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pdfItems Booklet for
Specification:
Section: Adult Well-Being TM
AW2_APT
Mark One Only
ASK ONLY IF NECESSARY
Is there more than one housing unit in this building?
(1)
(2)
Yes
No
@
AW5_CNDUR
Multiple Entry
SHOW FLASHCARD II
READ ANSWER CATEGORIES IF NECESSARY
Do you currently have the following items in your home, in
working condition?
(1)
@1
@2
@3
@4
@5
@6
@7
@8
@9
@10
@11
@12
@13
Yes
(2) No
(01)Washing machine
(02)Clothes dryer
(03)Dishwasher
(04)Refrigerator
(05)Stand-alone food freezer (separate from refrigerator)
(06)Color television
(07)Gas or electric stove (with or without oven)
(08)Microwave oven
(09)VCR or DVD (or other video recorder-player such as TiVo)
(10)Air conditioner (central or room)
(11)Personal computer
(12)Cellular phone or mobile phone
(13)Regular telephone
AW6_CBLD1
Mark One Only
You didn't list a washing machine in your home. Is there a
washing machine in your BUILDING provided for your use?
(1)
(2)
Yes
No
@
AW7_CBLD2
Mark One Only
You didn't list a dryer in your home.
BUILDING provided for your use?
(1)
(2)
Is there a dryer in your
Yes
No
@
Monday, November 29, 2010
Page 1 of 24
Survey:
Section: Adult Well-Being TM
Items Booklet
AW8_CBLD13
Mark One Only
You didn't list a telephone in your home.
people to reach you by telephone?
(1)
(2)
(3)
(4)
Is there a way for
Yes, neighbor's phone, common phone, pay phone
Yes, cell phone
Yes, other device
No, cannot be reached by telephone
@
AW9_ROOMS
Enter Number
The next set of questions are about the quality of your
neighborhood, crime in your neighborhood, and the type of services
available to you. First, I will ask about your home.
How many rooms are there in your home?
not count the bathrooms.
Count the kitchen but do
ACCEPTABLE RANGE IS 1-20
ENTER (20) TO INDICATE 20 OR MORE ROOMS
@ (Number of rooms)
Multiple Entry
AW10_HOUSE1
SHOW FLASHCARD JJ
READ ANSWER CATEGORIES IF NECESSARY
Are any of the following conditions present in your home?
ENTER ALL THAT APPLY/ENTER (N) FOR NO MORE
[fill AW10_1:b](1) Problem with pests such as rats, mice, roaches,
or other insects
[fill AW10_2:b](2) A leaking roof or ceiling
[fill AW10_3:b](3) Broken window glass or windows that can't shut
[fill AW10_4:b](4) Exposed electrical wires in the finished areas
of your home
[fill AW10_5:b](5) A toilet, hot water heater, or other plumbing
that doesn't work
[fill AW10_6:b](6) Holes in the walls or ceiling, or cracks wider
than the edge of a dime
[fill AW10_7:b](7) Holes in the floor big enough for someone to
catch their foot on
@1
Enter Text
AW10_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Page 2 of 24
Monday, November 29, 2010
Items Booklet
Survey:
Section: Adult Well-Being TM
Multiple Entry
AW11_HOUSE2
SHOW FLASHCARD KK
Now I'm going to ask you a few questions about your satisfaction
with certain aspects of your housing.
Are you very satisfied, somewhat satisfied, somewhat dissatisfied,
or very dissatisfied, with the following:
(1)
(2)
(3)
(4)
(5)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Haven't lived here long enough to know
@1
@2
@3
@4
@5
@6
(1)
(2)
(3)
(4)
(5)
(6)
The
The
The
The
The
The
general state of repair of your home
amount of room or space in your home
furnishings in your home
warmth of your home in winter
coolness of your home in summer
amount of privacy your home offers
Mark One Only
AW12_SATLV1
SHOW FLASHCARD LL
READ ANSWER CATEGORIES IF NECESSARY
Overall, how satisfied are you with your home?
