NSLTP - Residential Care Community

NCHS Questionnaire Design Research Laboratory

QDRL OMB-10-day letter LTC Attt 1a - LTC RCC Questionaire 061113

Testing Long-term Care Questions

OMB: 0920-0222

Document [docx]
Download: docx | pdf

Attachment 1a.

Note to reviewers: No changes have been made to the questionnaire since OMB’s approval of OMB# 0902-0943. In addition to the questions presented in the questionnaire below, additional questions probing the respondents’ cognitive processes will be administered, following the methodology laid out in the QDRL Generic IRC, OMB# 0902-0222 (ex 06/30/2015).

Shape1

2012 National Study of Long-Term Care Providers (NSLTCP)

Residential Care Community Questionnaire

Shape2

Dear Administrator / Executive Director,

The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) is conducting the new National Study of Long-Term Care Providers (NSLTCP), which includes a national survey of residential care communities. RTI International has been contracted to carry out the data collection.

Please answer all of the questions in reference to the residential care community at the location shown on the pre-printed label below. If your residential care community is part of a multi-facility campus, please only answer for the residential care community portion of the campus. The accuracy of your answers is important to this study.

Residential care places are known by many different names. Just a few terms used to refer to these places are assisted living, personal care, and adult care homes, facilities, and communities; adult family and board and care homes; adult foster care; homes for the aged; and housing with service establishments. For this study, we refer to these places and others like them as residential care communities. Nursing homes are excluded.

If you need assistance or have any questions while completing this questionnaire, please call 1‑800-957-6456 to speak to a member of the NSLTCP project team.

Thank you for taking the time to complete this questionnaire.

Label here

Sincerely,



Angela M. Greene
RTI International,
Survey Contractor to NCHS

Shape3

NOTICE – The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any 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 the 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). Public reporting burden for this collection of information is estimated to average 1 hour 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 (0920-0222). OMB #0920-0222; Expiration Date: 06/30/2015

Shape4

INSTRUCTIONS:

Shape5

  • Please clearly mark your responses in the boxes provided. Examples Shape6 or Shape7

    Shape8

    25

  • Written answers should be printed in the space provided. Example Shape9



Residential care places are known by many different names. Just a few terms used to refer to these places are assisted living, personal care, and adult care homes, facilities, and communities; adult family and board and care homes; adult foster care; homes for the aged; and housing with service establishments. For this study, we refer to these places and others like them as residential care communities. Nursing homes are excluded.



Shape10

1

Study Eligibility


3b. Does this residential care community exclusively serve both persons with mental retardation/a developmental disability and persons with severe mental illness?

Shape11

Shape12 Yes SKIP TO BOX A

Shape13

Shape14 No CONTINUE

4. Does this residential care community provide or arrange for a personal care aide, registered nurse (RN), licenses practical nurse (LPN), or the director or assistant director (if they provide personal care or nursing services to residents) to be on-site 24 hours a day, 7 days a week to meet any resident needs that may arise? On-site means they are located in the same building, in an attached building or next door, or on the same campus.

Shape15

Shape16 Yes CONTINUE

Shape17

Shape18 No SKIP TO BOX A

5. Does this residential care community offer help with activities of daily living, such as help with bathing, either directly or arranged through an outside vendor?

Shape19

Shape20 Yes SKIP TO QUESTION 6

Shape21

Shape22 No CONTINUE

5a. Does this residential care community offer assistance with the administration of medications, give reminders, or provide central storage of medications?

Shape23

Shape24 Yes CONTINUE

Shape25

Shape26 No SKIP TO BOX A


The answers to the questions below determine if this residential care community meets the study definition for the 2012 National Study of Long-Term Care Providers. Please answer the following question(s) and follow the instructions next to the answer you mark.

1. Is this residential care community currently licensed, registered, listed, certified, or otherwise regulated by the state?

Shape27

Shape28 Yes CONTINUE

Shape29

Shape30 No SKIP TO BOX A

2. Does this residential care community have 4 or more licensed, registered, or certified beds?

Shape31

Shape32 Yes CONTINUE

Shape33

Shape34 No SKIP TO BOX A

3. Does this residential care community exclusively serve adults with mental retardation or a developmental disability, such as Down's syndrome or autism?

