Pretest Followup Questionnaire

Attachment I: Follow-up Measures for Pretest (CATI)

Form Approved

OMB No. __0920-XXX__

Exp. Date _xx/xx/20xx_

Respondent No. ___________

A. Quality of Life SF-12 Health Survey (Ware, Kisinski, & Keller, 1996)

Please se SF-12^® in Attachment L.

B. Disability

1. During the 30 days from {date from 30 days before baseline interview to baseline interview}, about how many days did you miss work because of an illness or injury (do not include maternity leave)?

____ days

____ Don’t remember

____ Don’t work outside my home

2. During the 30 days from {date from 30 days before baseline interview to baseline interview}, about how many days were you unable to do your housework tasks because of an illness or injury (do not include maternity leave)?

____ days

____ Don’t remember

C. Chronic Conditions

1. Do you take medications for asthma?

__ YES

__ NO

__ Don’t know

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

__ YES

__ NO

__ Don’t know or don’t remember

D. Health Care Utilization outside Bureau

1. In the past year, have you been admitted to the hospital, stayed at least one night – not just in the emergency room, at a hospital other than here at County (Stroger )?

___ Yes  How many times? ____

___ No

2. In the past year, have you gone to an Emergency Room other than here at our ER room at County (Stroger)

___ Yes  How many times? ____

___ No

E. Acceptability of referral strategy

1. Last week {DATE OF BASELINE} your {health care provider asked you v. we asked you on a computer survey}about domestic or partner violence. You were asked if you were afraid or had been hurt or threatened by a current or former intimate partner? Do you remember being asked about this?

__ YES

__ NO  SKIP TO Q4.

2. Sometimes being asked sensitive questions affect patient’s feelings. How did you feel about being asked these questions?

Not at all Yes a little Yes a lot

a. Did they make you feel relieved?

b. Did they bother you?

c. Did they make you feel you were not alone?

d. Did they make you feel afraid?

e. Did they make you feel nervous?

3. Because of being asked these questions, did you have any small or big problems, or no problems? Interviewers remind answers are private for a-c.

a. Big problems  What were the big problems?

b. Small problems?  What were the smaller problems?

c. Both big and small problems  What were the big problems? Smaller problems?

d. No problems at all

(Instructions to interviewers for problems probe for free text to include- description of problems including who, what, when, etc)

4. Do you remember if you received a list of services from {the computer (arms b-d)/ your provider (arm a)}?

___ Yes  (continue with next question)

___ No  (skip to next section)

b. Did you share this list of services with anyone?

__ Yes  who? {interviewer probe relationship}

__ No

c. Did you use the list to contact one of the services?

Yes  (to next section)

No  Do you expect to use any of the services in the next month?

__ No

__ Yes

F. Acceptability of CATI

1. Overall, was it easy or difficult to answer these questions on the telephone?

__ easy

__ difficult – how difficult, a little or a lot?

__ a little

__ a lot

2. Was it easy or difficult to understand the questions?

__ easy  (skip to next section)

__ difficult – how difficult, a little or a lot?

__ a little

__ a lot

In what way was it difficult? (open text)___________________

3. In the future, would you prefer to answer questions about your health using the touch screen – like you did last week, or a telephone interview?

__ Prefer touch screen

__ Prefer telephone interview

__ No preference

4. Is there anything we could have done to make this better or easier for you?

(open text)______________________________

G. Demographics

One final question so we know a little bit of the background of those who have participated in our study.

What is the highest grade in school or year of college that you have completed? Would you say…

___ Less than high school

___ completed high school /GED

___ Trade school/vocational program after high school

___ some college but without degree

___ 2-year college graduate

___ 4-year college graduate

___ Graduate degree

___ Other

___ Don’t Know/Refused