(1)
(2)
(3)
(4)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
@
Mark One Only
AW13_SATLV2
Are conditions in your home undesirable enough that you would
like to move?
(1)
(2)
Yes
No
@
Mark One Only
AW14_CRIME1
The next few questions are about crime and
things you have done to protect yourself from crime.
Is there any area right around your home --- that is, within a
mile --- where you would be afraid to walk alone at night?
(1)
(2)
Yes
No
@
Monday, November 29, 2010
Page 3 of 24
Survey:
Section: Adult Well-Being TM
Items Booklet
AW15_CRIME2
Multiple Entry
In the past month, have you done any of the following because you
thought you might be unsafe?
(1)
Yes
@1
@2
(1)
(2)
@3
(3)
(2)
No
Have you stayed in your home at certain times?
Have you taken someone with you or traveled with other
people when going out into your neighborhood?
Have you carried anything to protect yourself?
Mark One Only
AW16_CRIME3
Do you consider your neighborhood very safe from crime, somewhat
safe, somewhat unsafe, or very unsafe?
(1)
(2)
(3)
(4)
Very safe
Somewhat safe
Somewhat unsafe
Very unsafe
@
Mark One Only
AW17_CRIME4
How about your home? Do you consider it very safe from crime,
somewhat safe, somewhat unsafe, or very unsafe?
(1)
(2)
(3)
(4)
Very safe
Somewhat safe
Somewhat unsafe
Very unsafe
@
Mark One Only
AW18_CRIME5
We are interested in finding out if people do anything in
particular to keep thieves or intruders out of their homes.
[fill TEMP2] [fill TEMP1] have a dog?
(1)
(2)
Yes
No
@
Mark One Only
AW19_CRIME6
When you got (this dog/these dogs), was it in part to keep your
home safe from thieves or intruders?
(1)
(2)
Yes
No
@
Page 4 of 24
Monday, November 29, 2010
Items Booklet
Survey:
Section: Adult Well-Being TM
Mark One Only
AW20_CRIME7
[fill TEMP2] [fill TEMP1] have any special safety DEVICES such
as electric timers for lights, or an alarm system?
(1)
(2)
Yes
No
@
Mark One Only
AW21_SATLV3
Overall, is the threat of crime where you live undesirable enough
that you would like to move?
(1)
(2)
Yes
No
@
Multiple Entry
AW22_NBRHD1
Now I will ask some questions about general conditions in your
neighborhood.
SHOW FLASHCARD MM
READ ANSWER CATEGORIES IF NECESSARY
Do you think any of the following conditions are problems in
your neighborhood?
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
[fill
[fill
[fill
[fill
[fill
AW22_1:b](1) Street noise or heavy street traffic
AW22_2:b](2) Streets in need of repair
AW22_3:b](3) Trash, litter, or garbage in the streets and lots
AW22_4:b](4) Rundown or abandoned houses or buildings
AW22_5:b](5) Industries, businesses, or other
non-residential activities
[fill AW22_6:b](6) Odors, smoke, or gas fumes
@1
Enter Text
AW22_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Mark One Only
AW23_NBRHD2
SHOW FLASHCARD LL
How satisfied are you with your relationship with your neighbors?
Are you very satisfied, somewhat satisfied, somewhat dissatisfied,
or very dissatisfied?
(1)
(2)
(3)
(4)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
@
Monday, November 29, 2010
Page 5 of 24
Survey:
Section: Adult Well-Being TM
Items Booklet
Mark One Only
AW24_SATLV4
SHOW FLASHCARD LL
Overall, how satisfied are you with conditions in your neighborhood?
READ IF NECESSARY
(1)
(2)
(3)
(4)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
@
Mark One Only
AW25_SATLV5
Is your neighborhood undesirable enough that you would like to move?
(1)
(2)
Yes
No
@
Mark One Only
AW27_CS1
SHOW FLASHCARD LL
How satisfied are you with the local public schools in your
neighborhood?