Shape35

Shape36 Yes SKIP TO BOX A

Shape37

Shape38 No CONTINUE

3a. Does this residential care community exclusively serve adults with severe mental illness, such as schizophrenia or psychosis? Please do not include Alzheimer’s disease or other dementias.

Shape39

Shape40 Yes SKIP TO BOX A

Shape41

Shape42 No CONTINUE


Shape43

6. Does this residential care community offer at least 2 meals a day to residents?

Shape44 Yes CONTINUE

Shape45

Shape46 No SKIP TO BOX A

7. Is there at least one resident living at this residential care community?

Shape47

Shape48 Yes SKIP TO QUESTION 8

THIS RESIDENTIAL CARE COMMUNITY IS ELIGIBLE TO PARTICIPATE IN THIS STUDY.

Shape49

Shape50 No SKIP TO BOX A

BOX A

Thank you very much for answering these questions. Unfortunately, this residential care community does not meet the study definition. This study is focused on residential care communities that are in some way regulated by the state and provide a broader array of residential care services.

Please return this questionnaire in the enclosed return envelope so we will know that this residential care community is not eligible to participate in the 2012 National Study of Long-Term Care Providers. After receiving this questionnaire, we will not need to contact you again.



9. Is this residential care community owned by a person, group, or organization that owns or manages two or more residential care communities? This may include a corporate chain.

Shape51 Yes

Shape52 No

10. Is this residential care community owned by any other type of organization?

Shape53

Shape54 Yes CONTINUE

Shape55

Shape56 No, not part of another
organization SKIP TO QUESTION 11

10a. For each item (a–f) below, please indicate whether or not this type of organization owns this residential care community.


Yes

No

a. Hospital

Shape57

Shape58

b. Nursing home or skilled nursing facility

Shape59

Shape60

c. Home health agency

Shape61

Shape62

d. Hospice agency

Shape63

Shape64

e. Adult day services center

Shape65

Shape66

f. Other

Shape67

Shape68

11. At this residential care community, what is the number of licensed, registered, or certified residential care beds? Include both occupied and unoccupied beds.

Shape69 Number of beds

12. What is the total number of residents currently living at this residential care community? Include respite care residents.

Shape70 Number of residents



2

Background Information

Please consult records and other staff as needed to answer questions.

Please provide answers only for the residential care community portion of your campus.

8. What is the type of ownership of this residential care community?

MARK ONLY ONE ANSWER

Shape71 Private, nonprofit

Shape72 Private, for profit

Shape73 Publicly traded company or limited liability company (LLC)

Shape74 Government—federal, state, county, or local government

13. Of the residents currently living in this residential care community, how many are respite care residents?

Shape75 Number of residents OR Shape76 None

14. Is this residential care community certified or otherwise set up to participate in Medicaid, either through the Medicaid State Plan or a home and community-based services waiver program?

Shape77 Yes

Shape78 No

15. During the last 30 days, how many of this residential care community’s residents had some or all of their long-term care services paid by Medicaid?

Shape79 Number of residents OR Shape80 None

16. A continuing care retirement community is a community that offers multiple levels of care such as independent living, residential care, and skilled nursing care, and provides residents the opportunity to remain in the same community as their needs change. Is this residential care community part of a continuing care retirement community?

Shape81 Yes

Shape82 No

17. What is the total number of years this residential care community has been operating as a residential care community at this location?

Shape83 Less than 1 year

Shape84 1 to 4 years

Shape85 5 to 9 years

Shape86 10 to 19 years

Shape87 20 or more years


3

Services Offered

Please provide answers only for the residential care community portion of your campus.


18. Does this residential care community only serve adults with dementia or Alzheimer’s disease?

Shape88

Shape89 Yes CONTINUE

Shape90

Shape91 No SKIP TO QUESTION 18b

18a. Does this residential care community have specially trained staff for residents with dementia or Alzheimer’s disease?

Shape92

Shape93 Yes SKIP TO QUESTION 19

Shape94

Shape95 No SKIP TO QUESTION 19

18b. Does this residential care community have a distinct unit, wing, or floor that is designated as a dementia or Alzheimer’s Special Care Unit?

