NSRCF - Resident Selection Questionnaire

Attachment J: Resident Selection 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	Resident Sampling Question item	Code categories	Resident Sampling skip pattern
P_CHECK	INTERVIEWER ENTER WHAT STAGE YOU HAVE REACHED IN INTERVIEWING THIS FACILITY.	1 HAVE COMPLETED THE FACILITY QUESTIONNAIRE 2 STARTED THE FACILITY QUESTIONNAIRE, IT IS NOT COMPLETE 3 HAVE NOT STARTED THE FACILITY QUESTIONNAIRE	All facilities
P_FA1	This is the first question included in the Pre-interview Worksheet that we mailed to your facility. If you have that form available it would be helpful to reference that now. At this facility, what is the number of licensed, registered, or certified residential care beds? INTERVIEWER: ACCORDING TO THE SCREENER, FACILITY HAS 4 OR MORE BEDS. IF FACILITY RESPONDENT TELLS YOU A NUMBER LESS THAN 4, PLEASE CLARIFY.	1..995	P_CHECK=3
P_FA1 (alternate wording)	I will now re-ask a question I asked earlier. This is because the information is needed for this next part of the interview. At this facility, what is the number of licensed, registered, or certified residential care beds? INTERVIEWER: ACCORDING TO THE SCREENER, FACILITY HAS 4 OR MORE BEDS. IF FACILITY RESPONDENT TELLS YOU A NUMBER LESS THAN 4, PLEASE CLARIFY.	1-995	P_CHECK=1 OR 2
P_FA1_CONFIRM	Can you confirm that your facility has less than 4 beds?	1 YES 2 NO	P_FA1=<4
P_FA1_ABORT	I am sorry but your facility is not eligible for this study. Thank you for your time.	1 CONTINUE	P_FA1_CONFIRM=1
P_FA1a	CAN’T ANSWER IN BEDS BECAUSE FACILITY IS LICENSED BY THE NUMBER OF UNITS, ASK: Thank you. In that case, what is the number of licensed, registered, or certified residential care rooms and apartments at this facility? CAPI CONVERTS LICENSED UNITS TO LICENSED BEDS BY MULTIPLYING P_FA1a BY STATE-SPECIFIC CONVERSION FACTOR PRELOADED WITH THIS FACILITY.	1-995	P_FA1= UNKNOWN BECAUSE LICENSED BY UNITS
P_INTRO_A	To help make a random selection of residents for our resident interviews, can you tell me the number of residents living in this residential care facility as of midnight last night? ENTER CURRENT NUMBER OF RESIDENTS.	1..995	P_CHECK = 1
P_INTRO_B	I will be able to complete the interviews about the residents now and come back to complete the facility information later. I'll need your help for a few more minutes right now. What is the current number of residents living at this residential care facility as of midnight last night? ENTER CURRENT NUMBER OF RESIDENTS.	1..995	P_CHECK = 2
P_INTRO_C	In order to obtain national level data about the residents of residential care facilities such as this one, we are collecting information from a sample of current residents. I will be asking questions about the background, health status, and charges for each sampled resident. I will need your help for a few minutes right now. What is the current number of residents living at this residential care facility as of midnight last night? ENTER CURRENT NUMBER OF RESIDENTS.	1..995	P_CHECK = 3
P_INTRO_OTHER	The next process is sampling the residents. In order to protect the confidentiality of your residents, I will need to work with someone who can best assist with selecting the sample from a list and locating staff who are familiar with the sampled residents Are you the best person to help the resident sampling process? INTERVIEWER: ASK FOR A SUBSTITUTE IF ONE IS AVAILABLE, TO ANSWER THESE QUESTIONS. OTHERWISE, USE ALT-X TO BREAKOFF THIS INTERVIEW IF NO ONE ELSE IS AVAILABLE OR IF ADMINISTRATOR NEEDS A BREAK FOR DUTIES OR OTHER REASONS.	1 YES 2 NO	All facilities
