Pretest Baseline Questionnaire

Attachment H. BASELINE MEASURE for PRETEST (A-CASI)

Form Approved

OMB No. __0920-XXX__

Exp. Date _xx/xx/20xx_

Respondent No. ___________

General procedures for audio

• There will be an 8 second pause after all of the responses have been read. After the pause, an option to skip or repeat the question will be offered to the participant

• Script for pause: “If you would like to hear the question again, press the repeat button, if you would like to skip this question, press the arrow”

Audio Script

In this survey, we are trying to learn more about women’s health. Only the assistant will see your answers. There is no right or wrong answer, and you do not have to answer any question that you do not want to answer. Please choose only 1 answer for each question. If you are unsure about how to answer, then please give the best answer that you can.

To get started:

• Use the headphones

• After the question and all responses have been read, touch the screen to select your answer

• After you have answered press the arrow to go to the next question {show arrow in location}. Touch the arrow now and you will go to the next screen.

• Touch the ‘help’ sign if you need help [show the sign]. After you select help, please ask the research assistant for help. You will be able to restart the survey at the same place.

• Now, we have some practice questions for you

ARMS 1,2,3,4

Practice Questions

1. There is a computer in my home:

___Yes ___No

2. My computer skills are:

E xcellent Very good Good Fair Poor

4. In the last 30 days, how many of those days did you use a computer?

Keypad response option

5. When I make a phone call, I use a cell phone:

All Most A good Some A little None

of the of the bit of of the of the of the

time time the time time time time

6. television oriented?

Not at all A little bit Moderately Quite a lot Extremely

Quality of Life: SF-12 Health Survey

Please see SF-12^® in Attachment L.

Disability

The next 2 questions will be asking about your ability to work. This can include any temporary and day jobs you may have had in the past 30 days.

13a. In the last 30 days have you had a job outside of your home?

___No  {Skip to question 14)

___Yes  13b. Please think about the last 30 days from {insert date of 30 days before interview – day of week, month, and date – such as Sunday, July 24^th ) until today, did you miss any days at work because you were sick or hurt?

___No  {Skip to question 14)

___Yes  13c. About how many days did you miss? __ __ (range

requirement=1-30)

14. Still thinking about the last 30 days from {insert date of 30 days before interview – day of week, month, and date – such as Sunday, July 24^th) until today, were you UNABLE to do your usual family or household activities because you were sick or hurt?

___No  {Skip to question 15)

___Yes  14b. About how many days? __ __ (range= 1-30)

Chronic conditions

The next 2 questions will ask about health issues that may affect you. Remember that there is no right or wrong answer.

15. Do you take medications for asthma (including sprays, inhalants, pills, and syrups prescribed by a doctor)?

__ Yes

__ No

16. Have you ever been told you have an abnormal PAP smear?

__ Yes

__ No

Health Care Utilization outside Bureau

The next 2 questions are about the health care you have had within the past year at a hospital other than County Hospital (Stroger). If you are unsure about how to answer a question, then please give the best answer that you can.

17a. In the past year, since month/year, have you been admitted to the hospital and stayed at least one night – not just in the Emergency Room – at a hospital other than here at County (Stroger)?

___ Yes  17b. How many times? ____

___ No  go to question 18

18a. In the past year, since month/year, have you gone to an Emergency Room other than here at our ER room at County (Stroger)?

___ Yes  18b. How many times? ____

___ No  go to question 19

Mental Health

These next several questions will be about your health. Please answer “YES” or “NO” to the following questions. Remember that there is no right or wrong answer.

19. Do you often have headaches? YES NO

20. Is your appetite poor? YES NO

21. Do you sleep badly? YES NO

22. Are you easily frightened? YES NO

23. Do your hands shake? YES NO

24. Do you feel nervous, tense or worried? YES NO

25. Is your digestion poor? YES NO

26. Do you have trouble thinking clearly? YES NO

27. Do you feel unhappy? YES NO

28. Do you cry more than usual? YES NO

29. Do you find it difficult to enjoy your daily activities? YES NO

30. Do you find it difficult to make decisions? YES NO

31. Is your daily work suffering? YES NO

32. Are you unable to play a useful part in life? YES NO

33. Have you lost interest in things? YES NO

34. Do you feel you are a worthless person? YES NO

35. Has the thought of ending your life been on your mind? YES NO

36. Do you feel tired all the time? YES NO

37. Do you have uncomfortable feelings in your stomach? YES NO

38. Are you easily tired? YES NO

ARMS 2,3, & 4

Partner Violence Screen

The next three questions are about whether you have experienced violence by a partner. Violence is a problem for many women. Because it affects their health, we are asking our patients about it. Just so you know, your answers will not be shared with anyone unless you choose to share them.

39. Have you been hit, kicked, punched, or otherwise hurt by an intimate partner within the past year? ___ YES ___NO

40. Do you feel safe in your current relationship? ___ YES ___NO

41. Is there a partner from a previous relationship who is making you feel unsafe now?

___ YES ___NO

42. Have you ever called or visited an agency that provides help to women who have been abused by their intimate partner?

___ YES ___NO

ARMS 2-4: Questions 42 & 43a-d are conditional on (YES to Q39 | NO to Q40 | YES to Q41)

43a. If (YES to 39, NO to 40, NO to 41) & NO to Q42

“Did you talk to anybody about the times you were hurt by your partner?

___ YES ___NO

43b. If (YES to 39, NO to 40, NO to 41) & YES to Q42

“Did you talk to anybody, different than the person you spoke to at the agency, about the times you were hurt by your partner?

___ YES ___NO

43c. If (YES Q40 or Q41) & NO to Q42

Did you talk to anybody about feeling unsafe?

___ YES ___NO

43d. If (YES Q40 or Q41) & YES to Q42

Did you talk to anybody, different than the person you spoke to at the agency, about feeling unsafe?

___ YES ___NO

ARM 3

Video if Screen Positive

Now we will show you a video that explains how you can get help if you feel that your safety is threatened.

Acceptability, ARMS 2,3, & 4

These last questions ask for your opinion on how easy or how hard it was to do this survey.

aCASI

42a. Overall, was it easy or hard to answer the questions using this touch screen?

__ easy

__ hard  42b. how hard? __ a little __ a lot

43a. Was it easy or hard to understand the person speaking?

__ easy

__ hard  43b. how hard? __ a little __ a lot

44a. In the future, would you like to answer these questions by computer or respond to a person?

___Computer ___Person ____Either one

45. The questions for this survey were read:

____ Too slow ____ Too fast ____ Just right

Screen negative: Software prints general health information

ARMS 2 & 4 (If IPV screen positive)

Your answers to some of the questions tell us that you may be at risk for being hurt by a partner, speaking to a counselor may be helpful for you. Please contact our services at 773-278-4566. This phone number will be listed on a piece of paper that will be printed at the end of this survey.

ARM 2: Your doctor is available to help you.

ARM 3

As recommended in the video, please remember to contact our services at 773-278-4566. This phone number will be listed on a piece of paper that will be printed at the end of this survey.

Screen positive: Software prints appropriate document

ARMS 2, 3, & 4 (All participants)

Please pick up the paper from the printer (two options for printout include general health information or IPV screen positive). There are resources to help you lead a healthy lifestyle.

Thank you for helping us and completing this survey!

Note: Throughout the interview, aCASI codes for difficulty by assessing time in seconds for patient response to each item; distinguish time for vocalization of question and response.