Shape96 Shape97 Yes CONTINUE

Shape98 Shape99 No SKIP TO QUESTION 19

18c. How many licensed beds are in the dementia or Alzheimer’s Special Care Unit?

Shape100 Number of beds

18d. Does this dementia or Alzheimer's Special Care Unit have . . .

MARK YES OR NO IN EACH ROW


Yes

No

a. Higher staff-to-resident ratios compared to other units?

Shape101

Shape102

b. Specially trained staff for residents with dementia or Alzheimer’s disease?

Shape103

Shape104



19. For each item (a–k) below, please mark whether or not this residential care community provides the service and, if it does, whether it is provided only by residential care community employees, only by others through arrangement, or by both. Please mark “Not provided” if the residential care community only refers residents to service providers.

a. Routine and emergency dental services by a licensed dentist

Shape105 Not provided

Shape106 Provided only by residential care community employees

Shape107 Provided only by others through arrangement

Shape108 Provided by both residential care community employees and others through arrangement

b. Hospice services

Shape109 Not provided

Shape110 Provided only by residential care community employees

Shape111 Provided only by others through arrangement

Shape112 Provided by both residential care community employees and others through arrangement

c. Social work services—provided by licensed social workers or persons with a bachelor’s or master’s degree in social work, and include an array of services such as psychosocial assessment, individual or group counseling, and referral services

Shape113 Not provided

Shape114 Provided only by residential care community employees

Shape115 Provided only by others through arrangement

Shape116 Provided by both residential care community employees and others through arrangement

d. Any case management services—generally a process of assessment, planning, and facilitation of options and services for an individual

Shape117 Not provided

Shape118 Provided only by residential care community employees

Shape119 Provided only by others through arrangement

Shape120 Provided by both residential care community employees and others through arrangement

e. Mental health services—target residents' mental, emotional, psychological, or psychiatric well-being and include diagnosing, describing, evaluating, and treating mental conditions

Shape121 Not provided

Shape122 Provided only by residential care community employees

Shape123 Provided only by others through arrangement

Shape124 Provided by both residential care community employees and others through arrangement

f. Any therapeutic services—physical, occupational, or speech

Shape125 Not provided

Shape126 Provided only by residential care community employees

Shape127 Provided only by others through arrangement

Shape128 Provided by both residential care community employees and others through arrangement

g. Pharmacy services—including filling of and delivery of prescriptions

Shape129 Not provided

Shape130 Provided only by residential care community employees

Shape131 Provided only by others through arrangement

Shape132 Provided by both residential care community employees and others through arrangement

h. Podiatry services

Shape133 Not provided

Shape134 Provided only by residential care community employees

Shape135 Provided only by others through arrangement

Shape136 Provided by both residential care community employees and others through arrangement

i. Skilled nursing services—must be performed by a RN or LPN and are medical in nature

Shape137 Not provided

Shape138 Provided only by residential care community employees

Shape139 Provided only by others through arrangement

Shape140 Provided by both residential care community employees and others through arrangement

j. Transportation services for medical or dental appointments

Shape141 Not provided

Shape142 Provided only by residential care community employees

Shape143 Provided only by others through arrangement

Shape144 Provided by both residential care community employees and others through arrangement

k. Transportation services for social and recreational activities, or shopping

Shape145 Not provided

Shape146 Provided only by residential care community employees

Shape147 Provided only by others through arrangement

Shape148 Provided by both residential care community employees and others through arrangement


20. For about how many of the current residents does this residential care community manage, supervise, or store medications; administer medications; or provide assistance with self-administration of medications?

Shape149 Number of residents OR Shape150 None

21. As a part of the admission process, does this residential care community screen residents for depression with a standardized tool such as the Geriatric Depression Scale, Beck Depression Inventory, or the Center for Epidemiological Studies-Depression (CES-D) scale?

Shape151 Yes

Shape152 No

22. Disease-specific programs may include one or more of the following services—educational programs, physical activity programs, diet/nutrition programs, medication management programs, and weight management programs. For each condition (a–d) below, please indicate whether or not this residential care community offers any of these services for residents with this condition.


