Form 1 Interview

Public reporting burden for this collection of information is estimated to average 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 20892-7974, ATTN: PRA (0925-0584). Do not return the completed form to this address.

OMB#: 0925-0584

Exp. X/XX/XXXX

HCHS/SOL Follow-up Interview Form

Contact Year 1

ID NUMBER:

FORM CODE: AFE VERSION: A

Contact Occasion

0

1

SEQ #

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Instructions: See the detailed QxQ instructions for completion of the Annual Follow-up form.

INTRODUCTION

Hello, my name is (interviewer name), and I am calling to follow up with (participant name) about the Hispanic Community Health Study / Study of Latinos (SOL), a health study in which s/he is currently enrolled. Is s/he available?

N o When would it be convenient to call back? ..............Thank you. I will call again.

Y es Hello, (participant name), this is (interviewer name) with the Hispanic Community Health Study / Study of Latinos (SOL). I’m calling to see how you have been since your visit to our center and to update our SOL records. Do you have a few minutes to speak on the phone?

No When would it be convenient to call back?.........Thank you. I will call again.

Yes We’d like to gather information about your general health and about specific medical conditions that you may have had since your visit to our center. I will ask you some questions about your health since your center visit on (date of center visit).

I want you to focus on what happened from (date of center visit) until today.

A. [GHE section for data entry screens begins here]

1. Participant status (choose one):

Contacted and alive 1 Go to item 2

Contacted and refused interview 2 Go to Contact tracking, item 31a1

Not contacted, reported alive 3 Go to Contact tracking, item 31a1

Not contacted, reported deceased 4 Continue to 1a, below

Unknown 9 Go to Contact tracking, item 31a1

1a. What was the date of death? / /

1b. What city, state, and country did the death occur? _______________________________

1c. Do you know if (insert decedent’s name) was hospitalized or visited an emergency room for

any reason since (date of center visit) and his/her death?

No 0 End interview

Yes 1 Record date and name of each hospitalization and/or ER visit. End interview after last event is reported.

GENERAL HEALTH

2. Since your SOL center visit on (date), would you say, in general, your health is Excellent, Very good, Good, Fair, or Poor?

Excellent 1 Very good 2 Good 3 Fair 4 Poor 5

[HOE section for data entry screens begins here]

B. HOSPITALIZED AND EMERGENCY ROOM EVENTS

“The following questions are about any hospitalizations or visits to an emergency room you may have had since your SOL center visit on (date).” [ Note: This section will repeat depending upon number of reported events ]

3. Since your SOL center visit on (date), have you at any time been admitted to a hospital or seen in an emergency room?

No 0 Go to item 5

Yes 1

Unsure 9 Go to item 5

“The next few questions are about one event, if there were more than one we would like to talk about each one separately, let’s start with the first event after your SOL visit on (date).”

4. Was this visit to the emergency room only, a hospital admission only, or a visit to the emergency room that resulted in being admitted to the hospital?

Emergency Department (only) 1

Hospital Admission (only) 2

Both 3

Unsure 9

4a. What was the main reason for going to the (insert emergency room or hospital) that day?

[Check one and do not read choices]

Myocardial infarction, heart attack 0

Angina, chest pain 1

Heart failure 2

Stroke or TIA 3

Peripheral vascular disease 4

Venous thrombosis or pulmonary embolism 5

Chronic Obstructive Pulmonary Disease, emphysema, or chronic bronchitis 6

Asthma 7

Other: 8

Specify: _______________

4b. What was the date of this event? / /

4c. What is the name of the medical facility?

4d. What is the address of this medical facility?

(Leave blank if unknown)

4e. For clarification of our records, under what name is this record?

4e1. First Name:

4e2. Second Name:

4e3. Last Name:

4e4. Maternal Last Name:

4f. Were you admitted to a hospital or seen at an ER at any another time since your SOL center visit? No 0 Go to item 5

Yes 1 (Line entry saved, screen refreshes to a new series at item 4)

[OPE section for data entry screens begins here]

C. OUT-PATIENT SELF-REPORTED CONDITIONS

“Now I would like to ask you about conditions that may have resulted in you seeing a doctor or health profession at a clinic or doctor’s office, but not actually being admitted to the hospital or visiting an emergency room.”

5. Since your SOL center visit on (date), has a doctor or health professional told you that you had emphysema, chronic bronchitis, or chronic obstructive pulmonary disease (COPD)? This does not include doctor’s visits for tuberculosis or TB.

No 0 Go to item 6

Yes 1

Unsure 9 Go to item 6

Did your doctor or healthcare professional order any of the following tests to help make the diagnosis?

5a. Breathing test or pulmonary function test?

No 0 Yes 1 Unsure 9

5b. Chest X-ray:

No 0 Yes 1 Unsure 9

5c. CT Scan of your chest:

No 0 Yes 1 Unsure 9

5d. Were you told by a doctor or health professional that you were having an attack, worsening or an exacerbation of your emphysema, chronic obstructive pulmonary disease (COPD), or chronic bronchitis?

No 0 Go to item 6

Yes 1

Unsure 9 Go to item 6

5e. Did the doctor or health care professional prescribe a change in your medication, such as increasing your inhalers, oxygen or pills for your lungs or prescribing a steroid pill for your lungs?

No 0 Yes 1 Unsure 9

6. Since your SOL center visit on (date), has a doctor or health professional told you that you had asthma? No 0 Go to item 7

Yes 1

Unsure 9 Go to item 7

Did your doctor or healthcare professional order any of the following tests to help make the diagnosis?

6a. Breathing test or pulmonary function test

No 0 Yes 1 Unsure 9

6b. Chest X-ray

No 0 Yes 1 Unsure 9

6c. CT Scan of your chest

No 0 Yes 1 Unsure 9

6d. Were you told by a doctor or health professional that you were having an attack, worsening or an exacerbation of your asthma?

No 0 Go to item 7

Yes 1

Unsure 2 Go to item 7

6e. Did the doctor or health care professional prescribe a change in your medication, such as increasing your inhalers, oxygen or pills for your lungs or prescribing a steroid pill for your lungs?

No 0 Yes 1 Unsure 9

7. Since your SOL center visit on (date), has a doctor or health professional told you that you had diabetes or high sugar in the blood?

No 0 Go to item 8

Yes 1

Unsure 9 Go to item 8

7a. Did the doctor recommend any new or different treatments?

No 0 Go to item 8

Yes 1

Unsure 9 Go to item 8

7b.What treatment was recommended?

(Do not prompt for specific response. Mark all that apply)

Pills

Insulin Alone

Insulin and pills

Referred for eye exam

Advice to change diet

Advice to stop smoking

Advice to increase excercise

Other

Specify:

8. Since your SOL center visit on (date), has a doctor or health professional told you that you had high blood pressure or hypertension?

No 0 Go to item 9

Yes 1

Unsure 9 Go to item 9

8a. Did the doctor recommend any new or different treatments?

No 0 Go to item 9

Yes 1

Unsure 9 Go to item 9

8b. What treatment was recommended? (Do not prompt for specific response. Mark all that apply)

Start new medicine

Increase dose of existing medicine

Advice to lose weight

Advice to change diet

Advice to stop smoking

Advice to increase exercise

Other

Specify:

9. Since your SOL center visit on (date), has a doctor or health professional told you that you had high blood cholesterol?

No 0 Go to item 10

Yes 1

Unsure 9 Go to item 10

9a. Did the doctor recommend any new or different treatments?

No 0 Go to item 10

Yes 1

Unsure 9 Go to item 10

9b. What treatment was recommended? (Do not prompt for specific response. Mark all that apply.)

Start new medicine

Increase dose of existing medicine

Advice to lose weight

Advice to change diet

Advice to stop smoking

Advice to increase exercise

Other

Specify:

[MEE section for data entry screens begins here]

D. MEDICATIONS

“Now I would like to ask about the prescription medications you currently use. By currently I mean in the past two weeks. Can you to bring all these prescription medications to the telephone?”

10. (Interviewer: Do not ask) Does the participant have medications to report?

No 0 Skip items 11-30

Yes 1

Participant refused 2 Skip items 11-30

Please read the names of all the medications prescribed by a doctor. This includes pills, liquid medications, skin patches, inhalers, injections and suppositories. Please do not include over the counter medications unless prescribed by a doctor.

#	(a) Medication UPC / NDC		Medication name (b)
11.
	(c) Strength	(d) Units
12.
	(c) Strength	(d) Units
13.
	(c) Strength	(d) Units
14.
	(c) Strength	(d) Units
15.
	(c) Strength	(d) Units
16.
	(c) Strength	(d) Units
17.
	(c) Strength	(d) Units
18.
	(c) Strength	(d) Units
19.
	(c) Strength	(d) Units
20.
	(c) Strength	(d) Units
#	(a) Medication UPC		Medication name (b)
21.
	(c) Strength	(d) Units
22.
	(c) Strength	(d) Units
23.
	(c) Strength	(d) Units
24.
	(c) Strength	(d) Units
25.
	(c) Strength	(d) Units
26.
	(c) Strength	(d) Units
27.
	(c) Strength	(d) Units
28.
	(c) Strength	(d) Units
29.
	(c) Strength	(d) Units
30.
	(c) Strength	(d) Units

Thank you so much for answering these questions. We greatly appreciate your participation in the SOL study. Now, I’d just like to make sure our records are up to date.

[CIE section for data entry screens begins here.]

E. PARTICIPANT TRACKING

31. Interviewer: Current tracking information from HCHS/SOL database is shown below. Record tracking information changes reported during the interview in the space provided.

“It is very important for this study to be able to reach you in the future. Although you provided your contact information at the time of your visit, in order to keep our records up to date please provide us with your current home address. All information you give us in strictly confidential and will not be shared with anyone else”.

31. Current home address*

31.A.1. PO Box, Box &/or Route and Number
31.B.1. Street Number Prefix
31.B.2. Street Number
31.B.3. Street Number Suffix
31.C.1. Street Name Prefix
31.C.2. Street Name
31.C.3. Street Name Type
31.C.4. Street Name Suffix
31.D.1. Unit Type
31.D.2. Unit Type Identifier
31.D.3. Unit Subtype
31.D.4. Unit Subtype Identifier
31.E.1. Other
31.F.1. City

31.G.1. County
31.H.1. State
31.I.1. Country/Territory (Select code from list)
31.J.1. Zip Code						–

*IF THE PARTICIPANT LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE HOME LOCATION IN 31.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 31.E.1.

IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER IT IN 31.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE ACTUAL HOME LOCATION IN 31.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 31.E.1.

32. Primary Phone Number: () -

33. What is the best time of day to reach you at this number?

Morning 1

Afternoon 2

Evening 3

34. Secondary Phone Number: () -

35. What is the best time of day to reach you at this number?

Morning 1

Afternoon 2

Evening 3

Local Contact 1

36. a. Title: _______________ b. First Name:

c. Second Name:

d. Last Name:

e. Maternal Last Name: ______________________________________

37. Relationship: __________________

38. Current home address of primary contact*

38.A.1. PO Box, Box &/or Route and Number
38.B.1. Street Number Prefix
38.B.2. Street Number
38.B.3. Street Number Suffix
38.C.1. Street Name Prefix
38.C.2. Street Name
38.C.3. Street Name Type
38.C.4. Street Name Suffix
38.D.1. Unit Type
38.D.2. Unit Type Identifier
38.D.3. Unit Subtype
38.D.4. Unit Subtype Identifier
38.E.1. Other

38.F.1. City
38.G.1. County
38.H.1. State
38.I.1. Country/Territory (Select code from list)
38.J.1. Zip Code						–

*IF THE PERSON LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE HOME LOCATION IN 38.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 38.E.1.

IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER IT IN 138.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE ACTUAL HOME LOCATION IN 38.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 38.E.1.

39. Telephone: () -

Local Contact 2

40. a. Title: _______________ b. First Name:

c. Middle/Second Name:

d. Paternal Last Name:

e. Maternal Last Name: ______________________________________

41. Relationship: __________________

42. Current home address of secondary contact*

42.A.1. PO Box, Box &/or Route and Number
42.B.1. Street Number Prefix
42.B.2. Street Number
42.B.3. Street Number Suffix
42.C.1. Street Name Prefix
42.C.2. Street Name
42.C.3. Street Name Type
42.C.4. Street Name Suffix
42.D.1. Unit Type
42.D.2. Unit Type Identifier
42.D.3. Unit Subtype
42.D.4. Unit Subtype Identifier
42.E.1. Other
42.F.1. City
42.G.1. County
42.H.1. State
42.I.1. Country/Territory (Select code from list)
42.J.1. Zip Code						–

43. Telephone: () -

*IF THE PERSON LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE HOME LOCATION IN 42.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 42.E.1.

IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER IT IN 42.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE ACTUAL HOME LOCATION IN 42.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 42.E.1.

Local Contact 3

44. a. Title: _______________ b. First Name:

c. Middle/Second Name:

d. Paternal Last Name:

e. Maternal Last Name: ______________________________________

45. Relationship: __________________

46. Current home address of third contact*

46.A.1. PO Box, Box &/or Route and Number
46.B.1. Street Number Prefix
46.B.2. Street Number
46.B.3. Street Number Suffix
46.C.1. Street Name Prefix
46.C.2. Street Name
46.C.3. Street Name Type
46.C.4. Street Name Suffix
46.D.1. Unit Type
46.D.2. Unit Type Identifier
46.D.3. Unit Subtype
46.D.4. Unit Subtype Identifier
46.E.1. Other
46.F.1. City
46.G.1. County
46.H.1. State
46.I.1. Country/Territory (Select code from list)
46.J.1. Zip Code						–

47. Telephone: () -

48. For this portion of the call, I have one more question. What is the name of your physician or other health care provider (HCP)?”

a. Name:

b. Address:

c. City, State, Zip Code:

F. END OF THIS PORTION OF THE CALL

“Thank you for answering the questions about your health. Now we would like to continue with the call by asking you some questions about the food that you eat. (GO to FPQ opening script)

Annual Follow-up Contact Year 1, AFE 2 of 16