NSRCF - Resident Questionnaire

Attachment K: Resident Data Collection 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 20 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 Survey Question item	Code categories	Resident asked and Skip pattern
R_A_INTRO1	INTERVIEWER READ ONLY ONCE FOR EACH RESPONDENT: 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. The information you provide will be held in strict confidence and will be used only by persons involved in the survey and only for the purpose of the survey. The interview for each of the selected residents should take about 15 minutes to complete. IF NEEDED, HAND R CONFIDENTIALITY BROCHURE.	1 CONTINUE	All facilities
R_A_INTRO1A	INTERVIEWER: MAKE SURE THE RESPONDENT KNOWS WHICH RESIDENT WAS SAMPLED FOR THIS INTERVIEW. TELL THE RESPONDENT THAT YOU WILL BE REFERRING TO THE RESIDENT BY THEIR INITIALS THROUGHOUT THE INTERVIEW. Now I am going to ask questions about the following resident – [RESIDENT INITIALS].	1 CONTINUE	All residents
R_A_INTRO2	Do you have the resident records for [RESIDENT INITIALS]? (You may want to use the resident file in answering a few of the questions in this survey. If you have not retrieved the records and would like to do so now, I can wait a few minutes while you obtain them.)	1 RECORD OBTAINED 2 RECORD NOT OBTAINED	All residents
R_A1	Please tell me [RESIDENT INITIALS] gender?	1 MALE 2 FEMALE	All residents
R_A3	Is [RESIDENT INITIALS] of Hispanic, Latino, or Spanish origin or descent?	1 YES 2 NO	All residents
R_A2	Please tell me [RESIDENT INITIALS] age?	0..120	All residents
ENDINT	I am sorry but our survey is about residents that are 18 or older. Since this person is not eligible, I won't complete an interview for this particular resident. I need to check my records for any other selected residents for whom you were identified as a caregiver.	1 CONTINUE	R_A2 = < 18
R_A4	HAND R SHOWCARD Which one or more of the following would you say is [RESIDENT INITIALS] race? SELECT ALL THAT APPLY	1 WHITE/CAUCASIAN 2 BLACK OR AFRICAN AMERICAN 3 ASIAN 4 HAWAIIAN OR OTHER PACIFIC ISLANDER 5 AMERICAN INDIAN OR ALASKA NATIVE	All residents
R_A5	What is the highest grade or level of education [RESIDENT INITIALS] completed…? High school or less or Some college or more	1 High school or less 2 Some college or more	All residents
R_A6	Is [RESIDENT INITIALS] currently married, divorced, legally separated, widowed, or never married?	1 Married 2 Divorced 3 Legally separated 4 Widowed 5 Never married	All residents
R_A7	How well does [RESIDENT INITIALS] speak English…? Excellent very well well fair poor or not at all	1 Excellent 2 Very well 3 Well 4 Fair 5 Poor or not at all 6 DOES NOT SPEAK BECAUSE OF A DISABILITY, OR SEVERE DEMENTIA	All residents
R_A8a	Overall, is [RESIDENT INITIALS] health…? Excellent very good good fair or poor	1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor	All residents
R_A9	HAND R SHOWCARD Which of these places best describes [RESIDENT INITIALS] living quarters?	1.ROOM DESIGNED FOR ONE PERSON 2. ROOM DESIGNED FOR TWO PERSONS 3. ROOM DESIGNED FOR THREE OR MORE PERSONS 4. STUDIO APARTMENT 5 ONE BEDROOM APARTMENT 6. TWO BEDROOM APARTMENT 7. THREE BEDROOM APARTMENT	All residents
R_A10	Does [RESIDENT INITIALS] currently share this (room/apartment) with another person?	1 YES 2 NO	All residents
R_A11	Is this person [RESIDENT INITIALS] spouse or other relative?	1 YES 2 NO	If R_A10=1
R_A12	How many other residents not counting [RESIDENT INITIALS] live in the (room/apartment)?	1 ONE OTHER PERSON 2 TWO OR MORE OTHER PERSONS	If R_A10=1
R_A13	Does [RESIDENT INITIALS] live in a Dementia/Alzheimer's Special Care Unit?	1 YES 2 NO 3 FACILITY DOES NOT HAVE DEMENTIA/ ALZHEIMERS UNIT	All residents