Yes

No

a. Alzheimer’s disease and other dementias

Shape153

Shape154

b. Cardiovascular disease (e.g., heart disease, stroke, high blood pressure)

Shape155

Shape156

c. Depression

Shape157

Shape158

d. Diabetes

Shape159

Shape160




23. On a regular basis, does this residential care community create daily schedules based on each resident’s life history, abilities, and interests?

Shape161 Yes

Shape162 No

24. On a regular basis, does this residential care community seek input from residents and their families into…

MARK YES OR NO IN EACH ROW


Yes

No

a. What personal care services are received by the resident?

Shape163

Shape164

b. How the resident’s room is decorated?

Shape165

Shape166

25. On a regular basis, does this residential care community give residents choices for each of the following?

MARK YES OR NO IN EACH ROW


Yes

No

a. Meal times

Shape167

Shape168

b. Where they eat

Shape169

Shape170

c. Meal types/menus

Shape171

Shape172



4

Staff Profile

Please consult records and other staff as needed to answer questions.

Please provide answers only for the residential care community portion of your campus.

26. For each item (a–d) below, please indicate the number of staff that currently work at this residential care community full-time and part-time. Please include:

  • both full-time and part-time residential care community employees (an individual is considered a community employee if the community is required to issue a Form W-2 on their behalf), and

  • other individuals or organization staff under contract with and working at this residential care community full-time and part-time.

Please report either the number of full-time and part time staff OR the number of full-time equivalent (FTE) staff, but not both, for the residential care community employee category and the contract staff category. If this residential care community does not have any staff for a specific category, enter “0” under the number of full-time and part-time staff.

Current Residential Care Community Staff

Number of Full-Time Staff

If none, enter “0”

Number of Part-Time Staff

If none, enter “0”


Number of
Full-Time Equivalent (FTE) Staff

If none, enter “0”

a. RNs

Residential care community employee(s)

Shape173

Shape174

OR

Shape175

Contract staff

Shape176

Shape177

OR

Shape178

b. LPNs/licensed vocational nurses (LVNs)

Residential care community employee(s)

Shape179

Shape180

OR

Shape181

Contract staff

Shape182

Shape183

OR

Shape184

c. Certified nursing assistants, nursing assistants, home health aides, home care aides, personal care aides, personal care assistants, and medication technicians or medication aides

Residential care community employee(s)

Shape185

Shape186

OR

Shape187

Contract staff

Shape188

Shape189

OR

Shape190

d. Social workers—licensed social workers or persons with a bachelor’s or master’s degree in social work

Residential care community employee(s)

Shape191

Shape192

OR

Shape193

Contract staff

Shape194

Shape195

OR

Shape196

27. Do any activities directors or activities staff work at this residential care community? Include residential care community employees and contract staff.

Shape197

Shape198 Yes CONTINUE

Shape199

Shape200 No SKIP TO QUESTION 29

28. On an average shift, how many activities directors or activities staff are on-site providing services? Include residential care community employees and contract staff.

Shape201 Number of activities directors or activities staff OR Shape202 None

5

Resident Profile

Please consult records and other staff as needed to answer questions.

Please provide answers only for the residential care community portion of your campus.

29. Of the residents currently living in this residential care community, how many are in each of the following categories? Count each resident only once. Enter “0” for any categories with no residents.


NUMBER OF RESIDENTS

a. Hispanic or Latino, of any race

Shape203

b. American Indian or Alaska Native, not Hispanic or Latino

Shape204

c. Asian, not Hispanic or Latino

Shape205

d. Black, not Hispanic or Latino

Shape206

e. Native Hawaiian or Other Pacific Islander, not Hispanic or Latino

Shape207

f. White, not Hispanic or Latino

Shape208

g. Two or more races, not Hispanic or Latino

Shape209

h. Some other category reported in this residential care community’s system

Shape210

i. Not reported (race and ethnicity unknown)

Shape211

TOTAL

Shape212

NOTE: Total should be the same as provided in Question 12.

30. Of the residents currently living in this residential care community, how many are in each of the following categories? Enter “0” for any categories with no residents.


NUMBER OF RESIDENTS

a. Male

Shape213

b. Female

Shape214

TOTAL

Shape215

NOTE: Total should be the same as provided in Question 12.


