Screeners

Attachment 3a.

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 5 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 06/30/2015

Sample screening script for respondent contact by QDRL Laboratory Manager/QDRL Staff

for Testing the DHCS National Survey of Long-Term Care Providers

recruited through list/ Residential Care Facilities)

Dial respondent’s telephone number [hereafter referred to as R] as indicated on the list.

 Note: Speak only to R. If the number is answered by an answering machine/voice mail, call back at another time.

QDRL Laboratory Manager/QDRL Staff: Good morning/afternoon, may I speak to [fill name]?

 If R is not available say, “Thank you” and try again at another time.

If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am returning their call to me. I’ll try to reach them at another time.

 If R has been successfully contacted, continue...

...Hello, my name is [Laboratory Manager’s/QDRL Staff name]. I am calling from the National Center for Health Statistics. You might remember receiving a letter from the Centers for Disease Control and Prevention’s National Center for Health Statistics. In it we asked for paid volunteers to help us evaluate questions on operations, staff, services, and resident characteristics of residential care facilities.

 If correct person has been contacted. Continue…

...In order to determine if you r facility is eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?

 If the potential respondent doesn’t remember receiving the letter from the Centers for Disease Control and Prevention’s National Center for Health Statistics…

The Questionnaire Design Research Laboratory within the National Center for Health Statistics will be conducting a study to evaluate questions on operations, staff, services, and resident characteristics of residential care facilities. In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?

 If not a good time to talk, schedule a time to call back.

 If good time to talk, continue...

Know_1 Are you the person who is most knowledgeable about the operations, staff, services, and resident characteristics of this facility?

1= Yes (Go to S_1)

2= No (Go to Know_1a)

Know_1a. Would you please give us the name and contact number of the person who is most knowledgeable about the operations, staff, services, and resident characteristics of this facility so we may contact them about participating in this study?

Record name and phone number: _________________________________

Thanks for your time and the information you provided. We will contact [fill name] about participating in this study.

Go back to beginning of telephone screener.

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S_1

[District of Columbia]

Is this residential care facility currently licensed, registered, or certified in the District of Columbia as Assisted Living Residence?

1= Yes

2= No

[Maryland]

Is this facility currently licensed, registered, or certified in the state of Maryland as Assisted Living Program?

1= Yes

2= No

[Virginia]

Is this facility currently licensed, registered, or certified in the state of Virginia as Assisted Living Facility?

1=Yes

2=No

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S_2

Does this residential care facility have 4 or more licensed, registered, or certified beds?

1= Yes

2= No  Go to S_ELIG_2

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S_3

Does this facility exclusively serve adults with mental retardation or a developmental disability, such as Down syndrome or autism?

1=Yes  Go to S_ELIG_2

2=No

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S_4

Does this facility exclusively serve adults with severe mental illness such as schizophrenia or psychosis? Please do not include Alzheimer’s disease or other dementias.

1=Yes  Go to S_ELIG_2

2=No

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S_5

Does this facility provide or arrange for a personal care aide, RN, or LPN to be located in the same building, in an

attached building or next door, or on the same campus, 24 hours a day, 7 days a week, to meet any resident needs that may arise? These needs can be met by the director or assistant director, if they provide personal care or nursing services to residents.

1= Yes

2= No  Go to S_ELIG_2

3= Provided on an as needed basis

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S_6

Does this facility offer help with activities of daily living, such as help with bathing, either directly or arranged through an outside vendor?

1= Yes

2= No

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S_7

Does this facility offer assistance with the administration of medications, give reminders, or provide central storage of

medications?

1= Yes

2= No

If S_6=2 and S_7=2 then Go to S_ELIG_2

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S_8

Does this facility offer at least 2 meals a day to residents?

1= Yes

2= No  Go to S_ELIG_2

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S_9

Is there at least one resident living at this residential care facility?

1= Yes, at least one current resident

2= No, 0 resident  Go to S_ELIG_2

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S_10

Let me verify that I have the correct name and address for your facility.

Is the correct name of your facility: [Facility Name]?

1= Yes

2= No  Go to S_10a

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S_10a

Please tell me the correct name of your facility.

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S_11

Is your facility located at: [Facility_Address]?

1= Yes

2= No  Go to S_11a

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S_11a

Please tell me the correct street address of your facility.

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Entry Script:

Thank you very much for answering these questions. Based on your responses, your facility is eligible to participate in our study. The in person interview will take about an hour and will be conducted during [fill dates] the first 2 weeks of November. During the interview, an interviewer will ask you about your [Facility Name], its operations, staff, services and resident characteristics. The interviewer will also ask you about your opinions of the survey questions. Everything you say will be kept private. Your individual responses will not be shared with anyone. Only summary reports will be available to those interested in the results of this study. With your permission, we would like to audio record your interview. The recording is a record of what we asked and what you said and will aid us in our analysis. Do you give permission to have your interview audio recorded? Yes/No. [Record response. Audiotaping is preferable, but not essential for this project.

Do you have any questions at this point? Pause to answer questions. If (not/you have no other questions), then let’s get you on the schedule, ok? What days /times during [fill dates] the first 2 weeks of November would you be available to participate? Schedule. [If date/times not available go to exit script SCHD.]