New question	HAND R SHOWCARD Which of the following are located inside [RESIDENT INITIALS] (room/apartment)? SELECT ALL THAT APPLY	1.MICROWAVE 2 COOK TOP OR HOT PLATE 3 OVEN 4 REFRIGERATOR 5 KITCHEN SINK 6 NONE OF THE ABOVE	All residents
R_A15	Does [RESIDENT INITIALS] (room/apartment) have a door to the hallway that can be locked from the inside?	1 YES 2 NO	All residents
R_A15A	Does [RESIDENT INITIALS] (room/apartment) have a bathroom located inside the (room/apartment)?	1 YES 2 NO	All residents
R_A15Bath	HAND R SHOWCARD Which type of bathroom is in [RESIDENT INITIALS] (room/apartment) . .	1 FULL BAHTROOM INCLUDING A TOILET, SINK, AND SHOWER OR TUB 2 HALF-BATH INCLUDING A SINK AND TOILET	If R_A15A=1
R_A16	HAND R SHOWCARD Please read this list of activities and tell me whether [RESIDENT INITIALS] regularly participates in any of these at least twice a month, regardless of whether or not it is arranged by the facility. SELECT ALL THAT APPLY	1 CARDS, BOARD GAMES, BINGO, PUZZLES 2 ARTS OR CRAFTS, SUCH AS SEWING, KNITTING, PAINTING, QUILTING, FLOWER ARRANGING 3 EXERCISE OR SPORTS 4 PLAYING, OR LISTENING TO MUSIC, OR SINGING 5 READING OR WRITING 6 SPIRITUAL OR RELIGIOUS ACTIVITIES 7 SHOPPING OR TRIPS 8 WATCHING TELEVISION 9 LEAVING THE FACILITY GROUNDS 10 TALKING WITH FRIENDS OR RELATIVES 11GOING OUT TO THE MOVIES, DINING OUT OR OTHER SOCIAL ACTIVITIES 12 GARDENING 13 TAKING CARE OF PETS 14 OTHER HOBBIES OR ACTIVITIES 15 NONE OF THE ABOVE	All residents
R_A16_outside	HAND R SHOWCARD Does [RESIDENT INITIALS] go outside the facility to do any of the following activities? SELECT ALL THAT APPLY	1 WORK AT A JOB FOR PAY 2 PARTICIPATE IN A SHELTERED WORKSHOP 3 PARTICIPATE IN A WORK TRAINING PROGRAM 4 ATTEND DAY PROGRAMS FOR SOCIAL OR RECREATIONAL ACTIVITIES 5 ATTEND AN EDUCATIONAL PROGRAM 6 ATTEND AN ADULT DAY CARE PROGRAM 7 NONE OF THE ABOVE	All residents
R_A17	Does [RESIDENT INITIALS] still drive?	1 YES 2 NO	All residents
R_A18	How often does [RESIDENT INITIALS] drive? Daily or every other day Once or twice a week or Less than once per week	1 Daily or every other day 2 Once or twice a week 3 Less than once per week	If R_A17=1
R_AEND	PRESS "1" AND ENTER TO CONTINUE.	1 CONTINUE
R_B1Month	When did [RESIDENT INITIALS] first move into this facility? MONTH	1 January 2 February 3 March 4 April 5 May 6 June 7 July 8 August 9 September 10 October 11 November 12 December	All residents
R_B1Year	(When did [RESIDENT INITIALS] first move into this facility?) YEAR	1970..2010	All residents
R_B1Range	HAND R SHOWCARD Please look at this card and tell me approximately how long it has been since [RESIDENT INITIALS] first moved into this facility?	1 0 TO 3 MONTHS 2 MORE THAN 3 MONTHS TO 6 MONTHS 3 MORE THAN 6 MONTHS TO 1 YEAR 4 MORE THAN 1 YEAR TO 3 YEARS 5 MORE THAN 3 YEARS TO 5 YEARS 6 MORE THAN 5 YEARS	If R_B1Year = DK
R_B2	When [RESIDENT INITIALS] first moved into this facility, was (he/she) directly admitted from a short-term stay at a: READ CHOICES hospital rehabilitation facility nursing home	1 Hospital 2 Rehabilitation facility 3 Nursing home 4 NONE OF THE ABOVE	All residents
R_B3	HAND R SHOWCARD Where did (he/she) live prior to (his/her) (moving to this facility/stay at the (hospital/rehabilitation facility/nursing home))?	1 PRIVATE HOME, APARTMENT, RENTED ROOM, OR FAMILY RESIDENCE 2 DIFFERENT RESIDENTIAL CARE, ASSISTED LIVING, OR GROUP HOME FACILITY 3 RETIREMENT OR INDEPENDENT LIVING COMMUNITY 4 NURSING HOME (THIS EXCLUDES SHORT NURSING HOME STAYS FOR REHABILITATION) 5 PSYCHIATRIC FACILITY 6 JAIL 7 HOMELESS 8 OTHER	All residents
R_B4	For last month, what was the total charge for [RESIDENT INITIALS] to live in this facility? Include the basic monthly charge and charges for any additional services. INTERVIEWER: IF RESIDENT LIVES WITH ANOTHER RESIDENT AND CHARGES ARE PROVIDED COLLECTIVELY, HAVE RESPONDENT TAKE ONE HALF OF THE AMOUNT OF THE BASIC MONTHLY CHARGE AND ADD CHARGES FOR ADDITIONAL SERVICES FOR SAMPLED RESIDENT	0..8000	All residents
R_B5	During the last 30 days did [RESIDENT INITIALS] have any of (his/her) long-term care services at this facility paid by Medicaid?	1 YES 2 NO	All residents
R_B6	Is [RESIDENT INITIALS] a veteran of U.S. Military service?	1 YES 2 NO	All residents
R_BEND	PRESS "1" AND ENTER TO CONTINUE.	1 CONTINUE
R_C_INTRO	The next questions are about [RESIDENT INITIALS] health status and physical functioning.	1 CONTINUE	All residents
R_C1	HAND R SHOWCARD As far as you know, has a doctor or other health professional ever diagnosed [RESIDENT INITIALS] with any of the following conditions? Please tell me the numbers that apply from this card. SELECT ALL THAT APPLY	1 ALZHEIMER’S DISEASE OR OTHER DEMENTIA 2 ANEMIA 3 ARTHRITIS OR RHEUMATOID ARTHRITIS 4 ASTHMA 5 CANCER OR MALIGNANT 6 NEOPLASM OF ANY KIND 7 CEREBRAL PALSY 8 CHRONIC BRONCHITIS 9 CONGESTIVE HEART FAILURE 10 COPD 11 CORONARY HEART DISEASE 12 DEPRESSION 13 DIABETES 14 EMPHYSEMA 15 GLAUCOMA 16 GOUT, LUPUS, OR FIBROMYALGIA 17 HEART ATTACK (MYOCARDIAL INFARCTION) 18 HIGH BLOOD PRESSURE OR HYPERTENSION 19 INTELLECTUAL OR DEVELOPMENTAL DISABILITIES SUCH AS MENTAL RETARDATION, SEVERE AUTISM, OR DOWN SYNDROME 20 KIDNEY DISEASE 21 MACULAR DEGENERATION 22 MUSCULAR DYSTROPHY 23 NERVOUS SYSTEM DISORDERS, INCLUDING MULTIPLE SCLEROSIS, PARKINSON’S DISEASE, AND EPILEPSY 24 OSTEOPOROSIS 25 OTHER MENTAL, EMOTIONAL OR NERVOUS CONDITION 26 PARTIAL OR TOTAL PARALYSIS 27 SERIOUS MENTAL PROBLEMS SUCH AS SCHIZOPHRENIA OR PSYCHOSIS 28 SPINAL CORD INJURY STROKE 29 TRAUMATIC BRAIN INJURY 30 ANY OTHER KIND OF HEART CONDITION OR HEART DISEASE (OTHER THAN LISTED ABOVE) 31 OTHER 32 NONE OF THESE	All residents
R_C1_Cancer	What kind of cancer? . SELECT ALL THAT APPLY	1 BLADDER 2 BLOOD 3 BONE 4 BRAIN 5 BREAST 6 CERVIX 7 COLON 8 ESOPHAGUS 9 GALLBLADDER 10 KIDNEY 11 LARYNX, WINDPIPE 12 LEUKEMIA 13 LIVER 14 LUNG 15 LYMPHOMA 16 MELANOMA 17 MOUTH, TONGUE, OR LIP 18 OVARY 19 PANCREAS 20 PROSTATE 21 RECTUM 22 SKIN, NON-MELANOMA 23 SKIN, DON'T KNOW WHAT KIND 24 SOFT TISSUE (MUSCLE OR FAT) 25 STOMACH 26 TESTIS 27 THROAT, PHARYNX 28 THYROID 29 UTERUS 30 OTHER	R_C1= CANCER
R_C1OTH	Specify other condition.	SPECIFY	R_C1_Cancer = 30
NEWR_XX1	HAND R SHOW CARD HAND R SHOWCARD Please look at this card and tell me which category best describes [RESIDENT INITIALS] documented vaccination status for a flu shot during the past 12 months.	1 VACCINATED WHILE RESIDING AT THIS FACILITY 2 VACCINATED BEFORE ADMISSION TO THIS FACILITY 3 NOT VACCINATED IN PAST 12 MONTHS – NO RECORD OF DOCTOR’S ORDER OR OF VACCINATION OFFERED 4 NOT VACCINATED IN PAST 12 MONTHS- VACCINATION MEDICALLY CONTRAINDICATED 5 NOT VACCINATED IN PAST 12 MONTHS- RESIDENT/FAMILY REFUSED VACCINATION 6 NOT VACCINATED IN PAST 12 MONTHS – OTHER REASON 7 NOT VACCINATED IN PAST 12 MONTHS – REASON UNKNOWN 8 DID NOT RESIDE IN THE FACILITY DURING THE MOST RECENT FLU SEASON	All residents
NEWR_XX2	HAND R SHOW CARD Which statement on this card best describes the documented vaccination status for whether [RESIDENT INITIALS] has ever had a pneumococcal vaccine?	1 VACCINATED WHILE RESIDING AT THIS FACILITY 2 VACCINATED BEFORE ADMISSION TO THIS FACILITY 3 NEVER VACCINATED – NO RECORD OF DOCTOR’S ORDER OR OF VACCINATION OFFERED 4 NEVER VACCINATED-VACCINATION MEDICALLY CONTRAINDICATED 5 NEVER VACCINATED- RESIDENT/FAMILY REFUSED VACCINATION 6 NEVER VACCINATED – OTHER REASON 7 NEVER VACCINATED – REASON UNKNOWN	All residents
R_C1_impair_4	HAND R SHOWCARD Which statement on this card best describes [RESIDENT INITIALS] hearing without a hearing aid?	1 HEARING IS GOOD 2 HAS A LITTLE TROUBLE HEARING 3 HAS A LOT OF TROUBLE HEARING 4 DEAF	All residents
