Form 1 Informant

OMB #0925-0493 Exp: 10/31/07

Multi-Ethnic Study of Atherosclerosis

Participant ID: 8000028

02

Sequence Num:
Public reporting burden for this collection of information is estimated to average 10 minutes per
response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information ,
including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD, 20892-7974, ATTN: PRA 0925-0493. Do not
return the completed form to this address.

Informant Interview

Where there is a blank ( ) in the text of a question, insert the name of the participant.
Date of
/
/
Death:
Month

Day

Informant Information

Year

3. Was anyone present when s/he died?
Yes

1a. Relationship of informant to deceased:
Spouse

No

Unknown
If "Yes," skip to Question 6.

Daughter/Son

4. Was anyone close enough to hear ( ) if s/he had
called out?

Parent
Friend

Yes

Workmate

No

Unknown

5. How long was it between the time ( ) was last known
to be alive and the time s/he was found dead?

Other Relative:

Less than 5 minutes
Other:

5 minutes to 1 hour
1 to 24 hours
Longer than 24 hours

1b. Name of informant (for interviewer use):

Unknown

Skip to Question 7.

6. Please tell me who was present:

Circumstances Surrounding Death

Self

I would like to ask you about the circumstances
surrounding ( )'s death. If you have any questions as we
go along, please ask me.
2. Please tell me about his/her general health, health on
the day s/he died, and about the death itself.

Nursing staff, physician or paramedic
Other lay person
If "Self," skip to Question 8.

7. When was the last time you saw ( ) prior to his/her
death?

Record a brief synopsis of the events surrounding the death as
related by the informant. Append a typed copy of this account to
this questionnaire.

Less than 5 minutes
5 minutes to 1 hour

Some of the remaining questions may repeat information
already provided, but it helps us to ask these items
specifically.

1 to 24 hours
Longer than 24 hours
Unknown

3196209437
11/09/2004

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Informant Interview (Page 2)

8000028
History

02

Symptoms

The next few questions concern ( )'s medical history.
8. Was s/he restricted to home, able to leave home only
with assistance or great effort, or was his/her activity
unrestricted?

The next set of questions deals specifically with acute
symptoms such as pain, discomfort or tightness that ( )
may have experienced at the time of his/her death (i.e.,
starting at the time s/he noticed the symptoms that
caused him/her to stop or change what s/he was doing).

Restricted to home
Able to leave home only with assistance or great
effort

13. Did s/he experience pain, discomfort or tightness in
the chest, left arm or jaw?

Unrestricted
Yes

No

9. Was s/he hospitalized within the four weeks prior to
death?
Yes

No

If "No" or "Unknown," skip to Question 20.

Unknown

If "No" or "Unknown," skip to Question 12a.

14. Did the pain, discomfort or tightness specifically
involve the chest?
Yes

10. What was the reason for the hospitalization?
Coronary heart disease, heart attack, angina, or
cardiac arrest
Cerebrovascular disease or stroke

Unknown

No

Unknown

15. Were these episodes new, or had they occurred
previously?
New symptoms

Other cardiovascular disease

Previous symptoms

Other non-cardiovascular disease

Unknown

Heart surgery

If "New symptoms," skip to Question 20.

Other surgical procedure(s)

16. Were the episodes getting longer or more frequent?

Diagnostic procedure(s)

Yes

No

Unknown

Other:
17. Were the episodes getting more severe?

Unknown

Yes

11a. What was the date of the hospital admission?

/
Month

/
Day

Unknown

If "No" or "Unknown," to Questions 16 and 17,
skip to Question 19.

Year

11b. What was the name and location of the hospital?

No

18. Over what period of time did these episodes become
longer, more frequent, or more severe?
Days
Weeks
Months

12a. Was ( ) seen by a physician at any other time in
the last four weeks prior to death?
Yes

No

Unknown

If "No" or "Unknown," skip to Question 13.

Unknown
19. You may not be able to answer this: How long was it
from ( )'s last episode of symptoms to the time that s/he
stopped breathing on his/her own?

12b. What is the name and address of this physician?

Less than 5 minutes
Less than 1 hour
Less than 24 hours
Greater than 24 hours
Unknown
6033209430

11/09/2004

page 2 of 3

Informant Interview (Page 3)

8000028

02

Emergency Medical Care
Reliability
20. Was ( ) taken to the hospital, emergency room, or
any other emergency care facility ?
Yes

No

Unknown

21. Is there anyone else we could contact who might
be able to provide additional information about the
circumstances surrounding ( )'s death or his/her usual
state of health?
Yes

24. What is your rating of reliability of the interview?

No

Good
Fair
Poor

Notes

Unknown

If "No" or "Unknown," skip to "Closing Script."

22. How is s/he related to the deceased?
Spouse
Daughter/Son
Parent
Friend
Workmate
Other Relative:

Other:

23. What is the name and address of this person?

Closing Script: Thank you very much for your
assistance in this important study. Do you have
any questions? (Pause, and continue if there are
no questions.) Thanks again for your help.

/
Month

/
Day

Interviewer ID:

Year

Data Entry ID:
2372209432

11/09/2004

page 3 of 3

8000028 02

Multi-Ethnic Study of Atherosclerosis

Seq. Num

Informant Interview Narrative

INFNOT

/
Month

/
Day

Year

Interviewer ID:
1762630511

12/13/2001

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