[After the appointment date/time is set] We will send you an email confirmation. A reminder call will also be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for being willing to participate and we look forward to seeing you at (LOCATION) at (DATE/TIME) Get respondent to cite date & time if possible.

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Exit script S_ELIG_2:

Thank you very much for answering these questions. Unfortunately, this facility does not qualify for our study (which is

focused on facilities with at least 4 beds, that have current residents and provide a broader array of residential care services). I appreciate your time today.

Exit script SCHD:

I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time.

Attachment 3b.

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 5 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 06/30/2015

Sample screening script for respondent contact by QDRL Laboratory Manager/QDRL Staff

for Testing the DHCS National Survey of Long-Term Care Providers

recruited through list/Adult Day Services center

Dial respondent’s telephone number [hereafter referred to as R] as indicated on the list.

 Note: Speak only to R. If the number is answered by an answering machine/voice mail, call back at another time.

QDRL Laboratory Manager/QDRL Staff: Good morning/afternoon, may I speak to [fill name]?

 If R is not available say, “Thank you” and try again at another time.

If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am returning their call to me. I’ll try to reach them at another time.

 If R has been successfully contacted, continue...

...Hello, my name is [Laboratory Manager’s/QDRL Staff name]. I am calling from the National Center for Health Statistics. You might remember receiving a letter from the Centers for Disease Control and Prevention’s National Center for Health Statistics. In it we asked for paid volunteers to help us evaluate questions on operations, staff, services, and resident characteristics of residential care facilities.

 If correct person has been contacted. Continue…

...In order to determine if your adult day service center is eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?

If the potential respondent doesn’t remember receiving the letter from the Centers for Disease Control and Prevention’s National Center for Health Statistics…



The Questionnaire Design Research Laboratory within the National Center for Health Statistics will be conducting a study to evaluate questions on operations, staff, services, and client characteristics of adult day services centers. In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?

 If not a good time to talk, schedule a time to call back.

 If good time to talk, continue...

Know_1 Are you the person who is most knowledgeable about the operations, staff, services, and client characteristics of this center?

1= Yes (Go to ADS_1)

2= No (Go to Know_1a)

Know_1a. Would you please give us the name and contact number of the person who is most knowledgeable about the operations, staff, services, and resident characteristics of this center so we may contact them about participating in this study?

Record name and phone number: _________________________________

Thanks for your time and the information you provided. We will contact [fill name] about participating in this study.

Go back to beginning of telephone screener.

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ADS_1

Is this Adult Day Services center currently licensed, registered, or certified in [the District of Columbia/ in the state of Virginia/ in the state of Maryland] as an adult day services center?

1= Yes  Go to S_2

2= No  Go to S_1a

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ADS_1a

Does this Adult Day Services center receive any funds from Medicaid, such as through Medicaid Personal Care or Medicaid Home and Community-Based Waiver?

1= Yes

2= No  Go to ADS_1b

ADS_1b

Is this Adult Day Services center accredited by Rehabilitation Accreditation Commission Certified (CARF) or Joint Commission on Accreditation of Healthcare Organizations (JCAHO)?

1= Yes

2= No  Go to ADS_ELIG_2

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ADS_2

Is there at least one client that this Adult Day Services center serves?

1= Yes, at least one current client

2= No, 0 client  Go to ADS_ELIG_2

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ADS_3

Let me verify that I have the correct name and address for your adult day services center.

Is the correct name of your center: [center Name]?

1= Yes

2= No  Go to ADS_3a

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ADS_3a

Please tell me the correct name of your center.

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ADS_4

Is your adult day services center at: [ center address]?

1= Yes

2= No  Go to ADS_4a

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ADS_4a

Please tell me the correct street address of your center.

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Entry Script:

Thank you very much for answering these questions. Based on your responses, your center is eligible to participate in our study. The in person interview will take about an hour and will be conducted during [fill dates] the first 2 weeks of November. During the interview, an interviewer will also ask you about your opinions of the survey questions. Everything you say will be kept private. Your individual responses will not be shared with anyone. Only summary reports will be available to those interested in the results of this study. With your permission, we would like to audio record your interview. The recording is a record of what we asked and what you said and will aid us in our analysis. Do you give permission to have your interview audio recorded? Yes/No. [Record response. Audiotaping is preferable, but not essential for this project.

Do you have any questions at this point? Pause to answer questions. If (not/you have no other questions), then let’s get you on the schedule, ok? What days /times during [fill dates] the first 2 weeks of November would you be available to participate? Schedule. [If date/times not available go to exit script SCHD.]

[After the appointment date is set] We will send you an email confirmation. A reminder call will also be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for being willing to participate and we look forward to seeing you at (LOCATION) at (DATE/TIME) Get respondent to cite date & time if possible.

---------------------------------------------------------

Exit script: ADS_ELIG_2:

Thank you very much for answering these questions. Unfortunately, this adult day services center does not qualify for our study (which is focused on adult day services centers that regulated by the State or receive Medicaid funding, have current clients and provide a broader array of adult day services). I appreciate your time today.

Exit script SCHD:

I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time.