R_C1_impair_6	Is [RESIDENT INITIALS] blind in both eyes or unable to see?	1 YES 2 NO	All residents
R_C1_impair_5	Does [RESIDENT INITIALS] have any trouble seeing even when wearing glasses or contact lenses	1 YES 2 NO	R_C1_impair_6 = 2
R_C2a	These next questions refer to the (past 12 months/# of months since [RESIDENT INITIALS] moved into this residential care facility). During this time, has [RESIDENT INITIALS] been treated in a hospital emergency room?	1 YES 2 NO	All residents
R_C2b	{This question refers to the (past 12 months/# months since [RESIDENT INITIALS] moved into this residential care facility)} During this time, has [RESIDENT INITIALS] been a patient in a hospital overnight or longer (excluding trips to the emergency room that did not result in a hospital stay)?	1 YES 2 NO	All residents
R_C2c	{This question refers to the (past 12 months/# months since [RESIDENT INITIALS] moved into this residential care facility)} during this time has [RESIDENT INITIALS]] had a stroke	1 YES 2 NO	All residents
R_C2d	{This question refers to the (past 12 months/# months since [RESIDENT INITIALS] moved into this residential care facility)} during this time has [RESIDENT INITIALS] had a heart attack	1 YES 2 NO	All residents
R_C2e	{This question refers to the (past 12 months/# months since [RESIDENT INITIALS] moved into this residential care facility)} during this time has [RESIDENT INITIALS] had a fall that caused a hip fracture	1 YES 2 NO	All residents
R_C2f	{This question refers to the (past 12 months/# months since [RESIDENT INITIALS] moved into this residential care facility)} during this time has [RESIDENT INITIALS] had a fall that caused an injury other than a hip fracture	1 YES 2 NO	All residents
R_C2g	{This question refers to the (past 12 months/# months since [RESIDENT INITIALS] moved into this residential care facility)} during this time has [RESIDENT INITIALS] had a stay in a nursing home	1 YES 2 NO	All residents
New question R)C2i	During the { past 12 months/# months since [RESIDENT INITIALS] moved into this residential care facility)} has [RESIDENT INITIALS] had a stay in a rehabilitation facility?	1 YES 2 NO	All residents
R_C3	How many times has [RESIDENT INITIALS] been treated in a hospital emergency room over this period?	1..35	R_C2a = 1
R_C4	HAND R SHOWCARD Does [RESIDENT INITIALS] currently use any of the items listed on this card? SELECT ALL THAT APPLY	1 DENTURES, INCLUDING A PARTIAL PLATE 2 GLASSES OR CONTACT LENSES 3 HEARING AID 4 CANE, INCLUDING A TRIPOD CANE 5 WALKER 6 MANUAL WHEEL CHAIR 7 ELECTRIC OR MOTORIZED WHEEL CHAIR OR SCOOTER 8 OXYGEN 9 COMMUNICATION BOARD OR OTHER APPLIANCE TO COMMUNICATE 10 ARTIFICIAL LIMB 11 NONE OF THE ABOVE	All residents
R_C4a	Does [RESIDENT INITIALS] currently use telescopic lenses, Braille, readers, a guide dog, white cane, or any other equipment for people with severe visual impairments?	1 YES 2 NO	R_C1_impair_ 6 = 1
R_C5a	Is [RESIDENT INITIALS] limited in any way because of difficulty remembering or because [RESIDENT INITIALS] experiences periods of confusion?	1 YES 2 NO	All residents
R_C5	During the last 7 days, has [RESIDENT INITIALS] given evidence of a problem with short-term memory, such as difficulty remembering what (he/she) had for breakfast or something you told (he/she) a few minutes earlier?	1 YES 2 NO	All residents
R_C6	During the last 7 days, has [RESIDENT INITIALS] given evidence of a problem with long-term memory, such as forgetting how old (he/she) is or forgetting that (he/she) was married?	1 YES 2 NO	All residents
R_C7	During the last 7 days, has [RESIDENT INITIALS] had any of the following problems with orientation, such as: Knowing the location of (his/her) bedroom? Recognizing staff names or faces? Knowing that (he/she) is in a facility? Knowing what the season of the year it is? READ CHOICES. SELECT ALL THAT APPLY	1 Knowing the location of (his/her) bedroom 2 Recognizing staff names or faces 3 Knowing that (he/she) is in a facility 4 Knowing what the season of the year it is 5 NONE OF THE ABOVE	All residents
R_C8	HAND R SHOWCARD The next question refers to the resident’s actual performance in making everyday decisions about the tasks or activities of daily living. During the last 7 days, which of these answers best describes [RESIDENT INITIALS] decision-making about such things as what to wear, how to organize (his/her) day, etc? Please tell me the number from the card. NOTE: THIS REFERS TO THE COGNITIVE ABILITY OF THE RESIDENT TO MAKE ACTUAL EVERYDAY DECISIONS ABOUT TASKS OR ACTIVITIES OF DAILY LIVING. EXAMPLES ARE CHOOSING CLOTHING THAT IS APPROPRIATE TO THE WEATHER AND THE ACTIVITY, KNOWING WHEN TO GO TO SCHEDULED MEALS OR ACTIVITIES, USING CUES LIKE CLOCKS APPROPRIATELY, AND SEEKING INFORMATION APPROPRIATELY WHEN MAKING DECISIONS, AND HOW THE RESIDENT HANDLES BEING IN A NEW SITUATION, SUCH AS A FIELD TRIP OUTSIDE THE FACILITY, A NEW ACTIVITY, OR BEING MOVED TO A NEW TABLE FOR MEALS	1 INDEPENDENT - DECISIONS WERE CONSISTENT, REASONABLE 2 MODIFIED INDEPENDENCE - HE/SHE HAD SOME DIFFICULTY IN NEW SITUATIONS 3 MODERATELY IMPAIRED - HIS/HER DECISIONS WERE POOR; CUES AND SUPERVISION WERE REQUIRED 4 SEVERELY IMPAIRED- HE/SHE NEVER OR RARELY MADE DECISIONS	All residents
R_C9	HAND R SHOWCARD During the last 7 days, which of these answers best describes [RESIDENT INITIALS] ability to make (himself/herself) understood by others? Please tell me the number from the card.	1 ALWAYS UNDERSTOOD BY OTHERS 2 USUALLY UNDERSTOOD - DIFFICULTY FINDING WORDS OR FINISHING THOUGHTS 3 SOMETIMES UNDERSTOOD - ABILITY IS LIMITED TO MAKING CONCRETE REQUESTS 4 RARELY OR NEVER UNDERSTOOD	All residents
R_C9a	Is [RESIDENT INITIALS] difficulty in making (himself/herself) understood by others due to a severe speech impairment or other disability?	1 YES 2 NO	R_C9 = 2-4
R_C10	Next, I would like to ask about everyday activities and whether [RESIDENT INITIALS] receives any assistance in doing them. By assistance, I mean help from special equipment, another person or both. READ THE ABOVE STATEMENT ONLY ONCE PER RESPONDENT	1 CONTINUE
R_c10a	Does [RESIDENT INITIALS] currently receive assistance in bathing or showering? This includes standby assistance.	1 YES 2 NO	All residents
R_c10a1	Does [RESIDENT INITIALS] bathe or shower with the help of: Special Equipment Another Person CODE ALL THAT APPLY.	1 Special Equipment 2 Another Person	R_c10a=1
R_c10b	Does [RESIDENT INITIALS] currently receive assistance in dressing? This includes standby assistance.	1 YES 2 NO	All residents
R_c10b1	Does [RESIDENT INITIALS] dress with the help of: Special Equipment, such as zipper pulls or button hook aids Another Person CODE ALL THAT APPLY.	1 Special Equipment 2 Another Person	R_c10b=1
R_c10c	Does [RESIDENT INITIALS] currently receive assistance in eating, such as cutting up food, or cueing?	1 YES 2 NO	All residents
R_c10c1	Does [RESIDENT INITIALS] eat with the help of: Special Equipment Another Person CODE ALL THAT APPLY.	1 Special Equipment 2 Another Person	R_c10c=1
R_C10d	Is [RESIDENT INITIALS] confined to bed by health problems?	1 YES 2 NO	All residents
R_C10e	Is [RESIDENT INITIALS] confined to a chair by health problems?	1 YES 2 NO	R_C10d = 2
R_C10f	Does [RESIDENT INITIALS] currently receive any assistance in transferring in and out of bed or a chair?	1 YES 2 NO	R_C10e = 2
R_C10f1	Does [RESIDENT INITIALS] transfer in or out of a bed or a chair with the help of: Special Equipment Another Person CODE ALL THAT APPLY.	1 Special Equipment 2 Another Person	R_C10f = 1
