NSRCF - Facility Screener Questionnaire

Attachment G: Facility Screener Questionnaire

Form Approved

OMB No. 0920-0780

Exp. Date __xx/xx/20xx

NOTICE – Public reporting burden of 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: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0780). Assurance of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
Question number	Telephone Screener Question item	Code categories	Facility asked and skip pattern
S_I_ STATEMENT_A	I would like to verify some information we have about [SAMPLED FACILITY]. The questions I have right now should take just a few minutes. Your facility was chosen by a random selection process to represent residential care facilities like yours. All information you provide will be held in strict confidence and will be used only for statistical purposes. All published information will be presented in such a way that no individual facility, staff, or residents can be identified. Your participation is voluntary and there are no penalties for not participating in the survey; however, data from your facility are necessary to accurately portray residential care facilities.	1 CONTINUE[	All sampled facilities
S_1	Our records show that this facility is currently registered, licensed, or certified in [STATE] as a [LICENSURE CATEGORY]. Is this correct?	1 YES 2 NO	Single licensure facilities
S_1_MULT	Our records show that this facility has multiple [licenses/registrations/certifications] in [STATE] as a [LICENSE CATEGORIES]. Is this correct? INTERVIEWER: IF ANY OF THE MULTIPLE LICENSES CITED ARE INCORRECT, CODE “NO”	1 YES 2 NO	Multiple licensure facilities
S_1A	Is this facility licensed as... READ THIS STATE'S LICENSE CATEGORIES TO RESPONDENT. R WILL SELECT THE CORRECT LICENSE. IF NONE OF THE LISTED CATEGORIES APPLY TO THE FACILITY, YOU MAY SELECT 'NONE OF THE ABOVE'	SPECIFY	S_1 = 2 or S_1_MULT = 2
S_2	Does this residential care facility have 4 or more licensed, registered, or certified beds?	1 YES 2 NO	All sampled facilities
S_4	Does this facility exclusively serve adults with mental retardation or a developmental disability, such as Down syndrome or autism?	1 YES 2 NO 3 SERVES BOTH MR/DD EXCLUSIVELY	All sampled facilities
S_5	Does this facility exclusively serve adults with severe mental illness, such as schizophrenia or psychosis? Please do not include Alzheimer’s disease or other dementias.	1 YES 2 NO 3 SERVES BOTH MR/DD EXCLUSIVELY
S_6	Does this facility provide or arrange for a personal care aide, RN, or LPN to be located in the same building, in an attached building or next door, or on the same campus 24 hours a day, 7 days a week, to meet any resident needs that may arise? These needs can be met by the director or assistant director, if they provide personal care or nursing services to residents.	1 YES 2 NO 3 PROVIDED ON AN AS NEEDED BASIS	All sampled facilities
S_7	Does this facility offer help with activities of daily living, such as help with bathing, either directly or arranged through an outside vendor?	1 YES 2 NO	All sampled facilities
S_8	Does this facility offer assistance with the administration of medications, give reminders, or provide central storage of medications?	1 YES 2 NO	All sampled facilities
S_9	Does this facility offer at least 2 meals a day to residents?	1 YES 2 NO	All sampled facilities
NEW S_10	What is the current number of residents living at this residential care facility?	0 residents 1-999 residents	All sampled facilities
S_11	Are any of the following types of places on this same property or at the same location? By at the same location, I mean this campus or address, not necessarily the same building. You may select all that apply. Independent living or independent apartments Nursing home Rehabilitation subacute or postacute care unit in a nursing home Hospital	1 Independent living or independent apartments 2 Nursing home 3 Rehabilitation subacute or postacute care unit in a nursing home 4 Hospital 5 NONE OF THE ABOVE	All eligible facilities
S_12	Does this facility have a designated Alzheimer's or dementia special care unit that is part of the nursing home?	1 YES 2 NO	S_11= 2 or 3
S_13	Is this a continuing care retirement community, that is, a community that offers multiple levels of care, such as independent living, residential care, and skilled nursing care, and gives residents the opportunity to remain in the same community as their needs change?	1 YES 2 NO	S_11 = 1 and (2 or 3)
S_16	Based on your responses, your facility is eligible to participate in our study. I would like to set up an appointment for an in person interview. The questions about [SAMPLED FACILITY], which will take about an hour, should be completed by someone who is familiar with the operations of the facility, usually the administrator or director of the facility. In [SAMPLED FACILITY] is that you or someone else?	1 THE RESPONDENT 2 SOMEONE ELSE	All eligible facilities
S_16_OTH	Can you please give me his or her name?	SPECIFY	S_16 = 2
S_17	Then we collect data about three to six residents, depending on the size of your facility. These take about 15 minutes per resident. We do not interview residents directly rather we interview the staff person most familiar with the resident and the resident’s records. Will that be someone else on your staff, or will you do that (as well)? ADD IF NECESSARY: You do not need to decide now.	1 THE RESPONDENT 2 SOMEONE ELSE ON THE STAFF	All eligible facilities
S_17_OTH	Can you please give me his or her name?	SPECIFY	S_17 = 2
S_18a	Let me verify that I have the correct name and address for your facility. Is the correct name of your facility [NAME OF SAMPLED FACILITY]?	1 YES 2 NO	All eligible facilities
S_18a_NAME	Please tell me the correct name of your facility.	SPECIFY	S_18a = 2
S_18b	Is your facility located at: [STREET ADDRESS OF SAMPLED FACILITY]?	1 YES 2 NO	All eligible facilities
S_18B_ADD	Please tell me the correct street address of your facility.	SPECIFY	S_18b = 2
S_18B_CITY	What is the city?	SPECIFY	S_18b = 2
S_18B_STATE	What is the state? INTERVIEWER START TYPING STATE NAME AND SELECT FROM LOOK-UP TABLE.	SPECIFY	S_18b = 2
S_18B_Zip	What is the Zip code?	01000..99999	S_18b = 2
S_18C	Is this also your mailing address?	1 YES 2 NO	All eligible facilities
S_18C_MAIL	Please tell me the correct mailing address of your facility.	SPECIFY	S_18C= 2
S_RESP_NAME	Let me verify the spelling of the name of [RESPONDENT NAME] INTERVIEWER: SAY NAME AND READ SPELLING. ENTER ANY CORRECTIONS.	SPECIFY	All eligible facilities
S_END	PRESS "1" AND ENTER TO CONTINUE WITH THE HARD COPY "SET AN APPOINTMENT CALL".	1 CONTINUE	All eligible facilities
NEWOUTREACH	Before you received the package about this study, had you heard about this study through newsletters or other information provided by national organizations that support it, such as American Association of Homes and Services for the Aging (AAHSA), American Seniors Housing Association (ASHA), Assisted Living Federation of America (ALFA), or National Center for Assisted Living (NCAL)?	1 YES 2 NO	All sampled facilities
S_ELIG_2	Thank you very much for answering these questions. Unfortunately, this facility does not qualify for our study, which is focused on facilities that are in some way regulated by the State and provide a broader array of residential care services. I appreciate your time today.	1 CONTINUE	All ineligible facilities- (i.e., those that have any of the following: S_2=2, S_4=1, S_5=1, S_6=2, {S_7 AND S_8=2], S_9=2, NEW_S_10=0)

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