3 Informant Interview Form (IFI)

The Jackson Heart Study: Annual Follow-up with Third Party Respondents (NHLBI)

Attachment 10 -Informant Interview (IFI) Form

Families

OMB: 0925-0491

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INFORMANT INTERVIEW FORM

OMB# 0925-0491

Expiration Date XX/XXXX




FORM CODE: IFI

Version: C 05/23/2007

ID Number: CONTACT YEAR


LAST NAME: INITIALS:

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 20892-7974, ATTN: PRA (0925-0491). Do not return the completed form to this address.









INSTRUCTIONS: The Informant Interview Form is completed for each informant for an out-of-hospital death as determined by the ARIC Event Investigation Summary. Event ID and Name must be entered above, as described in the document, "General Instructions For Completing Paper Forms". Informant Number should be determined from the Event Investigation Summary Form. For "multiple choice" and "yes/no" type questions, circle the letter corresponding to the most appropriate response. If a letter is circle incorrectly, mark through it with an "X" and circle the correct response.


INFORMANT INTERVIEW TRACING INFORMATION

DECEDENT

Name: ________________________________________________________________________________


Address: ________________________________________________________________________________


________________________________________________________________________________


________________________________________________ _____________ ________________

City State Zip Code


Date of death: / / Age: ______ years

mm dd yyyy

Place of death: ___________________________________________________________________________


INFORMANT


Name: ________________________________________________________________________________


Address: ________________________________________________________________________________


________________________________________________________________________________


________________________________________________ _____________ ________________

City State Zip Code


Telephone: ( _ ) _- ______


Relationship to the deceased: ________________________________________________________________






RECORD OF CALLS

Day of Week

Date

Time

Notes

Code*

Int

S M T W R F S

MM/DD/YYY

A


P




S M T W R F S

MM/DD/YYY

A


P




S M T W R F S

MM/DD/YYY

A


P




S M T W R F S

MM/DD/YYY

A


P




S M T W R F S

MM/DD/YYY

A


P




S M T W R F S

MM/DD/YYY

A


P




S M T W R F S

MM/DD/YYY

A


P




S M T W R F S

MM/DD/YYY

A


P




S M T W R F S

MM/DD/YYY

A


P




S M T W R F S

MM/DD/YYY

A


P




S M T W R F S

MM/DD/YYY

A


P




* RESULT CODES (CIRCLE THE FINAL SCREENING RESULT CODE)


1 Complete 5 Informant away or can't be found

2 Partially complete 6 Language barrier

3 Unknowledgable 7 No one home

4 Refusal 9 Other (specify in Notes)




INFORMANT INTERVIEW FORM (IFIC Screen 1 of 16)


A. HISTORY


1. Before we get started could you please tell me

what was your relationship to the deceased?


{Respondent was deceased's}


Spouse .....…… S

Parent ...…...... P

Daughter/Son ... C

Other relative .. R

Friend .…........ F

Workmate ...... W

Other .…......... O



"I'd like to ask you about ( )'s medical

history. If you have any questions as we go along,

please ask me."



2. First, think back to about one month before ( )

died. At that time, was he/she sick or ill,

with his/her activities limited, or was he/she

normally active for the most part?


Sick/ill/limited activities .... R


Normally Active ................ N


Unknown ..................….... U



INFORMANT INTERVIEW FORM (IFIC Screen 2 of 16)


3. Was ( ) being cared for at a nursing

home, or at another place at the time of death?

Yes, nursing home ......…. R

Yes, at home ...........……. H

Yes, assisted living ..…..... A

Yes, Hospice facility ..…. F

Go to Item 5 Yes, other .............……... O

No ....................……….... N

Unknown .............…….... U


4. Could you tell me the name and

location of the nursing home?

Specify Name, City, State Yes ...... Y

Skip Name, City, State No ....... N


[Place Name, City, State in notelog]

Name _____________________________

_____________________________


City _____________________________

State _____________________________



5. Was ( ) hospitalized

within the four weeks prior

to death?


