…2 No …1 Yes

5. What is the resident’s race? Please select one or
more?

…1 American Indian or Alaska Native
…2 Asian

[record all that the respondent identifies with;

…3 Native Hawaiian or Other Pacific Islander

code 7 for don’t know; 8 for refusal]

…4 Black or African American
…5 White

6. What is the resident’s gender?

…1 Male
…2 Female

7. What is the resident’s marital status?

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