Respondent Name:
Respondent Street Address:
Respondent City:
Respondent State:
Respondent ZIP Code:
Social Security Number:
Medicaid ID number:
Check here if the Sample Member is deceased and record date of death:
[_________] [_________] [__________] GO TO END
Month Day Year
Hello, my name is _______ and I am from ________. I’m here to ask for your help with an important study of Medicaid beneficiaries in the state of __________. The Quality of Life Survey, sponsored by the Centers for Medicare & Medicaid Services (CMS) and the state of __________, is an essential part of an evaluation of the Money Follows the Person Program, a program designed to help Medicaid beneficiaries transition out of institutional care into the community. I’d like to ask you some questions about your housing, access to care, community involvement, and your health and well-being. Results from the study will help CMS and the state of __________ evaluate how well its programs are meeting the needs of Medicaid beneficiaries like you.
Before we begin, let me assure you that all information collected will be kept strictly confidential and will not be reported in any way that identifies you personally. Your answers will be combined with the answers of others and reported in such a way that no single individual could ever be identified. Further, the information collected will not be used by anyone to determine your continuing eligibility for Medicaid benefits. We are collecting this information for research purposes only. However, I may be required to report any instances of abuse or neglect that you tell me about to authorities. Your participation is completely voluntary and if we come to any question you prefer not to answer, just tell me and we’ll move on to the next one.
If you have any questions, please stop me and ask me. Also, please let me know if you do not understand a question or if you would like me to repeat it.
1. I’m going to ask you a few questions about the place you live. About how long have you lived (here/in your home)?
Probe: Your best estimate is fine.
Interviewer: If respondent indicates less than 1 month, enter 1 month.
[_________] [__________] GO TO QUESTION 2
Years Months
DON’T KNOW DK
REFUSED R
1a. Would you say you have lived here more than five years?
Yes 01
No 02
Don’t Know DK
Refused R
2. Interviewer: Does sample member live in a group home or nursing facility?
Yes 01
No 02
Don’t Know DK
Refused R
3. Do you like where you live?
Yes 01
No 02
Sometimes 03
DON’T KNOW DK
REFUSED R
4. Did you help pick (this/that) place to live?
Yes 01
No 02
DON’T KNOW DK
REFUSED R
5. Do you feel safe living (here/there)?
Yes 01 GO TO QUESTION 6
No 02
DON’T KNOW DK GO TO QUESTION 6
REFUSED R GO TO QUESTION 6
5a. How often do you feel unsafe living (here/there)?
Sometimes 01
Most of the Time 02
DON’T KNOW DK
REFUSED R
6. Can you get the sleep you need without noises or other disturbances where you live?
Yes 01
No 02
Sometimes 03
DON’T KNOW DK
REFUSED R
7. Can you go to bed when you want?
Yes 01
No 02
Sometimes 03
DON’T KNOW DK
REFUSED R
8. Can you be by yourself when you want to?
Yes 01
No 02
Sometimes 03
DON’T KNOW DK
REFUSED R
9. When you are at home, can you eat when you want to?
Yes 01
No 02
Sometimes 03
DON’T KNOW DK
REFUSED R
10. Can you choose the foods that you eat?
Yes 01
No 02
Sometimes 03
DON’T KNOW DK
REFUSED R
11. Can you talk on the telephone without someone listening in?
Yes 01
No 02
Sometimes 03
No access to telephone 04
DON’T KNOW DK
REFUSED R
12. Can you watch TV when you want to?
Yes 01
No 02
Sometimes 03
No access to TV 04
DON’T KNOW DK
REFUSED R
13. [AFTER TRANSITION ONLY] Some people get an allowance from the state to pay for the help or equipment they need. Do you get an allowance like this?
Yes 01
No 02 GO TO QUESTION 14
DON’T KNOW DK GO TO QUESTION 14
REFUSED R GO TO QUESTION 14
13a. [AFTER TRANSITION ONLY] In the last 12 months, what help or equipment did you buy with this allowance?
[Code all that apply]
Modified Home 01
Modified Car 02
Special Equipment 03
Paid Help 04
Transportation 05
Household Goods 06
Security Deposit 07
Other 08
DON’T KNOW DK
REFUSED R
14. Now I’d like to ask you about some everyday activities, like getting dressed or taking a bath. Some people have no problem doing these things by themselves. Other people need somebody to help them. First, does anyone help you with things like bathing, dressing, or preparing meals?
Probe: Please include any help received by another person, including cueing or standby assistance.
Yes 01
No 02 GO TO QUESTION 15
DON’T KNOW DK GO TO QUESTION 15
REFUSED R GO TO QUESTION 15
14a. Do any of these people get paid to help you?