31. Of the residents currently living in this residential care community, how many are in each of the following age categories? Enter “0” for any categories with no residents.


NUMBER OF RESIDENTS

a. 17 years or younger

Shape216

b. 18–44 years

Shape217

c. 45–54 years

Shape218

d. 55–64 years

Shape219

e. 65–74 years

Shape220

f. 75–84 years

Shape221

g. 85 years and older

Shape222

TOTAL

Shape223

NOTE: Total should be the same as provided in Question 12.

32. Of the residents currently living in this residential care community, about how many have been diagnosed with each of the following conditions?

NUMBER OF RESIDENTS

a. Alzheimer’s disease or other dementias

Shape224

OR

Shape225 None

b. Developmental disability, such as mental retardation, autism, or Down's syndrome

Shape226

OR

Shape227 None

c. Severe mental illness, such as schizophrenia and psychosis

Shape228

OR

Shape229 None

d. Depression

Shape230

OR

Shape231 None

33. Before or upon admission, does this residential care community use a standardized tool to conduct a formal assessment of its residents to identify anyone with a cognitive impairment?

Shape232

Shape233 Yes CONTINUE

Shape234

Shape235 No SKIP TO QUESTION 34

33a. Based on this assessment, about how many of the residents currently living in this residential care community have been identified as having a cognitive impairment?

Shape236 Number of residents OR Shape237 None

34. This next question asks about the number of residents at this residential care community who currently need assistance in activities of daily living (ADLs).

Assistance refers to needing any help or supervision from another person, or use of special equipment. As a reminder, please provide answers only for the residential care portion of your campus.

Of the residents currently living in this residential care community, about how many need any assistance in each of the following activities?

NUMBER OF RESIDENTS

a. Transferring in and out of bed

Shape238

OR

Shape239 None

b. Transferring in and out of a chair

Shape240

OR

Shape241 None

c. With eating, like cutting up food

Shape242

OR

Shape243 None

d. With dressing

Shape244

OR

Shape245 None

e. With bathing or showering

Shape246

OR

Shape247 None

f. In using the bathroom (toileting)

Shape248

OR

Shape249 None

g. With locomotion or walking—this includes using a cane, walker, or wheelchair and/or help from another person.

Shape250

OR

Shape251 None

35. Of the residents currently living in this residential care community, about how many use a manual, electric, or motorized wheelchair or scooter?

Shape252 Number of residents OR Shape253 None




36. Of the residents currently living in this residential care community, about how many were discharged from an overnight hospital stay in the last 90 days? Exclude trips to the hospital emergency department that did not result in an overnight hospital stay.

Shape254

Shape255 Number of residents CONTINUE

Shape256

Shape257 None SKIP TO QUESTION 37

36a. Of the residents who were discharged from an overnight hospital stay in the last 90 days, about how many of those residents were re-admitted to the hospital for an overnight stay within 30 days of their hospital discharge?

Shape258 Number of residents OR Shape259 None

37. Of the residents currently living in this residential care community, about how many were treated in a hospital emergency department in the last 90 days?

Shape260 Number of residents OR Shape261 None

Questions 3840b refer to the last 12 months.

38. In the last 12 months, about how many residents moved into this residential care community? Count all residents who moved in—including respite care residents, residents who later died, and residents who no longer live here—regardless of the reason.

Shape262 Number of residents OR Shape263 None

39. In the last 12 months, about how many residents living in this residential care community died? Include respite care residents.

Shape264 Number of residents OR Shape265 None

40. In the last 12 months, about how many residents, including respite care residents, moved out of this residential care community? Exclude deaths and residents for whom the community is currently holding a bed for the resident.

Shape266

Shape267 Number of residents CONTINUE

Shape268

Shape269 None SKIP TO QUESTION 41

40a. Where did each of these residents go immediately after they moved out? Enter “0” for any categories with no residents.


NUMBER OF RESIDENTS

a. Another assisted living or similar residential care community (e.g., adult care or personal care residence)

Shape270

b. Hospital

Shape271

c. Nursing home

Shape272

d. Private residence (house or apartment)

Shape273

e. Some other place

Shape274

TOTAL

Shape275

NOTE: Total should be the same as provided in
Question 40.