P_INTRO_START	We'll begin by selecting a sample of your residents. Because this is a statistical survey, I will need to follow procedures to do this. To start, I will ask you to provide a list of the current residents as of midnight last night. The sampling procedures do not require the full name of the residents. I will only record the initials of each resident. Each resident should be listed on a separate line. If you list by rooms or apartments, I will ask you how many residents are currently in each of the rooms or apartments. Then, I will briefly review the list with you. Finally after I enter the total number of current residents, the computer program will randomly choose which residents we will include in the sample.	1 CONTINUE	All facilities
P_CONFIRM	INTERVIEWER: WHEN YOU GET THE LIST FROM THE RESPONDENT, READ: I just need to confirm that this is a complete list of all the residents as of midnight last night. INTERVIEWER: LOOK AT THE LIST TOGETHER WITH THE RESPONDENT. Please take a moment to check for anyone on the list who was not a resident as of midnight last night or who is younger than 18 years old. Also check for new residents who might not be on the list but were admitted before midnight last night. To the best of your knowledge, is this list complete and accurate? INTERVIEWER: IF NO, ASK THE RESPONDENT TO MAKE ANY ADJUSTMENTS NECESSARY TO THE LIST. YOU WILL NOT BE ABLE TO PROCEED UNTIL THE LIST IS CORRECT AND THE RESPONSE IS YES.	1 YES 2 NO	All facilities
P_ENUMERATE	NUMBER THE RESIDENTS BEGINNING WITH 1. IF THERE ARE MULTIPLE PAGES OF RESIDENTS, THEN CONTINUE NUMBERING THE NEXT PAGE WHERE YOU LEFT OFF. THE PROGRAM WILL MAKE A RANDOM SELECTION WHICH WILL REFER TO YOUR PERSON-LEVEL NUMBERING. WHEN YOU ARE DONE NUMBERING, PRESS 1 TO CONTINUE	1 CONTINUE	All facilities
P_UNIT_RES	INTERVIEWER: IS THE LIST BY RESIDENTS OR ROOMS/APARTMENTS	1 RESIDENTS-GO TO SELECTION BY RESIDENT 2 ROOMS/APARTMENTS- GO TO SECTION BY ROOMS/APARTMENTS	All facilities
P_ASK_R	I have counted {n lines} on the list. Would you say that is an accurate number of residents? INTERVIEWER: IF THE RESPONSE IS NO THEN CORRECT AND RENUMBER THE LIST BEFORE ENTERING YES TO CONTINUE.	1 YES 2 NO	P_UNIT_RES = 1
P_NUM_R	INTERVIEWER: ENTER THE TOTAL NUMBER OF RESIDENTS ON THE CONFIRMED LIST.	1..999	P_ASK_R = 1
P_ASK_U	I have counted (n) rooms/apartments. Would you say that is an accurate number of rooms/apartments?	1 YES 2 NO	P_UNIT_RES = 2
p_end	PLEASE PRESS "1" AND ENTER TO CONTINUE.	1 CONTINUE	All facilities
S_Start	PLEASE PRESS "1" AND ENTER TO SELECT RESIDENTS AT THIS FACILITY.	1 CONTINUE	All facilities
S_ResinUnit	How many residents are in room/apartment- List [1]?	1-10	P_UNIT_RES = 2
S_CHOOSE_R	INTERVIEWER: THIS DISPLAY TELLS YOU WHICH ARE YOUR SELECTED CASES. MARK YOUR LISTS NOW BY CIRCLING THE SELECTED CASES. NOW SAY TO YOUR RESPONDENT: The computer program has identified the following residents [READ RESIDENTS SELECTED]. To complete interviews about these selected residents, I would like to speak with a caregiver who knows about them. Our Resident Questionnaire asks about services provided to the resident and a little about his or her background. I can interview different caregivers for different residents. I would like your help arranging to speak with the caregiver in a private place or some place where we won't be disturbed. The Resident Questionnaire takes about 20 minutes for each selected resident. It will also be helpful if the resident records for each of the residents selected could be retrieved before we begin these interviews.	1 CONTINUE	All facilities
S_RESIDENTID	Here I will record a description of our selected residents. INTERVIEWER: ENTER THE FIRST AND LAST INITIALS OF THE SAMPLED RESIDENTS. NO OTHER INFORMATION ABOUT THE RESIDENTS SHOULD BE ENTERED HERE.	1-6 SAMPLED RESIDENTS INITIALS	All facilities
S_End	PLEASE PRESS "1" AND ENTER TO CONTINUE.	1 CONTINUE	All facilities
S_THANKU	Thank you, now we can proceed with the Resident portion of the study.	1 CONTINUE	All facilities

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