Yes 01
No 02 GO TO QUESTION 15
Don’t Know DK GO TO QUESTION 15
Refused R GO TO QUESTION 15
14b. Do you pick the people who are paid to help you?
Yes 01
No 02
Don’t Know DK
Refused R
15. Do you ever go without a bath or shower when you need one?
Yes 01
No 02 GO TO QUESTION 16
DON’T KNOW DK GO TO QUESTION 16
REFUSED R GO TO QUESTION 16
15a. How often do you go without a bath or shower when you need one? Would you say only sometimes or most of the time?
Sometimes 01
Most of the time 02
DON’T KNOW DK
REFUSED R
15b. Is this because there is no one there to help you?
Probe: Please include any help received by another person, including cueing or standby assistance.
Yes 01
No 02
DON’T KNOW DK
REFUSED R
16. Do you ever go without a meal when you need one?
Yes 01
No 02 GO TO QUESTION 17
DON’T KNOW DK GO TO QUESTION 17
REFUSED R GO TO QUESTION 17
16a. How often do you go without a meal when you need one? Would you say only sometimes or most of the time?
Sometimes 01
Most of the Time 02
DON’T KNOW DK
REFUSED R
16b. Is this because there is no one there to help you?
Probe: Please include any help received by another person, including cueing or standby assistance.
Yes 01
No 02
DON’T KNOW DK
REFUSED R
17. Do you ever go without taking your medicine when you need it?
Probes: Medicines are pills or liquids that are given to you by a doctor to help you feel better.
Yes 01
No 02 GO TO QUESTION 18
DON’T KNOW DK GO TO QUESTION 18
REFUSED R GO TO QUESTION 18
17a. How often do you go without taking your medicine when you need it? Would you say only sometimes or most of the time?
Sometimes 01
Most of the Time 02
DON’T KNOW DK
REFUSED R
17b. Is this because there is no one there to help you?
Probe: Please include any help received by another person, including cueing or standby assistance.
Yes 01
No 02
DON’T KNOW DK
REFUSED R
18. Are you ever unable to use the bathroom when you need to?
Yes 01
No 02 GO TO QUESTION 19
DON’T KNOW DK GO TO QUESTION 19
REFUSED R GO TO QUESTION 19
18a. How often are you unable to use the bathroom when you need to? Would you say only sometimes or most of the time?
Sometimes 01
Most of the Time 02
DON’T KNOW DK
REFUSED R
18b. Is this because there is no one there to help you?
Probe: Please include any help received by another person, including cueing or standby assistance.
Yes 01
No 02
DON’T KNOW DK
REFUSED R
19. [AFTER TRANSITION ONLY] Have you ever talked with a case manager or support coordinator about any special equipment or changes to your home that might make your life easier?
Probe: Equipment means things like wheelchairs, canes, vans with lifts, and automatic door opener.
Yes 01
No 02 GO TO QUESTION 20
DON’T KNOW DK GO TO QUESTION 20
Not Applicable N/A GO TO QUESTION 20
REFUSED R GO TO QUESTION 20
19a. [AFTER TRANSITION ONLY] What equipment or changes did you talk about?
DON’T KNOW DK
REFUSED R
19b. [AFTER TRANSITION ONLY] Did you get the equipment or make the changes you needed?
Yes 01
No 02
In Process 03
DON’T KNOW DK
REFUSED R
20. [AFTER TRANSITION ONLY] Please think about all the help you received during the last week around the house like cooking or cleaning. Do you need more help with things around the house than you are now receiving?
Yes 01
No 02
DON’T KNOW DK
REFUSED R
21. [AFTER TRANSITION ONLY] During the last week, did any family member or friends help you with things around the house?
Yes 01
No 02 GO TO QUESTION 22
DON’T KNOW DK GO TO QUESTION 22
REFUSED R GO TO QUESTION 22
21a. [AFTER TRANSITION ONLY] Please think about all the family members and friends who help you. About how many hours did they spend helping you yesterday?
Probe: Your best estimate is fine.
Interviewer: if less than one hour, enter 1 hour.
[_________]
Hours
DON’T KNOW DK
REFUSED R
Note: If Q14 = No, DK or R GO TO QUESTION 27
Interviewer: For questions in this module, refer to your state’s policy on reporting any suspected incidents of abuse and neglect. For this survey, record only reports of current abuse.
22. You said that you have people who help you. Do the people who help you treat you the way you want them to?
Yes 01 GO TO QUESTION 23
No 02
DON’T KNOW DK GO TO QUESTION 23
REFUSED R GO TO QUESTION 23
22a. How often do they not treat you the way you want them to? Would you say only sometimes or most of the time?