R_C10g	Does [RESIDENT INITIALS] currently receive any assistance in walking?	1 YES 2 NO	R_C10d = 2 and R_C10e = 2
R_C10g1	Does [RESIDENT INITIALS] walk with the help of: Special Equipment Another Person CODE ALL THAT APPLY.	1 Special Equipment 2 Another Person	R_C10g = 1
R_C10h	Does [RESIDENT INITIALS] currently receive any assistance going outside the grounds of this facility?	1 YES 2 NO 3 DOES NOT GO OUTSIDE FACILITY GROUNDS	R_C10d = 2 and R_C10e = 2
R_C10h1	When [RESIDENT INITIALS] goes outside the grounds does [RESIDENT INITIALS} require the help of: Special Equipment Another Person CODE ALL THAT APPLY.	1 Special Equipment 2 Another Person	R_C10h = 1
R_C10i	Does [RESIDENT INITIALS] have an ostomy, an indwelling catheter or similar device?	1 YES 2 NO	All residents
R_C10i1	Does [RESIDENT INITIALS] receive any help from another person in caring for this device?	1 YES 2 NO	R_C10i = 1
R_C10j	Does [RESIDENT INITIALS] currently receive any assistance using the bathroom?	1 YES 2 NO 3 DOES NOT USE TOILET (AN OSTOMY PATIENT, CHAIRFAST, ETC.)	All residents
R_C10j1	Does [RESIDENT INITIALS] require the help of: Special equipment Another person CODE ALL THAT APPLY.	1 Special equipment 2 Another person	R_C10j = 1
R_C10k	Has [RESIDENT INITIALS] had any episode of bowel incontinence during the last 7 days?	1 YES 2 NO 3 NOT APPLICABLE (E.G., HAD A COLOSTOMY, ILEOSTOMY)	All residents
R_C10l	Has [RESIDENT INITIALS] had any episode of urinary incontinence during the last 7 days?	1 YES 2 NO 3 NOT APPLICABLE (E.G., HAS AN INDWELLING CATHETER, HAD AN UROSTOMY)	All residents
R_C10m	Is [RESIDENT INITIALS] able to get out of the facility without the help of another person in case of an emergency? IF VERBAL CUEING REQUIRED, CODE NO	1 YES 2 NO	R_C10d ≠ 1 and R_C10e ≠ 1
R_C11	HAND R SHOWCARD For the next questions, please tell me whether or not [RESIDENT INITIALS] needs help from another person or does not perform this activity.	1 CONTINUE
R_C11a	Does [RESIDENT INITIALS] currently need help from another person with: Going shopping for personal items, such as toilet items or medicine. If the only help [RESIDENT INITIALS] needs is for transportation to and from the store, choose “No.” NOTE: DOES NOT INCLUDE TRANSPORTATION TO AND FROM STORE. INTENDED TO DETERMINE WHETHER RESIDENT CAN MAKE DECISIONS ABOUT WHAT TO PURCHASE, LOCATE THE ITEMS, ETC…	1 YES, NEEDS HELP 2 NO, DOES NOT NEED HELP 3 DOES NOT PERFORM THIS ACTIVITY	All residents
R_C11b	(Does [RESIDENT INITIALS] currently need help from another person with:) Managing money, such as keeping track of expenses or paying bills?	1 YES, NEEDS HELP 2 NO, DOES NOT NEED HELP 3 DOES NOT PERFORM THIS ACTIVITY	All residents
R_C11c	Does [RESIDENT INITIALS] currently need help from another person or a special device with: Using the telephone? This includes TTY or dialing out.	1 YES, NEEDS HELP 2 NO, DOES NOT NEED HELP 3 DOES NOT PERFORM THIS ACTIVITY	All residents
R_C11c_1	Does [RESIDENT INITIALS] receive help using the telephone from another person or a special device?	1 ANOTHER PERSON 2 SPECIAL DEVICE 3 BOTH	R_C11c = 1
R_C11d	Does [RESIDENT INITIALS] currently need help from another person with: Doing light housework, like straightening up (his/her) room or apartment?	1 YES, NEEDS HELP 2 NO, DOES NOT NEED HELP 3 DOES NOT PERFORM THIS ACTIVITY	All residents
R_C11e	(Does [RESIDENT INITIALS] currently need help from another person with:) Taking medication -- this includes opening the bottle, remembering to take medication on time, and taking the prescribed dosage?	1 YES, NEEDS HELP 2 NO, DOES NOT NEED HELP 3 DOES NOT TAKE ANY MEDICATION	All residents
R_C12a	Does [RESIDENT INITIALS] now use an amplifier for the telephone, a TDD, TTY or teletype, closed caption TV, assistive listening or signaling devices, an interpreter, or any other equipment for people with hearing or speech impairments?	1 YES 2 NO	All residents