READ IF NECESSARY
(1)
(2)
(3)
(4)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
@
AW28_CS2
Multiple Entry
SHOW FLASHCARD NN
READ ANSWER CATEGORIES IF NECESSARY
We are interested in schools from kindergarten through 12th grade.
Do any of the children in your household attend:
(1)
Yes
@1
@2
(1)
(2)
@3
@4
@5
(3)
(4)
(5)
(2)
No
Private school
Magnet, charter, or other public school apart from the
assigned school
Assigned public school
Home school
Not in school or other arrangement
Mark One Only
AW29_CS3
Would [fill TEMP1] prefer a different school for any
child in this home?
(1)
(2)
Yes
No
@
Page 6 of 24
Monday, November 29, 2010
Items Booklet
Survey:
Section: Adult Well-Being TM
Multiple Entry
AW30_CS4
Are you very satisfied, somewhat satisfied, somewhat dissatisfied,
or very dissatisfied with each of the following services in your
neighborhood:
(1)
(2)
(3)
(4)
(5)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
Haven't lived here long enough to know
@1 (1)
@2 (2)
@3 (3)
Hospitals, health clinics, and doctors
Police services
Fire department services
Mark One Only
AW31_CS5
Are the public transportation services available in your
neighborhood adequate for you?
(1)
(2)
(3)
Yes
No
Not sure because you do not use public transportation
@
Mark One Only
AW32_SATLV6
SHOW FLASHCARD LL
Overall, how satisfied are you with the public services
in your neighborhood?
READ IF NECESSARY
(1)
(2)
(3)
(4)
Very satisfied
Somewhat satisfied
Somewhat dissatisfied
Very dissatisfied
@
Mark One Only
AW33_SATLV7
Are the public services undesirable enough that you would
like to move?
(1)
(2)
Yes
No
@
Monday, November 29, 2010
Page 7 of 24
Survey:
Section: Adult Well-Being TM
Items Booklet
AW34_MEET
Mark One Only
Next are questions about difficulties people sometimes have in
meeting their essential household expenses for such things as
mortgage or rent payments, utility bills, or important medical
care.
During the past 12 months, has there been a time when
[fill TEMP1] did not meet all of your essential expenses?
(1)
(2)
Yes
No
@
AW35_NEED1
Mark One Only
The following are some of the specific difficulties people
experience with household expenses.
Was there any time in the past 12 months when [fill TEMP1]
did not pay the full amount of the rent or mortgage?
(1)
(2)
Yes
No
@
AW36_GETH1
Mark One Only
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
AW37_WHOH1
Multiple Entry
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
@1
AW37_1:b](1)
AW37_2:b](2)
AW37_3:b](3)
AW37_4:b](4)
AW37_5:b](5)
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
Enter Text
AW37_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Page 8 of 24
Monday, November 29, 2010
Items Booklet
Survey:
Section: Adult Well-Being TM
AW38_NEED2
Mark One Only
In the past 12 months [fill TEMP1] [fill TEMP2]
evicted from your home or apartment for not paying the rent or
mortgage?
(1)
(2)
Yes
No
@
AW39_GETH2
Mark One Only
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
AW40_WHOH2
Multiple Entry
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
@1
AW40_1:b](1)
AW40_2:b](2)
AW40_3:b](3)
AW40_4:b](4)
AW40_5:b](5)
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
Enter Text
AW40_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Mark One Only
AW41_NEED3
How about not paying the full amount of the gas, oil, or
electricity bills?
Was there a time in the past 12 months when that happened to
[fill TEMP1]?
(1)
(2)
Yes
No
@
Mark One Only
AW42_GETH3
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
Monday, November 29, 2010
Page 9 of 24
Survey:
Section: Adult Well-Being TM
Items Booklet
Multiple Entry
AW43_WHOH3
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
AW43_1:b](1)
AW43_2:b](2)
AW43_3:b](3)
AW43_4:b](4)
AW43_5:b](5)
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
@1
AW43_ERR
Enter Text
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Mark One Only
AW44_NEED4
In the past 12 months did the gas or electric company turn off
service, or the oil company not deliver oil?