40b. Of the residents who moved out in the last 12 months, about how many left because the cost of care, including housing, meals, and services required to meet their needs, exceeded their ability to pay?

Shape276 Number of residents OR Shape277 None



6

Record Keeping

Please provide answers only for the residential care community portion of your campus.

41. An Electronic Health Record is a computerized version of the resident’s health and personal information used in the management of the resident’s health care. Other than for accounting or billing purposes, does this residential care community use Electronic Health Records?

Shape278 Yes

Shape279 No

42. For each item (as) below, please indicate in Column 1 whether or not this residential care community collects or tracks this information about residents. If this community does collect or track the information, please indicate in Column 2 whether or not this community has the computerized capability to collect or track it.


Column 1

Does this residential care community collect/track this information?

IF YES IN

COLUMN 1

Column 2

Does this residential care community have the computerized capability to collect/track this information?

a. Contact information for the resident’s medical providers

Shape280 Shape281 Yes

Shape282 No


Shape283 Yes

Shape284 No

b. Resident demographics

Shape285 Yes

Shape286 No


Shape287 Yes

Shape288 No

c. Functional assessments

Shape291 Shape290 Shape289 Shape292 Yes

Shape293 No


Shape294 Yes

Shape295 No

d. Individual service plans

Shape296 Yes

Shape297 No


Shape298 Yes

Shape299 No

e. Resident service records (a record of the services being provided to each resident)

Shape300 Shape301 Yes

Shape302 No


Shape303 Yes

Shape304 No



42. Cont’d


Column 1

Does this residential care community collect/track this information?

IF YES IN

COLUMN 1

Column 2

Does this residential care community have the computerized capability to collect/track this information?

f. Clinical notes, such as medical history and daily progress notes

Shape305

Shape306 Yes

Shape307 No


Shape308 Yes

Shape309 No

g. Resident problem list (medical and behavioral concerns)

Shape310

Shape311 Yes

Shape312 No


Shape313 Yes

Shape314 No

h. Advance directives

Shape315

Shape316 Yes

Shape317 No


Shape318 Yes

Shape319 No

i. Automatic reminders for updating records, scheduling screening tests or guideline based interventions

Shape320

Shape321 Yes

Shape322 No


Shape323 Yes

Shape324 No

j. Lists of medications

Shape325

Shape326 Yes

Shape327 No


Shape328 Yes

Shape329 No

k. Medication administration records

Shape330

Shape331 Yes

Shape332 No


Shape333 Yes

Shape334 No

l. Active medication allergy lists

Shape335

Shape336 Yes

Shape337 No


Shape338 Yes

Shape339 No

m. Warning of drug interactions or contraindications

Shape340

Shape341 Yes

Shape342 No


Shape343 Yes

Shape344 No

n. Discharge and transfer summaries

Shape345

Shape346 Yes

Shape347 No


Shape348 Yes

Shape349 No

o. Outside health care visits, including emergency room visits and overnight hospital admissions

Shape350

Shape351 Yes

Shape352 No


Shape353 Yes

Shape354 No

p. Orders for prescriptions

Shape355

Shape356 Yes

Shape357 No


Shape358 Yes

Shape359 No

q. Orders for tests

Shape360 Yes

Shape361 No


Shape362 Yes

Shape363 No

r. Viewing laboratory/imaging results (seeing and reading test results)

Shape364 Yes

Shape365 No


Shape366 Yes

Shape367 No

s. Public health reporting

Shape370 Shape369 Shape368

Shape371 Yes

Shape372 No


Shape373 Yes

Shape374 No

43. Does this residential care community’s computerized system support electronic health information exchange with each of the following providers?

MARK YES OR NO IN EACH ROW


Yes

No


a. Physician

Shape375

Shape376


b. Pharmacy

Shape377

Shape378




7

Contact Information


We would like to reach you if we have questions about your answers. Please provide your name, telephone number, work e-mail address, and job title. Your contact information will be kept confidential and will not be shared with anyone outside the project team.

PLEASE PRINT

Your full name: Shape379

( )

Your work telephone number, with extension: Shape380

Your work e-mail address: Shape381

Your job title: Shape382





Thank you for participating in the NSLTCP.





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