R_C13	Does [RESIDENT INITIALS] have a landline telephone or cellular telephone in (his/her) room?	1 YES 2 NO	All residents
R_C12	HAND R SHOWCARD Over the last 30 days, how often did [RESIDENT INITIALS] receive one or more outside visitors?	1 EVERY DAY 2 AT LEAST SEVERAL TIMES A WEEK 3 ABOUT ONCE A WEEK 4 SEVERAL TIMES DURING THE PAST 30 DAYS BUT LESS THAN EVERY WEEK 5 AT LEAST ONCE IN THE LAST 30 DAYS 6 NOT AT ALL IN THE LAST 30 DAYS	All residents
R_C12a1	HAND R SHOWCARD Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to... Walk a quarter mile, about three city blocks? Please tell me the number that applies from this card.	1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN’T DO AT ALL- HEALTH REASON 6 DOES NOT DO- OTHER REASON	R_C10d and R_C10e ≠ 1
R_C12a2	Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to... Walk up 10 steps without resting?	1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN’T DO AT ALL-HEALTH REASON 6 DOES NOT DO- OTHER REASON	R_C10d ≠ 1 and R_C10e ≠ 1
R_C12a3	Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to... Stand or be on feet for about two hours?	1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN’T DO AT ALL- HEALTH REASON 6 DOES NOT DO- OTHER REASON	R_C10d ≠ 1 and R_C10e ≠ 1
R_C12a4	(Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS]) Sit for about two hours?	1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN’T DO AT ALL- HEALTH REASON 6 DOES NOT DO- OTHER REASON	All residents
R_C12a5	(Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to) Stoop, bend, or kneel?	1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN’T DO AT ALL- HEALTH REASON 6 DOES NOT DO- OTHER REASON	R_C10d ≠ 1 and R_C10e ≠ 1
R_C12a6	(Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to) Reach up over head?	1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN’T DO AT ALL- HEALTH REASON 6 DOES NOT DO- OTHER REASON	All residents
R_C12a7	(Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to) Use fingers to grasp or handle small objects?	1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN’T DO AT ALL- HEALTH REASON 6 DOES NOT DO- OTHER REASON	All residents
R_C12a8	Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to) Lift or carry something as heavy as 10 pounds, such as a bag of groceries?	1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN’T DO AT ALL- HEALTH REASON 6 DOES NOT DO- OTHER REASON	All residents
R_C12a9	(Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to) Push or pull a large object like a living room chair?	1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN’T DO AT ALL- HEALTH REASON 6 DOES NOT DO- OTHER REASON	All residents
R_C12a10	Without assistance and without equipment, how difficult is it for [RESIDENT INITIALS] to) Go out to do things like shopping, movies, or sporting events?	1 NOT AT ALL DIFFICULT 2 ONLY A LITTLE DIFFICULT 3 SOMEWHAT DIFFICULT 4 VERY DIFFICULT 5 CAN’T DO AT ALL- HEALTH REASON 6 DOES NOT DO- OTHER REASON	R_C10d ≠ 1 and R_C10e ≠ 1
R_C14	In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?	1 CONTINUE
R_C14a	HAND R SHOWCARD (In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Refusing to take prescribed medicines at the appropriate time or in the prescribed dosage-	1 OFTEN 2 SOMETIMES(INCLUDES 1TIME) 3 NEVER 4 RESIDENT DOES NOT TAKE ANY PRESCRIBED MEDICATIONS 5 FACILITY DOES NOT HANDLE RESIDENTS' MEDICATIONS	All residents
R_C14c	(In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Creating disturbances or being excessively noisy by knocking on doors or yelling or being verbally abusive?	1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never	All residents