(1)
(2)
Yes
No
@
Mark One Only
AW45_GETH4
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
Multiple Entry
AW46_WHOH4
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
AW46_1:b](1)
AW46_2:b](2)
AW46_3:b](3)
AW46_4:b](4)
AW46_5:b](5)
@1
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
Enter Text
AW46_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Page 10 of 24
Monday, November 29, 2010
Items Booklet
Survey:
Section: Adult Well-Being TM
Mark One Only
AW47_NEED5
How about the telephone company disconnecting service because
payments were not made?
Was there a time in the past 12 months when that happened to
[fill TEMP1]?
(1)
(2)
Yes
No
@
Mark One Only
AW48_GETH5
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
Multiple Entry
AW49_WHOH5
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
AW49_1:b](1)
AW49_2:b](2)
AW49_3:b](3)
AW49_4:b](4)
AW49_5:b](5)
@1
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
Enter Text
AW49_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Mark One Only
AW50_NEED6
In the past 12 months was there a time [fill TEMP2] needed
to see a doctor or go to the hospital but did not go?
(1)
(2)
Yes
No
@
Mark One Only
AW51_GETH6
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
Monday, November 29, 2010
Page 11 of 24
Survey:
Section: Adult Well-Being TM
Items Booklet
Multiple Entry
AW52_WHOH6
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
AW52_1:b](1)
AW52_2:b](2)
AW52_3:b](3)
AW52_4:b](4)
AW52_5:b](5)
@1
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
AW52_ERR
Enter Text
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Mark One Only
AW53_NEED7
In the past 12 months was there a time [fill TEMP2] needed
to see a dentist but did not go?
(1)
(2)
Yes
No
@
Mark One Only
AW54_GETH7
When [fill TEMP1] had this problem, did any person or
organization help?
(1)
(2)
Yes
No
@
Multiple Entry
AW55_WHOH7
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
Who was that?
[fill
[fill
[fill
[fill
[fill
AW55_1:b](1)
AW55_2:b](2)
AW55_3:b](3)
AW55_4:b](4)
AW55_5:b](5)
@1
A family member or relative
A friend, neighbor or other non-relative
A department of social services
A church or nonprofit group
Other
Enter Text
AW55_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Page 12 of 24
Monday, November 29, 2010
Items Booklet
Survey:
Section: Adult Well-Being TM
Mark One Only
AW56_HELP1
SHOW FLASHCARD OO
READ ANSWER CATEGORIES IF NECESSARY
If [fill TEMP1] had a problem with which you needed help
(for example, sickness or moving), how much help would you expect
to get from family living nearby?
(1)
(2)
(3)
(4)
All of the help needed
Most of the help needed
Very little of the help needed
No help
@
Mark One Only
AW57_HELP2
SHOW FLASHCARD OO
READ ANSWER CATEGORIES IF NECESSARY
If [fill TEMP1] had a problem with which you needed help
How much help would you expect to get from friends?
(1)
(2)
(3)
(4)
All of the help needed
Most of the help needed
Very little of the help needed
No help
@
Mark One Only
AW58_HELP3
SHOW FLASHCARD OO
READ ANSWER CATEGORIES IF NECESSARY
If [fill TEMP1] had a problem with which you needed help
How much help would you expect to get from other people in the
community besides family and friends, such as a social agency
or a church?
(1)
(2)
(3)
(4)
All of the help needed
Most of the help needed
Very little of the help needed
No help
@
Mark One Only
AW59_FOOD1
SHOW FLASHCARD PP
Getting enough food can also be a problem for some people. Which
of these statements best describes the food eaten in your household
in the last four months:
READ ANSWER CATEGORIES IF NECESSARY
(1)
(2)
(3)
(4)
Enough of the kinds of food we want
Enough but not always the kinds of food we want to eat
Sometimes not enough to eat
Often not enough to eat
@
Monday, November 29, 2010
Page 13 of 24
Survey:
Section: Adult Well-Being TM
Items Booklet
Multiple Entry
AW60_FOOD2
ENTER ALL THAT APPLY
ENTER (N) FOR NO MORE
In which of the last four months did [fill TEMP2]
NOT have enough to eat?
[fill
[fill
[fill
[fill
[fill
AW60_1:b]
AW60_2:b]
AW60_3:b]
AW60_4:b]
AW60_5:b]
(1)
(2)
(3)
(4)
(5)
@1
4 mos. ago [fill month1]
3 mos. ago [fill month2]
2 mos. ago [fill month3]
last month [fill month4]
current month [fill month5]
Enter Text
AW60_ERR
"Don't Know and/or Refused" response not permitted with other answers
ENTER (B) TO BACK UP
@
Mark One Only
AW61_FOOD3
I'm going to read you some statements that people have made
about their food situation. For these statements, please
tell me whether it was OFTEN TRUE, SOMETIMES TRUE, or NEVER
TRUE for [fill TEMP2] in the last four months.
"The food that [fill TEMP3] bought just didn't last and
[fill TEMP3] didn't have money to get more."
Was that often, sometimes or never true for [fill TEMP4]
in the last four months?
(1)
(2)
(3)
Often true
Sometimes true
Never true
@
Mark One Only
AW62_FOOD4
The next statement is: "[fill TEMP3] couldn't afford to eat
balanced meals."
Was that often, sometimes or never true for [fill TEMP4]
in the last four months?
(1)
(2)
(3)
Often true
Sometimes true
Never true
@
Mark One Only
AW63_FOOD5
The next statement is: "[fill TEMP1] not eating enough
because [fill TEMP3] couldn't afford enough food."
Was that often, sometimes or never true for [fill TEMP2] in
the last four months?
(1)
(2)
(3)
Often true
Sometimes true
Never true
@
Page 14 of 24
Monday, November 29, 2010
Items Booklet
Survey:
Section: Adult Well-Being TM
Mark One Only
AW64_FOOD6
The next questions refer to adults in the household.
In the past four months did [fill TEMP1]
ever cut the size of your meals or skip meals because there
wasn't enough money for food?
(1)
(2)
Yes
No
@
Mark One Only
AW65_FOOD7
In the past four months, did [fill TEMP1] ever eat less than
you felt you should because there wasn't enough money to
buy food?
(1)
(2)
Yes
No
@
Mark One Only
AW66_FOOD8
In the past four months, did [fill TEMP1] ever not eat for a
whole day because there wasn't enough money for food?
(1)
(2)
Yes
No
@
Monday, November 29, 2010
Page 15 of 24
Survey:
Section: Informal Care-Giving TM
Items Booklet
HH01A
Mark One Only
There are situations in which people provide regular unpaid care or
assistance to a family member or friend who has a long-term
illness or a disability.
During the past month, did [fill TEMPNAME] provide any such care
or assistance to a family member or friend living here or living
elsewhere?
[r]H[n]
INCLUDE ONLY UNPAID CARE OR ASSISTANCE ACTIVITIES. INCLUDE ONLY
THOSE ACTIVITIES MADE NECESSARY BY THE ILLNESS OR DISABILITY
OF THE RECIPIENT.
(1)
(2)
@
Yes
No
Mark One Only
HH02
Did [fill TEMPNAME] provide such care or assistance to someone
living here in the past month?
(1)
(2)
Yes
No
@
Enter Number
HH03
During the past month, for how many persons living here did
[fill TEMPNAME] provide care or assistance?
@
Number
Multiple Entry
HH04
[if HH03 ge <3> or HH03 eq or HH03 eq ]
For which person(s) in this household did [fill TEMPNAME] provide
reqular unpaid care or assistance? (Please list only the two
persons for whom [fill TEMPNAME] provided the most assistance,
or care in the past month.)
[else]
[if HH03 eq <1> or HH03 eq <2>]
For which person(s) in this household did [fill TEMPNAME]
provide reqular unpaid care or assistance?
[endif]
[endif]
IF THERE IS ONLY ONE ENTRY, ENTER "N" AFTER THAT ENTRY.
@1
Page 16 of 24
@2
Monday, November 29, 2010
Items Booklet
Survey:
Section: Informal Care-Giving TM
HH05A
Mark One Only
What is [fill PTEMPNAME] relationship to [fill FAMILYNAM]?
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Spouse
Partner
Child
Grandchild
Parent
Brother/sister
Other relative
Nonrelative
@
HH06A
Enter Number
For how many years [fill HAVHAS] [fill TEMPNAME] provided care or
assistance to [fill FAMILYNAM]?
ENTER "0" IF LESS THAN 1 YEAR.
@
Years
HH07A
Multiple Entry
Now think about last month, what kind of care or assistance did
[fill TEMPNAME] give to [fill FAMILYNAM]?
Did [fill HESHE]:
(1) Yes
a.
b.
c.
d.
e.
(2) No
Help him/her dress, eat, bathe, or get to the
bathroom?
@1
Help with medical needs such as taking
medicines or changing bandages?
@2
Help him/her keep track of bills, checks,
or other financial matters?
@3
Help by taking him/her shopping
or to the doctor's office?
@4
Help in any other way?
@5
Specify
Enter Text
HH07A1
Please specify "OTHER" care or assistance provided.
@
Enter Number
HH08A
On average, how many hours a week did [fill TEMPNAME] usually spend
providing care or assistance for [fill FAMILYNAM] in the past month?
@
Hours
Monday, November 29, 2010
Page 17 of 24
Survey:
Section: Informal Care-Giving TM
Mark One Only
Items Booklet
HH09A
Did [fill FAMILYNAM] receive similar unpaid care or assistance
from anyone other than you in the past month?
(1)
(2)
Yes
No
@
Enter Number
HH10A
Think about the unpaid care and assistance provided by other
person(s) in the past month, on average, how many hours per
week did [fill FAMILYNAM] usually receive care or assistance?
@ Hours
Mark One Only
HH12A
Sometimes people receive professional home health care services
such as visits by nurses or therapists or home health aides.
Did [fill FAMILYNAM] receive professional home health services
in the past month?
(1)
(2)
Yes
No
@
Enter Number
HH12A1
In terms of professional care or assistance from home health care
services, how many hours per week did [fill FAMILYNAM] usually
receive in the past month?
@ Hours
Mark One Only
HH05B
What is [fill PTEMPNAME] relationship to [fill FAMILYNAM]?
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Spouse
Partner
Child
Grandchild
Parent
Brother/sister
Other relative
Nonrelative
@
Enter Number
HH06B
For how many years [fill HAVHAS] [fill TEMPNAME] provided care or
assistance to [fill FAMILYNAM]?
ENTER "0" IF LESS THAN 1 YEAR.
@ Years
Page 18 of 24
Monday, November 29, 2010
Items Booklet
Survey:
Section: Informal Care-Giving TM
HH07B
Multiple Entry
Now think about last month, what kind of care or assistance did
[fill TEMPNAME] give to [fill FAMILYNAM]?
Did [fill HESHE]:
(1) Yes
a.
b.
c.
d.
e.
(2) No
Help him/her dress, eat, bathe, or get to the
bathroom?
@1
Help with medical needs such as taking
medicines or changing bandages?
@2
Help him/her keep track of bills, checks,
or other financial matters?
@3
Help by taking him/her shopping
or to the doctor's office?
@4
Help in any other way?
@5
Specify
Enter Text
HH07B1
Please specify "OTHER" care or assistance provided.
@
Enter Number
HH08B
On average, how many hours a week did [fill TEMPNAME]
usually spend providing care or assistance for [fill FAMILYNAM]
in the past month?
@
Hours
Mark One Only
HH09B
Did [fill FAMILYNAM] receive similar unpaid care or assistance
from anyone other than you in the past month?
(1)
(2)
Yes
No
@
Enter Number
HH10B
Think about the unpaid care and assistance provided by other
person(s) in the past month, on average, how many hours per
week did [fill FAMILYNAM] usually receive care or assistance?
@ Hours
Monday, November 29, 2010
Page 19 of 24
Survey:
Section: Informal Care-Giving TM
Items Booklet
HH12B
Mark One Only
Sometimes people receive professional home health care services
such as visits by nurses or therapists or home health aides. Did
[fill FAMILYNAM] receive professional home health care services
in the past month?
(1)
(2)
Yes
No
@
HH12B1
Enter Number
In terms of professional care or assistance from home health care
services, how many hours per week did [fill FAMILYNAM] usually
receive in the past month?
@ Hours
HH13
Mark One Only
During the past month, did [fill TEMPNAME] provide any unpaid care
or assistance to any persons who lived outside of [fill PTEMPNAME] home?
INCLUDE ONLY UNPAID CARE OR ASSISTANCE ACTIVITIES. INCLUDE ONLY
THOSE ACTIVITIES MADE NECESSARY BY THE ILLNESS OR DISABILITY
OF THE RECIPIENT.
[r]H[n]
(1)
(2)
Yes
No
@
Enter Number
HH14
For how many persons living outside of [fill PTEMPNAME] home did
[fill TEMPNAME] provide care or assistance in the past month?
@
Number
HH15
Multiple Entry
[if HH14 ge <3> or HH14 eq or HH14 eq ]
What [fill WASWERE] the name(s) of the person(s) outside
[fill PTEMPNAME] home for whom you provided care or
assistance? (Please list only the two persons for whom
[fill TEMPNAME] provided the most assistance in the past month).
[else]
[if HH14 eq <1> or HH14 eq <2>]
What [fill WASWERE] the name(s) of the person(s) outside
[fill PTEMPNAME] home for whom you provided care or
assistance?
[endif]
[endif]
IF THERE IS ONLY ONE ENTRY, ENTER "N" AFTER THAT ENTRY.
1st Person's Name
@1
2nd Person's Name
@2
Page 20 of 24
Monday, November 29, 2010
Items Booklet
Survey:
Section: Informal Care-Giving TM
HH16A
Mark One Only
What is [fill PTEMPNAME] relationship to [fill OUTSIDNAM]?
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Spouse
Partner
Child
Grandchild
Parent
Brother/sister
Other relative
Nonrelative
@
HH17A
Enter Number
For how many years [fill HAVHAS] [fill TEMPNAME] provided care or
assistance to [fill OUTSIDNAM]?
ENTER "0" IF LESS THAN 1 YEAR.
@ Years
HH18A
Mark One Only
In what type of residence did [fill OUTSIDNAM] live in the past month?
Was it in an ordinary residence, such as a house or apartment, or
was it some other type of care facility?
(1)
(2)
(3)
House or apartment
Care facility
Other, specify
@
HH18A1
Enter Text
Please specify "OTHER" type of residence.
@
HH19A
Multiple Entry
What kind of assistance did [fill TEMPNAME] give to [fill OUTSIDNAM]?
Did [fill HESHE]:
(1) Yes (2) No
a.
Help him/her dress, eat, bathe, or
get to the bathroom?
@1
b.
c.
d.
e.
Help with medical needs such as taking
medicines or changing bandages?
@2
Help him/her keep track of bills, checks,
or other financial matters?
@3
Help by taking him/her shopping or to
the doctor's office?
@4
Help in any other way?
@5
Monday, November 29, 2010
Specify
Page 21 of 24
Survey:
Section: Informal Care-Giving TM
Enter Text
Items Booklet
HH19A1
Please specify "OTHER" type of assistance.
@
Enter Number
HH20A
On average, how many hours a week did [fill TEMPNAME]
usually spend providing care or assistance for [fill OUTSIDNAM]?
@
Hours
Mark One Only
HH21A
During the past month, did [fill OUTSIDNAM] receive similar unpaid
care or assistance from any other persons?
(1)
(2)
Yes
No
@
Enter Number
HH21A1
Think about the last month, how many hours per week of unpaid care
or assistance did [fill OUTSIDNAM] usually receive from that person?
@ Hours
Mark One Only
HH22A
During the past month, did [fill TEMPNAME] regularly spend time with
[fill OUTSIDNAM] in order to provide companionship and emotional support
because of his/her long-term illness or disability?
(1)
(2)
Yes
No
@
Mark One Only
HH24A
Sometimes people receive professional home health care services
such as visits by nurses or therapists or home health aides. Did
[fill OUTSIDNAM] receive professional health care or assistance
during the past month?
(1)
(2)
Yes
No
@
Enter Number
HH24A1
In terms of professional care and assistance from home health care
services, how many hours per week did [fill OUTSIDNAM] usually
receive in the past month?
@ Hours
Page 22 of 24
Monday, November 29, 2010
Items Booklet
Survey:
Section: Informal Care-Giving TM
HH16B
Mark One Only
What is [fill PTEMPNAME] relationship to [fill OUTSIDNAM]?
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Spouse
Partner
Child
Grandchild
Parent
Brother/sister
Other relative
Nonrelative
@
HH17B
Multiple Entry
For how long [fill HAVHAS] [fill TEMPNAME] provided care or
assistance to [fill OUTSIDNAM]?
@2
Years
HH18B
Mark One Only
In what type of residence did [fill OUTSIDNAM] live in the past
month? Was it in an ordinary residence, such as a house or
apartment, or was it some other type of care facility?
(1)
(2)
(3)
@
House or apartment
Care facility
Other, specify
HH18B1
Enter Text
Please specify "OTHER" type of residence.
@
HH19B
Multiple Entry
What kind of assistance did [fill TEMPNAME] give to [fill OUTSIDNAM][fill
HESHE]:
(1) Yes (2) No
a.
Help him/her dress, eat, bathe, or
get to the bathroom?
@1
b.
c.
d.
e.
Help with medical needs such as taking
medicines or changing bandages?
@2
Help him/her keep track of bills, checks,
or other financial matters?
@3
Help by taking him/her shopping or to
the doctor's office?
@4
Help in any other way?
@5
Specify
Enter Text
HH19B1
Please specify "OTHER" type of assistance.
@
Monday, November 29, 2010
Page 23 of 24
Survey:
Section: Informal Care-Giving TM
Enter Number
Items Booklet
HH20B
On average, how many hours a week did [fill TEMPNAME] usually
spend providing care or assistance for [fill OUTSIDNAM]?
@
Hours
Mark One Only
HH21B
During the past month, did [fill OUTSIDNAM] receive similar unpaid care
or assistance from any other persons?
(1)
(2)
Yes
No
@
Enter Number
HH21B1
Think about the last month, how many hours per week of unpaid care
or assistance did [fill OUTSIDNAM] usually receive from that person(s)?
@ Hours
Mark One Only
HH22B
During the past month, did [fill TEMPNAME] regularly spend time with
[fill OUTSIDNAM] in order to provide companionship and emotional
support because of this illness or disability?
(1)
(2)
Yes
No
@
Mark One Only
HH24B
Sometimes people receive professional home health care services
such as visits by nurses or therapists or home health aides. Did
[fill OUTSIDNAM] receive professional health care or assistance
during the past month?
(1)
(2)
Yes
No
@
Enter Number
HH24B1
In terms of professional care and assistance from home health care
services, how many hours per week did [fill OUTSIDNAM] usually
receive in the past month?
@ Hours
Page 24 of 24
Monday, November 29, 2010
| File Type | application/pdf |
| File Modified | 2010-11-29 |
| File Created | 2010-11-29 |