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pdfOMB#: 0925-0281
Exp. XX/XXXX
SEMI-ANNUAL FOLLOW-UP FORM
ID
NUMBER:
STUDY YEAR
25
SEQ
#
FORM CODE: SAF
VERSION: A – 7/15/10
ADMINISTRATIVE INFORMATION
/
0a. Completion Date:
Month
/
0b. Staff ID:
Day
Year
Public reporting burden for this collection of information is estimated to average 6-15 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: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 208927974, ATTN: PRA (0925-0281). Do not return the completed form to this address.
Instructions: This form should be completed during the interview portion of the participant's semi-annual follow-up.
ID Number, Contact Year, and Name must be entered above. Code the correct entry clearly above the incorrect entry.
For "multiple choice" and "yes/no" type questions, circle the letter corresponding to the most appropriate response. If
a letter is circled incorrectly, mark through it with an "X" and circle the correct response.
A. VITAL STATUS
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1. Date of status determination:
Month
2. Final Status (choose one)
Contacted and Alive
Contacted and Refused
Reported Alive
Reported Deceased
C
/
Day
Year
3. Information obtained from (choose one)
Phone
A Go to Question 6
Personal Interview / Proxy Interview
B Go to Question 6
Letter
C Go to Question 17
Go to Question 31
F
R
D
Semi-Annual Follow-Up Form (SAFA)
Relative, spouse, acquaintance
D
Employer information
E
Other
F
Relative, spouse, acquaintance
G
Surveillance
H
Go to Question 17
Go to Question 4
Page 1 of 15
Other (National Death Index)
Unknown
U
Semi-Annual Follow-Up Form (SAFA)
I
Go to Question 31
Page 2 of 15
B. DEATH INFORMATION
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4. Date of death:
Month
/
Day
Year
5. Location of death:
a. City/ County
b. State:
If deceased, skip to Question 17.
C. GENERAL HEALTH
“I would like to start with some questions about your health that ARIC has not asked you before:”
6. Have you ever been told by a physician that you that had gout?
Yes .............................
No ...............................
Unknown .....................
Go to Question 7
Go to Question 7
a. How old were you when a physician first told you had gout?
Age in years
b. When was the last time you had to get health care for your gout?
Age in years (for the QxQs: within the year = 0 years)
7. Have you ever been told by a doctor or heath professional that you had/have Parkinson’s disease?
Yes .............................
No ............................... Go to Question 8
Don’t know .................. Go to Question 8
a. How old were you when you were first told you had Parkinson’s disease?
Age in years
b. Are you currently being treated for Parkinson’s?
Yes .............................
No ............................... Go to Question 8
Don’t know .................. Go to Question 8
Semi-Annual Follow-Up Form (SAFA)
Page 3 of 15
“The ARIC study would like to ask the physician to tell us more about your health. If you agree to do this
I will send you a form that tells your physician that you authorize the ARIC study to get this information
from your doctor. Once you sign that form and mail it back to me I will contact your physician’s office.”
c. May I send you this release form and an addressed envelope for you to mail it back?
Yes .............................
No ...............................
d. What is the name and address of the doctor who is seeing you for Parkinson’s disease
Name: _______________________________________
Address: _______________________________________________________
D. QUALITY OF LIFE
Use of the SF-12 form for AFU call. (Copied from http://www.bellmorept.com/SF12%20Health%20Survey.pdf)
Semi-Annual Follow-Up Form (SAFA)
Page 4 of 15
Semi-Annual Follow-Up Form (SAFA)
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E. HEALTH CARE UTILIZATION
8. "Now I will ask you some questions about your health since the last time we contacted you on
(mm/dd/yyyy). Since that time and compared to other people your age, would you say that your
health has been excellent, good, fair or poor?"
Excellent .....................
Good ...........................
Fair .............................
Poor ............................
9. When you get sick or need advice about your health, what kind of place do you go to
most often – a clinic, doctor’s office, emergency room, or some other place? .............
Clinic or health center ..................................................................... A
Doctor’s office or HMO ................................................................... B
Hospital emergency room ............................................................... C
Hospital outpatient department ....................................................... D
Other, specify: __________________________________............ E
Doesn’t go to one place most often ................................................ F
Don’t know...................................................................................... G
10. In the past 12 months, was there any time when you delayed getting medical care
when you needed it?
Yes ....................................
No .....................................
Refused ............................
Don’t know .........................
Go to Question 12
Go to Question 12
Go to Question 12
11. What reason(s) did delay getting medical care in the past 12 months when you needed it?
Yes
No
a. You couldn’t get through on the telephone ....................................
b. You couldn’t get an appointment soon enough.................................
c. Once you got there, you had to wait too long to see the doctor .....
d. The clinic/doctor’s office wasn’t open when you could get there ...
e. You didn’t have transportation .............................................................
f. You did not have health insurance......................................................
Semi-Annual Follow-Up Form (SAFA)
Page 6 of 15
12. During the past 12 months, was there any time when you needed any of the following,
but didn’t get it because you couldn’t afford it?
Yes
No
a. Prescription medications ......................................................................
b. To be seen by doctor ............................................................................
c. Mental health care or counseling ........................................................
d. Nursing home care ................................................................................
e. Surgery ....................................................................................................
13. To help pay for medical care, do you NOW have:
a.Health insurance or a health plan, such as Blue Cross/Blue Shield or a HMO Y/N/U
b.Medicare Y/N/U
c.Medicaid Y/N/U
d. Other Y/N/U
14. How often do you have a routine physical examination that is not for a particular illness, but for a
general check-up? (At least once every five years, less than once every five years, do not have routine
physical examinations, unknown)
15. During the last year, have you not received a doctor’s care or prescription medications because you
needed the money to buy food, clothing , or pay for housing? YES/NO
16. Which of these is the main problem that caused you difficulty, delay, or not receiving needed health
care?
a. Can’t afford care
b. Insurance company won’t approve, cover, or pay for care
c. Pre-existing condition
d. Insurance required a referral, but couldn’t get one
e. Doctor refused to accept my insurance plan
f. Medical care too far away
g. Can’t drive/ don’t have car/ no public transportation available
h. Too expensive to get there
i. Hearing impairment or loss
j. Hard to get into building
k. Hard to get around inside building
l. No appropriate equipment in office
m. Couldn’t get time off work
n. Didn’t know where to get car
o. Was refused services
p. Didn’t have time or took too long
q. Other
Semi-Annual Follow-Up Form (SAFA)
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F. HEALTH CARE SATISFACTION
17. In the last 12 months, how many times did you go to a doctor’s office or clinic to get care for
yourself? Do not include times you were hospitalized or went to an emergency room.
Enter number of times IF 0, Go to Question 17
18. In the last 12 months, how often did doctors …
Never Sometimes
a. listen carefully to you? ...............................................
b. explain things in a way you could understand? ..........
c. show respect for what you had to say? ......................
d. spend enough time with you? ....................................
Usually
Always
Usually
Always
19. In the last 12 months, how often did nurses …
Never Sometimes
a. listen carefully to you? ...............................................
b. explain things in a way you could understand? ..........
c. show respect for what you had to say? ......................
d. spend enough time with you? ....................................
20. Using a number from 0 to 10, where 0 is the worst health care possible and 10 is the health care
possible, what number would you use to rate all your health care in the last 12 months?
21. Does this health care provider have office hours at night or on weekends? Yes/No
II. How difficult is it to get appointments with this health care provider on short notice, for example, within
one or two days? Would you say it is:
a. very difficult
b. somewhat difficult
c. not too difficult
d. not at all difficult
22. If you arrive on time for an appointment, about how long do you usually have to wait before seeing a
medical person at your health care provider?
a. Less than 5 minutes
b. 5 to 15 minutes
c. 16 to 30 minutes
d. 31 to 59 minutes
e. 1 to 2 hours
f. More than 2 hours
23. How difficult is it to contact a medical person at your health care provider over the telephone about a
health problem? Would you say it is:
a. Very difficult
b. Somewhat difficult
c. Not too difficult
d. Not at all difficult
Semi-Annual Follow-Up Form (SAFA)
Page 8 of 15
24. How satisfied are you with the professional staff at your health care provider’s office? Would you
say that you are:
a. Very satisfied
b. Somewhat satisfied
c. Not too satisfied
d. Not at all satisfied
25. Overall, how satisfied are you with the quality of care received from your health care provider.
Would you say that you are:
a. very satisfied
b. somewhat satisfied
c. not too satisfied
d. not satisfied at all
G. ADMISSIONS
26. Since our last contact on (mm/dd/yyyy),have you stayed (Did [name]stay) overnight as a patient in a
hospital?
Yes .............................
No ............................... Go to Question 17D
Unknown ..................... Go to Question 17D
a. Were you (Was [name])hospitalized for a heart attack since our last contact on (mm/dd/yyyy)?
Yes .............................
No ...............................
Unknown .....................
b. Were you hospitalized for a stroke, slight stroke, transient ischemic attack or TIA?
Yes .............................
No ...............................
Unknown .....................
c. Since we last contacted you on mm/dd/yyyy, were you hospitalized for heart failure or
congestive heart failure?
Yes .............................
No ...............................
Unknown .....................
If "Yes" to 17a, 17b or 17c, add to "HOSPITALIZATIONS" section G and return.
d. Were you (Was [name]) admitted to an emergency room or a medical facility for outpatient
treatment since our last contact on(mm/dd/yyyy)?
Yes .............................
No ...............................
Unknown .....................
If No orIfUnknown:
Go to Q Go
xx.fto
No or Unknown:
Question 18.
e. Was this related to a heart problem or difficulty breathing ?
Yes .............................
No ...............................
Unknown .....................
If No or Unknown: Go to Question 18.
Semi-Annual Follow-Up Form (SAFA)
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What is the name and address of this medical facility ?
e1. Name: _______________________________________
e2. Address: _______________________________________________________
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e3. What was the approximate date?
M
M
Y
Y
Y
Y
27. Since our last contact, (Did [name]stay)have you stayed overnight as a patient in a nursing home?
Yes .............................
No ...............................
Go to Question 27
For DECEASED, REPORTED ALIVE, or CONTACTED BY LETTER statuses, go to
Question 31.
28. Are you currently staying in a nursing home?
Yes .............................
No ...............................
Semi-Annual Follow-Up Form (SAFA)
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H. HOSPITALIZATIONS
“For each time you were (he/she was) a patient in a hospital, I would like to obtain the reason you were
(he/she was) admitted, the name of the hospital, and the date. When was the first time you were (he/she
was) hospitalized since our last contact with you (him/her) on (mm/dd/yyyy of last contact)?” Fill in,
probing as necessary. Probe for additional hospitalizations.
29a. Hospitalization Reason:
__________________________________________________________________________________
29b. Hospital Name, City, and State:
___________________________________________________________________________________
/
29c. Month and Year:
M
M
Y
Y
Y
Y
30a. Hospitalization Reason:
__________________________________________________________________________________
30b. Hospital Name, City, and State:
___________________________________________________________________________________
/
30c. Month and Year:
M
M
Y
Y
Y
Y
31a. Hospitalization Reason:
__________________________________________________________________________________
31b. Hospital Name, City, and State:
___________________________________________________________________________________
/
31c. Month and Year:
M
M
Y
Y
Y
Y
32a. Hospitalization Reason:
__________________________________________________________________________________
32b. Hospital Name, City, and State:
___________________________________________________________________________________
/
32c. Month and Year:
M
M
Semi-Annual Follow-Up Form (SAFA)
Y
Y
Y
Y
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33a. Hospitalization Reason:
__________________________________________________________________________________
33b. Hospital Name, City, and State:
___________________________________________________________________________________
/
33c. Month and Year:
M
M
Y
Y
Y
Y
34a. Hospitalization Reason:
__________________________________________________________________________________
34b. Hospital Name, City, and State:
___________________________________________________________________________________
/
34c. Month and Year:
M
M
Y
Y
Y
Y
35a. Hospitalization Reason:
__________________________________________________________________________________
35b. Hospital Name, City, and State:
___________________________________________________________________________________
/
35c. Month and Year:
M
M
Y
Y
Y
Y
I. INVASIVE PROCEDURES
"Next I am going to ask about various types of surgery and medical procedures. We are interested in
those that occurred in the hospital, or in an emergency department, or as an outpatient."
36. Since we last contacted you on (mm/dd/yyyy) have you had any surgery on your heart, or the
arteries of your neck or legs, not counting surgery for varicose veins?
Yes .............................
No ............................... Go to Question 29
37. Did you have:
a. Coronary bypass?
Yes .............................
No ...............................
b. Other heart procedure?
Yes .............................
No ...............................
Semi-Annual Follow-Up Form (SAFA)
Specify: ________________________________________
Page 12 of 15
c. Carotid endarterectomy?
Yes .............................
No ...............................
Go to Question 29
d. Site:
Right ...........................
Left .............................
Both ............................
e. Other arterial revascularization?
Yes .............................
No ...............................
Specify: ________________________________________
f. Any other type of surgery on your heart or the arteries of your neck or legs?
Yes .............................
No ...............................
38. Since we last contacted you on (mm/dd/yyyy) have you had a balloon angioplasty or stent on the
arteries of your heart, neck, or legs?
Yes .............................
No ............................... Go to Question 30
Did you have:
a. Angioplasty or stent of the coronary arteries of your heart:
Yes .............................
No ...............................
b. Angioplasty or stent in the arteries of your neck:
Yes .............................
No ...............................
c. Angioplasty or stent of the lower extremity arteries:
Yes .............................
No ...............................
J. INTERVIEW
"Now I would like to ask about medication use during the past two weeks."
39. Did you take any medications during the past two weeks for:
a. High blood pressure?
Yes .............................
No ...............................
Unknown .....................
b. High blood cholesterol?
Yes .............................
No ...............................
Unknown .....................
c. Diabetes or high blood sugar?
Semi-Annual Follow-Up Form (SAFA)
Page 13 of 15
Yes .............................
No ...............................
Unknown .....................
d. Heart failure?
Yes .............................
No ...............................
Unknown .....................
[ Closure script ]
K. ADMINISTRATIVE INFORMATION
40. Does participant (still) live within official ARIC study boundaries?
Yes .............................
No ...............................
Unknown .....................
41. Will your center (still) be able to get his/her records via community surveillance?
Yes .............................
No ...............................
42. Result code:
Result Codes
01 – No Action Taken
02 – Tracing (Not yet contacted any source)
3A – Contacted, Interview Complete by Cohort Member
3B - Contacted, Interview Complete, Proxy/Informant
04 – Contacted, Interview Partially Complete or Rescheduled
05 – Contacted, Interview Refused
06 – Reported Alive, Will Continue to Attempt Contact This Year
07 – Reported Alive, Contact Not Possible This Year
08 – Reported Deceased
09 – Unknown
98 – Does Not Want Any Further AFU Contact
L. MEDICATION ADHERENCE
Questions modified from the Sueta Medication Survey, Version 7
43. How convinced are you that it is important to take your heart medicines every day? Circle one.
Not important 0 1 2 3 4 5 6 7 8 9 10 Very important
44. How difficult is it for you to pay for your heart medicines? (Very difficult, Somewhat difficult, Not
difficult, Easy)
45. In the last year, how often did you miss your heart medicines? (Often, Sometimes, Rarely, Never)
46. In the last year, have you “stretched” (take less of) your heart medicines to make it last longer?
(Often, Sometimes, Rarely, Never)
Semi-Annual Follow-Up Form (SAFA)
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47. In the last year, how often did you run out of your heart medicines? (Often, Sometimes, Rarely,
Never)
48. If you ran out, what were the reasons? Check all that apply: Cost, Lack of transportation to get heart
medicines, Forgot, Other___)
Morisky Scale Questions[5]
49. Do you ever forget to take your medicine? Y/N
50. Are you careless at time about taking your medicine? Y/N
51. When you feel better, do you sometimes stop taking your heart medicine? Y/N
52. Sometimes if you feel worse when you take the heart medicines, do you sometimes stop taking it?
Y/N
Semi-Annual Follow-Up Form (SAFA)
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| File Type | application/pdf |
| File Title | Semi-AFU |
| Author | Gerardo |
| File Modified | 2010-08-19 |
| File Created | 2010-08-19 |