R_C14cc	(In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Wandering or moving aimlessly about in the building or on the grounds?	1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never	All residents
R_C14d	(In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Refusing to bathe or clean (himself/herself)?	1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never	All residents
R_C14e	(In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Rummaging through or taking other people's belongings?	1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never	All residents
R_C14f	(In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Damaging or destroying property?	1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never	All residents
R_C14g	(In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Verbally threatening other persons including staff or other residents?	1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never	All residents
R_C14h	(In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Being physically aggressive towards other persons including staff or other residents?	1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never	All residents
R_C14i	(In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Removing clothing in public?	1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never	All residents
R_C14j	In the past 30 days, how often has [RESIDENT INITIALS] exhibited any of the following behaviors?) Making unwanted sexual advances towards staff or other residents?	1 Often 2 Sometimes (INCLUDES 1 TIME) 3 Never	All residents
R_C15	Does a physician ever prescribe medications to help control [RESIDENT INITIALS] behavior or to reduce agitation?	1 YES 2 NO	R_C14a-j: = 1 or 2 in any of these questions
R_C16	HAND R SHOWCARD The following services may be offered by facility staff or provided at the facility by non-facility staff. Please look at this Showcard and tell me if [RESIDENT INITIALS] uses any of these services. SELECT ALL THAT APPLY	1 SPECIAL DIETS 2 ASSISTANCE WITH ACTIVITIES OF DAILY LIVING 3 ASSISTANCE WITH A BATH OR SHOWER AT LEAST ONCE A WEEK 4 SKILLED NURSING SERVICES 5 BASIC HEALTH MONITORING SUCH AS BLOOD PRESSURE AND WEIGHT CHECKS 6 SOCIAL AND RECREATIONAL ACTIVITIES WITHIN THE FACILITY 7 SOCIAL AND RECREATIONAL ACTIVITIES OUTSIDE THE FACILITY 8 INCONTINENCE CARE 9 TRANSPORTATION TO MEDICAL APPOINTMENTS 10 TRANSPORTATION TO STORES AND ELSEWHERE 11 PERSONAL LAUNDRY 12 LINEN LAUNDRY SERVICES 13 SOCIAL SERVICES COUNSELING 14 NONE OF THE ABOVE	All residents
R_C17a	HAS THIS RESPONDENT ALSO COMPLETED EITHER THE FACILITY QUESTIONNAIRE OR ANOTHER RESIDENT'S QUESTIONNAIRE?	1 YES 2 NO
R_C17	The next few questions are about you. How long have you worked at this facility?	1 6 MONTHS OR LESS 2 MORE THAN 6 MONTHS BUT LESS THAN ONE YEAR 3 AT LEAST ONE YEAR TO LESS THAN TWO YEARS 4 TWO YEARS OR MORE	R_C17a = 2
R_C18	HAND R SHOWCARD Please look at this card and tell me which best describes your position at this facility:	1 RN 2 LPN 3 CERTIFIED MEDICATION AIDE 4 NURSING ASSISTANT/CNA/ PERSONAL CARE AIDE 5 ACTIVITY DIRECTOR OR STAFF 6 OWNER, ADMINISTRATOR, EXECUTIVE DIRECTOR, ASSISTANT DIRECTOR, DIRECTOR OF OPERATIONS, OR MANAGER 7 SOME OTHER POSITION	R_C17a = 2
R_CEND	Thank you. These are all the questions I have for you regarding this resident. Now I need to check my records if there are any other selected residents for whom you were identified as a caregiver.	1 CONTINUE	R_C17a = 1 or 2
R_C_DR	INTERVIEWER: ARE YOU READY TO FINALIZE THIS RESIDENT INTERVIEW? HAVE YOU ANSWERED ALL QUESTIONS TO THE BEST OF YOUR ABILITY AND THAT OF YOUR RESPONDENT(S)? IF THERE ARE QUESTIONS ANSWERED DON'T KNOW (?)OR REFUSED (!) FOR WHICH YOU CAN STILL DO DATA RETRIEVAL, ANSWER NO ON THIS SCREEN.	1 YES 2 NO

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