Sometimes 01
Most of the Time 02
DON’T KNOW DK
REFUSED R
23. Do the people who help you listen carefully to what you ask them to do?
Yes 01 GO TO QUESTION 24
No 02
DON’T KNOW DK GO TO QUESTION 24
REFUSED R GO TO QUESTION 24
23a. How often do they not listen to you? Would you say only sometimes or most of the time?
Sometimes 01
Most of the time 02
DON’T KNOW DK
REFUSED R
24. [Optional] Have you ever been physically hurt by any of the people who help you now?
Probe: Physically hurt means someone could have pushed, kicked, or slapped you.
Yes 01
No 02 GO TO QUESTION 25
DON’T KNOW DK GO TO QUESTION 25
REFUSED R GO TO QUESTION 25
24a. [Optional] What happened when the people who help you now physically hurt you?
DON’T KNOW DK
REFUSED R
24b. [Optional] How many times have you been physically hurt by the people who help you now?
Probe: Your best guess is fine.
[_________]
Times
DON’T KNOW DK
REFUSED R
25. [Optional] Are any of the people who help you now mean to you or do they yell at you?
Probe: Do they treat you in a way that makes you feel bad or do they hurt your feelings?
Yes 01
No 02 GO TO QUESTION 26
DON’T KNOW DK GO TO QUESTION 26
REFUSED R GO TO QUESTION 26
25a. [Optional] How often are they mean to you? Would you say only sometimes or most of the time?
Sometimes 01
Most of the Time 02
DON’T KNOW DK
REFUSED R
26. [Optional] Have any of the people who help you now ever taken your money or things without asking first?
Yes 01
No 02 GO TO QUESTION 27
DON’T KNOW DK GO TO QUESTION 27
REFUSED R GO TO QUESTION 27
26a. [Optional] How many times have they taken your money or things without asking first?
Probe: Your best guess is fine.
[_________]
Times
DON’T KNOW DK
REFUSED R
27. I’d like to ask you a few questions about things you do. Can you see your friends and family when you want to see them?
Interviewer: Code “yes” if respondent indicates that they have either gone to see friends or family or that friends and family have come to visit them.
Yes 01
No 02 GO TO QUESTION 28
DON’T KNOW DK GO TO QUESTION 28
REFUSED R GO TO QUESTION 28
27a. How often do you see your friends and family when you want to see them? Would you say only sometimes or most of the time?
Sometimes 01
Most of the Time 02
DON’T KNOW DK
REFUSED R
28. Can you get to the places you need to go, like work, shopping, or the doctor’s office?
Yes 01
No 02 GO TO QUESTION 29
DON’T KNOW DK GO TO QUESTION 29
REFUSED R GO TO QUESTION 29
28a. How often do you get to the places you need to go, like work, shopping, or the doctor’s office? Would you say only sometimes or most of the time?
Sometimes 01
Most of the Time 02
DON’T KNOW DK
REFUSED R
29. Is there anything you want to do outside [the facility/your home] that you can’t do now?
Yes 01
No 02 GO TO QUESTION 30
DON’T KNOW DK GO TO QUESTION 30
REFUSED R GO TO QUESTION 30
29a. What would you like to do that you don’t do now?
DON’T KNOW DK
REFUSED R
29b. What do you need to do these things?
DON’T KNOW DK
REFUSED R
30. When you go out, can you go by yourself or do you need help?
Go out Independently 01 GO TO QUESTION 31
Need Help 02
DON’T KNOW DK GO TO QUESTION 31
REFUSED R GO TO QUESTION 31
30a. Please think about all the help you received during the last week with getting around the community, such as shopping and going to a doctor’s appointment, do you need more help getting around than you are receiving?
Yes 01
No 02
DON’T KNOW DK
REFUSED R
31. [AFTER TRANSITION ONLY] Are you working for pay right now?
Probe: Do you get any money for doing work?
Yes 01 GO TO QUESTION 32
No 02
DON’T KNOW DK GO TO QUESTION 32
REFUSED R GO TO QUESTION 32
31a. [AFTER TRANSITION ONLY] Do you want to work for pay?
Yes 01
No 02
DON’T KNOW DK
REFUSED R
32. [AFTER TRANSITION ONLY] Are you doing volunteer work or working without getting paid?
Probe: Are you doing work but not getting any money for it?
Yes 01 GO TO QUESTION 33
No 02
DON’T KNOW DK GO TO QUESTION 33
REFUSED R GO TO QUESTION 33
32a. [AFTER TRANSITION ONLY] Would you like to do volunteer work or work without getting paid?
Probe: would you like to do work without getting paid for it?