Yes ....... Y

Go to Item 9, No ........ N

Screen 3

Unknown ... U


6. What was the reason for hospitalization?


{Circle (Y), (N), or (U) for each. Probe if not

offered.}


If no or Yes No Unknown

unknown, go a. Heart attack

to Item 9, or chest pain Y N U

Screen 3

b. Heart surgery Y N U

c. Other Y N U



INFORMANT INTERVIEW FORM (IFIC Screen 3 of 16)

7. What was the date of the hospital admission?

Month Day Year

8. Could you tell me the name

and location of the hospital?


Specify Name, City, State Yes .….. Y

Skip Name, City, State No ..…... N



[Place Name, City, State in notelog]


Name ____________________________

____________________________


City ____________________________

State ____________________________





9. Was ( ) seen by a physician anytime

in the last four weeks prior to death?


Yes ....……. Y


No ......…… N

Go to Item 11

Unknown ... U

10. Could you tell me the name

and address of this physician?


Specify Name, City, State Yes ...... Y

Skip Name, City, State No ....... N


[Place Name, City, State in notelog]


Name _____________________________

_____________________________

City _____________________________

State _____________________________

11. Could you tell me the name

and address of ( )'s

usual physician? (If same as

Q10 record as "same.")

Specify Name, City, State Yes ...... Y

Skip Name, City, State No ....... N


[Place Name, City, State in notelog]


Name ______________________________

______________________________

City ______________________________

State ______________________________




12. Before ( ) 's final illness,

had he/she ever had pains in the chest

from heart disease, for example angina

pectoris?


Yes ..……... Y


Go to Item 14, No ...……... N

Screen 4

Unknown ... U






INFORMANT INTERVIEW FORM (IFIC Screen 4 of 16)

13. Did ( ) ever take

nitroglycerin for this pain?


Yes ...…….. Y


No ....…….. N


Unknown ... U




14. Did a doctor ever say that

( ) had a heart

attack prior to his/her

final illness?

Yes ....….... Y


No ......……. N

Go to Item 16

Unknown ... U


15. Was ( ) hospitalized

for a heart attack?


Yes ...…..... Y


No ....…….. N


Unknown ... U





16. Did he/she ever have a coronary bypass operation,

balloon angioplasty or some other operation or

procedure to improve the circulation of blood to

the heart?


Yes ...…….. Y


No ....…….. N


Unknown ... U



INFORMANT INTERVIEW FORM (IFIC Screen 5 of 16)

17. Did ( ) ever have any other heart disease or heart condition before his/her final illness?

┌────────Yes .....….. Y

No .....……. N

Unknown ... U

└──If yes, specify: _______________________________


___________________________________________


___________________________________________


18. Did ( ) ever have a stroke?


Yes ....…... Y

No .....…... N

Go to Item 19b

Unknown ... U




19.a. Did he/she have a stroke within

four weeks of his/her final illness?

Yes .....…… Y


No .....……. N


Unknown ... U



b. Did he/she have a history of cigarette smoking?

Yes .....…… Y


No ......…… N


Unknown ... U




c. Did he/she have a history of diabetes?

Yes ...…….. Y


No ....…….. N


Unknown ... U





INFORMANT INTERVIEW FORM (IFIC Screen 6 of 16)

B. CIRCUMSTANCES SURROUNDING DEATH

Attach Event ID Label Here


"The next few questions are concerned with the circumstances surrounding ( )'s death."



20. Could you please tell me what you can of ( )'s general health, on the day he/she died, and of the death

itself?


┌───────Yes ..…….. Y

No .....…… N

Unknown ... U

└───────Specify: _______________________________________________________________________________


______________________________________________________________________________________


______________________________________________________________________________________

______________________________________________________________________________________


______________________________________________________________________________________

______________________________________________________________________________________


______________________________________________________________________________________


______________________________________________________________________________________

______________________________________________________________________________________


______________________________________________________________________________________

______________________________________________________________________________________


______________________________________________________________________________________


______________________________________________________________________________________

______________________________________________________________________________________


______________________________________________________________________________________

______________________________________________________________________________________


______________________________________________________________________________________


______________________________________________________________________________________

______________________________________________________________________________________


INFORMANT INTERVIEW FORM (IFIC Screen 7 of 16)

"The next set of questions may go over some of what you have

already told me. Although it may seem repetitious, I must

ask these questions for consistency of information."

