NSRCF - Verification Form

Attachment N: Verification Form

Form approved

OMB No. 0920-0780

Exp. Date __xx/xx/20xx

National Survey of Residential Care Facilities (NSRCF)

Verification Form

REFER TO PROJECT FAQs IF NECESSARY

READ IF NECESSARY

NOTICE – Public reporting burden of this collection of information is estimated to average 5 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).

INTRODUCTION: Hello, my name is _______________. I’m a supervisor with RTI International. May I speak with DIRECTOR’S NAME)?

I am calling to verify the work of one of our interviewers FI NAME who conducted a recent survey with this facility, called the National Survey of Residential Care Facilities.

1. Do you remember completing an interview with FI NAME on DATE?

   1. YES

   2. NO

   3. DON’T REMEMBER

2. Were you (IF Q1=DON’T REMEMBER: You would have been) asked questions about NAME OF FACILITY, such as the number of residents, the number of rooms, the services you offer, and general information on staffing?

   1. YES

   2. NO. FS: CODE AS PROBLEM. SKIP TO Q.5 IF REMEMBERS INTERVIEW, OR Q6 IF DOESN’T. RECORD ANY INFORMATION AT BOTTOM.

   3. DON’T REMEMBER

3. Did the interviewer ask you to provide a list of residents?

   1. YES

   2. NO. FS: CODE AS A PROBLEM

   3. DON’T REMEMBER

4. And did the interviewer ask a series of questions about NUMBER residents?

   1. YES

   2. NO. FS: CODE AS A PROBLEM

   3. DON’T REMEMBER.

5. About how long did the interview take?

6. Thanks, those are all the questions I have. Do you have any additional comments you’d like to make about the interview or interviewer?

CONCLUSION: Thank you very much for your time. Have a nice day/evening.

ADDITIONAL COMMENTS: