Form 1 Sr Corps Independent Living Evaluation CATI Pre and Post

Study 3 Senior Corps Independent Living Evaluation Survey

Pre/Post Survey

OMB Control Number xxxx-xxxx Expires xx/xx/xxxx

REVISED August 28, 2013

Senior Corps Independent Living Impact Evaluation Study

Client Consent Process

Telephone survey

My name is (name) and I work at JBS International. The Corporation for National and Community Service, the agency that supports the Senior Companion Program, has asked JBS to do a survey with people who use Senior Companion services. The purpose is to learn how the support of a Senior Companion may affect your life, and to improve our services. This is a new nationwide study and your input is important.

INTERVIEWER: For respondents completing the pre-survey, add the following:

We are asking you to take the survey now. You will be asked to complete a follow-up survey within the next year. You may also be contacted at some point within the next two years for an additional follow up.

INTERVIEWER: Read the following to all respondents and for each post-survey:

Participation in this survey is voluntary and will not affect your access to Senior Companion services. You may choose not to answer particular questions or not to take the survey at all. Only group results will be reported. No individual results will be reported. Do you have any questions?

Would you be willing to take a survey?

If YES, continue.

If NO, thank the person and end the call.

“The survey will take about 20 minutes. Do you have some time to answer questions now?”

If YES, continue.

If NO, ask for a better time to do the survey, and write the time to call back.

To begin the survey, say:

“Thank you for taking the time to complete this survey.. All information will be confidential.”

“Let’s begin the survey. For each question, I will read the question and all the answers options first, and then I will write down the answer you give me. You may choose not to answer questions.” (Continue to questions and go through the survey.)

1. Sponsoring Organization

This section will be pre-loaded based on information gathered from the project director or another representative from the sponsoring organization.

_________________________________ _________________

Organization Name Grant Number

2. Name of Client

______________________ ____ ________________________

First Middle Last

3. Salutation used for the client

   1. Ms. or Mrs.

   2. Mr.

INTERVIEWER: ONLY ASK QUESTION 4 ON THE POST-TEST.

4. When did the client begin receiving services from a Senior Companion?

Month___________________ Year_____________

5. Date of the interview

_______________ ______ ____________

Month Day Year

Part 1: First I want to start with questions about you and your Senior Companion services.

I want to ask you a few questions about yourself. Your answers will help us understand who is participating in this survey.

INTERVIEWER: DO NOT ASK QUESTIONS 6-8 ON POST-TEST; POST-TEST BEGINS WITH QUESTION 9..

6. In what month and year were you born?

1. Month

01. JAN

02. FEB

03. MAR

04. APR

05. MAY

06. JUN

07. JUL

08. AUG

09. SEP

10. OCT

11. NOV

12. DEC

98. Don’t Know

99. Refuse

2. Year _______________

9998. Don’t Know

9999. Refuse

7. Are you of Hispanic or Latino origin?

   1. Yes        

   2. No  

 

 

8. What is your race?  Please select one or more. 

   1. White   

   2. Black or African American  

   3. