2 survey

OMB#: 0925-0584

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 10 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.

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OMB#: 0925-0584

Exp. X/XX/XXXX

CHS/SOL Follow-up Interview Form

Contact Year 1

ID NUMBER:

FORM CODE: AFE VERSION: A 11/03/08

Contact Occasion

0

1

SEQ #

Acrostic:

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, 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. I’m calling to see how you have been since your visit to our clinic and to update our HCHS/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 clinic. I will ask you some questions about your health since your clinic visit on (date of clinic visit).

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

1. Participant status:

a. Contacted and alive 0 Go to item 2

b. Contacted and refused interview 1 Go to Contact tracking, item X

c. Not contacted, reported alive 2 Go to Contact tracking, item 12

d. Not contacted, reported deceased 3 See Death investigation protocol

e. Unknown 4 Go to Contact tracking, item 12

GENERAL HEALTH

2. Since your HCHS/SOL clinic visit on (date), would you say, in general, your health is Excellent, Very good, Good, Fair, Poor, or Unsure? (read all response categories except Unsure)

Excellent 0 Very good 1 Good 2 Fair 3 Poor 4

HOSPITALIZED AND EMERGENCY DEPARTMENT EVENTS

“The following set of questions are about any hospital stays or visits to emergency rooms you may have had since your HCHS/SOL clinic visit on (date).”

3. Since your HCHS/SOL clinic visit on (date), have you at any time been admitted to a hospital?

No 0 Go to item 4

Yes 1

Unsure 2 Go to item 4

3a. What was the reason of this hospital stay? (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

COPD 6

Asthma 7

Other: 8 Specify: _______________

3b. What was the date of this hospitalization: / /

3c. What was the name of the hospital: _________________ Facility code:

3d. What was the address of this hospital: _________________ ; Don’t know 0

3e. Were you admitted to a hospital at any another time since your HCHS/SOL clinic visit?

No 0 Go to item 4

Yes 1 Data saved and screen refreshes to 3a.

4. Since your HCHS/SOL clinic visit on (date), were you seen in an emergency room but not admitted to the hospital?

No 0 Go to item 5

Yes 1

Unsure 2 Go to item 5

4a. What was the reason of going to the emergency room? (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

COPD 6

Asthma 7

Other: 8 Specify: _______________

4b. What was the date of the visit: / /

4c. What was the name of the emergency room: _________ Facility code:

4d. What was the address of the emergency room: ____________ ; Don’t know 0

4e. Were you seen in an emergency room on any other occasion since your HCHS/SOL clinic visit?

No 0 Go to item 5

Yes 1 Data saved and screen refreshes to 4a.

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 department/room.”

5. Since your HCHS/SOL clinic 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 2 Go to item 6

5a. Did your doctor or healthcare professional order any of the following tests to help make the diagnosis?

i. Breathing test or pulmonary function test?

No 0 Yes 1 Unsure 2

ii. Chest X-ray:

No 0 Yes 1 Unsure 2

iii. CT Scan of your chest:

No 0 Yes 1 Unsure 2

5b. 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 bronchitis?

No 0 Go to item 6

Yes 1

Unsure 2 Go to item 6

i. 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 2

6. Since your HCHS/SOL clinic visit on (date), has a doctor or health professional told you that you had asthma?

No 0 Go to item 7

Yes 1

Unsure 2 Go to item 7

6a. Did your doctor or healthcare professional order any of the following tests to help make the diagnosis?

i. Breathing test or pulmonary function test?

No 0 Yes 1 Unsure 2

ii. Chest X-ray:

No 0 Yes 1 Unsure 2

iii. CT Scan of your chest:

No 0 Yes 1 Unsure 2

6b. 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

i. 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 2

7. Since your HCHS/SOL clinic 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 2 Go to item 8

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

No 0 Go to item 8

Yes 1

Unsure 2 Go to item 8

i.What treatment was recommended?

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

Pills 0

Insulin Alone 1

Insulin and pills 2

Referred for eye exam 3

Advice to change diet 4

Advice to stop smoking 5

Advice to increase excercise 6

Other: 7 Specify: _______

8. Since your HCHS/SOL clinic 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 2 Go to item 9

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

No 0 Go to item 9

Yes 1

Unsure 2 Go to item 9

i. What treatment was recommended?

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

Start new medicine 0

Increase dose of existing medicine 1

Advice to lose weight 2

Advice to change diet 3

Advice to stop smoking 4

Advice to increase exercise 5

Other 6 specify ________________

9. Since your HCHS/SOL clinic 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 2 Go to item 10

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

No 0 Go to item 10

Yes 1

Unsure 2 Go to item 10

i. What treatment was recommended?

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

Start new medicine 0

Increase dose of existing medicine 1

Advice to lose weight 2

Advice to change diet 3

Advice to stop smoking 4

Advice to increase exercise 5

Other 6 specify ________________

MEDICATIONS

“Now I would like to ask about the prescription medications you currently use. Can I ask you to bring all the prescription medications you are taking to the telephone?”

10. (do not ask) Does the participant have medications to report?

No 0 Skip item 11

Yes 1

Participant refused 2 Skip item 11

11. Please read the names of all the medications prescribed by a doctor. This includes pills, liquid medications, skin patches, inhalers, and injections. Please do not include over the counter medications unless prescribed by a doctor. (If asked, currently taking applies to medications taken in the past two weeks.)

a. _____________________________

b. _____________________________

c. _____________________________

d. _____________________________

T hank you so much for answering these questions. We greatly appreciate your participation in the HCHS/SOL study. Should you have any questions, please feel free to call us at the clinic at (telephone number). Before we hang up, I’d just like to make sure our records are up to date. Could you please tell me if the following information I have is still correct?

PARTICIPANT TRACKING

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

a. Participant Tracking: ­­­___________________ Changes: ___________________

Current data to be shown here Record changes here

b. Contacts/proxies: _____________________ Changes: ____________________

Current data to be shown here Record changes here

c. Health care providers: _____________________ Changes: _____________________

Current data to be shown here Record changes here