21. Were you present when ( ) died?

Go to Item 25, Screen 8

Yes ....... Y

No ……. N

22. Did anyone see or hear ( ) when he/she died?

Go to Item 25,

Screen 8

Yes ..……... Y

No .....……. N


Unknown ... U


23. Was anyone close enough to hear ( )

if he/she had called out?

Go to Item 25,

Screen 8

Yes ....... Y

No ........ N


Unknown ... U


24. How long after ( ) was last

known to be alive was he/she found dead?


{Enter the shortest interval known to be true}


5 minutes or less .…... A


1 hour or less .....….. B


24 hours or less ...….. C


More than 24 hours .... D


Unknown ............…... U




INFORMANT INTERVIEW FORM (IFIC Screen 8 of 16)

25. Where was ( ) when he/she died?


Home (or other private residence) ........ A

Work .................................…………... B

In a public building .................………. C

On a bus or public transportation .….... D

On the street .........................………… E

In an automobile ...................………... F

In a nursing home ..................……..... G

In an emergency room ...............…..... H


In an ambulance ...................……….... I

In the hospital ......................…………. J

Other ..............................…………..... O

Unknown ........................………......... U



C. SYMPTOMS


"The next few questions are concerned

with any symptoms ( ) may

have had shortly before he/she died."



26. Did ( ) experience pain or

discomfort in his/her chest, left

arm, or shoulder or jaw either

just before death or within 3 days

(72 hours) of death?


Yes ...…….. Y


Go to Item 30,

Screen 10

No ....……. N

Go to Item 30,

Screen 10 Unknown ... U



INFORMANT INTERVIEW FORM (IFIC Screen 9 of 16)

"The next set of questions deal specifically with the last

episode of ( )'s pain or discomfort. The last

episode is defined as starting at the time ( )

noticed discomfort that caused him/her to stop or change

what he/she was doing."



27. Did ( )'s last episode of pain or

discomfort specifically involve the chest?

Yes ...…….. Y

No .....……. N

Unknown ... U



28. Did he/she take nitroglycerin

because of this last episode

of pain or discomfort?


Yes .....…… Y

No ......…… N

Unknown ... U









INFORMANT INTERVIEW FORM (IFIC Screen 10 of 16)

29. How long was it from the beginning

of ( )'s last episode of

pain or discomfort to the time he/she

stopped breathing on his/her own?


{Circle the shortest interval known to be true}


5 minutes or less .....……... A

10 minutes or less .....……. B

1 hour or less .........……… C

24 hours or less ........……. D

More than 24 hours ......…. E


Unknown .............……...... U


30. Within 3 days of death or just

before ( ) died, did

any of the following symptoms

begin for the first time?


{Circle (Y), (N) or (U) for each}

Yes No Unknown

a. Shortness of breath Y N U

b. Dizziness Y N U

c. Palpitations (pounding Y N U

in the chest)


d. Marked or increased Y N U

fatigue,tiredness, or

weakness


e. Headache Y N U

f. Sweating Y N U

g. Paralysis Y N U


h. Loss of speech Y N U

i. Attack of indigestion Y N U

or nausea or vomiting


j. Other Y N U

k. Swelling of legs

and/or feet Y N U

If Other, specify:_________________________________

_______________________________________________

_______________________________________________



INFORMANT INTERVIEW FORM (IFIC Screen 11 of 16)


D. EMERGENCY MEDICAL CARE



" The next few questions are concerned with emergency

medical care ( ) may have received prior

to or at the time of death. You may have already

given this information in an answer to an earlier

question. Since it is important to obtain information

specifically on emergency medical care, I hope you

don't mind if these questions seem repetitive."



31. Was a physician, ambulance, or

other emergency medical team called?


Yes ....…… . Y


No .....……. N

Go to Item 35,

Screen 13 Unknown ... U



32. Was (the physician, ambulance,

or EMS team) called because of

symptoms ( ) was having

or after he/she was already dead?

Symptoms ....... S

Go to Item 35, Already Dead ... D

Screen 13







INFORMANT INTERVIEW FORM (IFIC Screen 12 of 16)


33. How long was it from the time

the last episode of symptoms

started to the time that medical

assistance was called for?


{Circle the shortest interval known to be true}


5 minutes or less ....…. A


10 minutes or less ...... B


1 hour or less .......….. C


6 hours or less .....….. D


24 hours or less ...….. E


More than 24 hours .... F

Unknown ..............…. U



34. How long was it from the time

that medical care was called

to the time when it arrived?


{Circle the shortest interval known to be true}


5 minutes or less .....…… A


10 minutes or less .....….. B


1 hour or less ........…….. C


6 hours or less ........……. D


24 hours or less .......…… E


More than 24 hours .....… F


Unknown ................…… U


Did not come ..........…… X






INFORMANT INTERVIEW FORM (IFIC Screen 13 of 16)


35. Were resuscitation measures, such as closed chest massage or CPR, attempted at the time?

Yes ...…….. Y

Go to Item 38,

Screen 14

No ...…..…. N

Unknown .... U


36. Who started the resuscitation or CPR?

Bystander, non‑health professional ..... A

M.D. .......................…………….......... B

Ambulance attendant, paramedic,

or other health professional ..……...... C

Fireman or policeman .……................. D

Other ...........................……………..... O

Unknown .............................………… U


37. Where was resuscitation or CPR started?

Home (or other

private residence) ...........… A

Work .........................…….. B

Public place ................…… C

Ambulance or

other emergency vehicle .... D

Go to Item 39,

Screen 14

Emergency room ................. E

Hospital ......……................. F

Other ....................……........ O

Unknown .......................…. U




INFORMANT INTERVIEW FORM (IFIC Screen 14 of 16)


38. Was ( ) taken to a hospital?

Yes ....…….. Y


No ......……. N

Go to Item 40

Unknown .... U


39. Could you tell me the name

and location of this hospital?

Specify Name, City, State Yes ...... Y

Skip Name, City, State No ....... N

[Place Name, City, State in notelog]

Name _______________________________

City __________________________


State __________________________



E. ADDITIONAL INFORMATION


40. Is there someone else whom we

could contact, who might know

more about the circumstances

surrounding ( )'s death

or his/her usual state of health?

Yes ....……. Y

Read "final script"

then go to Item 43,

Screen 15

No ......…… N

Unknown .... U

41. Could you tell me the name, address,

and telephone number of this person?

Specify Name, City, State, Phone Yes .... Y

Skip Name, City, State, Phone No ..... N

[Place Name, City, State, Phone in notelog]


Name ___________________________________

City ___________________________________


State ___________________________________


Phone ___________________________________



INFORMANT INTERVIEW FORM (IFIC Screen 15 of 16)


42. How was he/she related to the deceased?

Spouse ..........…… S

Parent ..........……. P

Daughter/Son .….. C

Other relative …... R

Friend ..........……. F

Workmate .....…... W

Other ..........…….. O

[Read "final script",then go to Item 43]


F. RELIABILITY


{To be completed immediately after the interview}


43. Did the respondent frequently

contradict himself/herself or

give information that he/she

would have no way of knowing? ...... Yes Y

No N


44. Did the respondent seem to

be reluctant to answer questions

and thus might not have given all

the information the interviewer

would wish to know? ................. Yes Y

No N



INFORMANT INTERVIEW FORM (IFIC Screen 16 of 16)

45. On the basis of these

questions, give your

rating of reliability

of the interview. ......... Good G

Fair F

Poor P


46. Would you like to add

other details concerning

the quality of the interview?

Yes ....... Y

No ........ N

If Yes, specify: ____________________________

_________________________________________

_________________________________________


47. Informant agreed to provide

consent to gather further

information?

Yes ............…… Y

No ............…….. N

Not applicable ... A

If Yes, specify _________________________________

______________________________________________

______________________________________________


G. ADMINISTRATIVE INFORMATION



48. Date of data collection:


Month Day Year


49. Method of data collection:


Computer ....... C


Paper Form ..... P


5 0. Code number of the person

completing this form. ....…..

51. Result Code:


File Typeapplication/msword
File TitleARIC
AuthorCSCC
Last Modified Bypandeym
File Modified2009-12-15
File Created2009-11-02

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