Yes 01
No 02
DON’T KNOW DK
REFUSED R
33. I’d like to ask you a few questions about how you get around. Do you go out to do fun things in your community?
Probe: These are things that you enjoy such as going to church, the movies or shopping?
Yes 01
No 02
DON’T KNOW DK
REFUSED R
34. When you want to go somewhere, can you just go, do you have to make some arrangements, or do you have to plan many days ahead and ask people for help?
Decide and Go 01
Plan Some 02
Plan Many Days Ahead 03
DON’T KNOW DK
REFUSED R
N/A…………………………………………NA
35. Do you miss things or have to change plans because you don’t have a way to get around easily?
Probe: Do you have to miss things because it is hard for you to get there?
Yes 01
No 02
Sometimes 03
DON’T KNOW DK
REFUSED R
36. Is their any medical care, such as a medical treatment or doctor’s visits, which you have not received or could not get to within the past month?
Probe: The medical care includes doctor visits or medical treatments that you may need.
Yes 01
No 02
DON’T KNOW DK
REFUSED R
37. Taking everything into consideration, during the past week have you been happy or unhappy with the help you get with things around the house or getting around your community?
Happy 01 GO TO QUESTION 37a
Unhappy 02 GO TO QUESTION 37b
DON’T KNOW DK GO TO QUESTION 38
REFUSED R GO TO QUESTION 38
37a Would you say you are a little happy or very happy?
A little happy 01 GO TO QUESTION 38
Very happy 02 GO TO QUESTION 38
Don’t Know DK GO TO QUESTION 38
Refused R GO TO QUESTION 38
37b Would you say you are a little unhappy or very unhappy?
A little unhappy 01
Very unhappy 02
Don’t Know DK
Refused R
38. Taking everything into consideration, during the past week have you been happy or unhappy with the way you live your life?
Happy 01 GO TO QUESTION 38a
Unhappy 02 GO TO QUESTION 38b
DON’T KNOW DK GO TO QUESTION 39
REFUSED R GO TO QUESTION 39
38a. Would you say you are a little happy or very happy?
A little happy 01 GO TO QUESTION 39
Very happy 02 GO TO QUESTION 39
Don’t Know DK GO TO QUESTION 39
Refused R GO TO QUESTION 39
38b. Would you say you are a little unhappy or very unhappy?
A little unhappy 01
Very unhappy 02
Don’t Know DK
Refused R
39. During the past week have you felt sad or blue?
Yes 01
No 02 GO TO QUESTION 40
DON’T KNOW DK GO TO QUESTION 40
REFUSED R GO TO QUESTION 40
39a. How often have you felt sad and blue? Would you say only sometimes or most of the time?
Sometimes 01
Most of the Time 02
DON’T KNOW DK
REFUSED R
40. During the past week have you felt irritable?
Probe: Irritable means grumpy or easily upset about things in your life.
Yes 01
No 02 GO TO QUESTION 41
DON’T KNOW DK GO TO QUESTION 41
REFUSED R GO TO QUESTION 41
40a. How often have you felt irritable? Would you say only sometimes or most of the time?
Probe: Irritable means grumpy or easily upset about things in your life.
Sometimes 01
Most of the Time 02
DON’T KNOW DK
REFUSED R
41. During the past week have you had aches and pains?
Yes 01
No 02 GO TO QUESTION 42
DON’T KNOW DK GO TO QUESTION 42
REFUSED R GO TO QUESTION 42
41a. How often do you have aches and pain? Would you say only sometimes or most of the time?
Sometimes 01
Most of the Time 02
DON’T KNOW DK
REFUSED R
42. Those are all the questions I have you now. We would like to talk with you in about a year or so to find out how you are doing. In case we have trouble reaching you, what is the name, address, and phone number of a close relative or friend who is not living with you and is likely to know your location in the future? For example, a mother, father, brother, sister, aunt, uncle, or close friend.
No Contact Available 01 GO TO QUESTION 43
Contact Available 02
42a. Contact Name:
42b. Contact Street Address:
42c. Contact City:
42d. Contact State:
42e. Contact ZIP
42f. Contact Phone:
43. Interviewer: Did you complete the interview with the sample member alone, the sample member who was assisted by another, or with a proxy?
Sample Member Alone 01
Sample Member with Assistance 02
Proxy 03
44. Interviewer: Record date the interview was completed:
[_________] [_________] [__________]
Month Day Year
END INTERVIEW
Prepared
by Mathematica Policy Research, Inc.
| File Type | application/msword |
| File Title | MEMORANDUM |
| Author | Letha Ferguson |
| Last Modified By | Carol Irvin |
| File Modified | 2007-12-06 |
| File Created | 2007-12-06 |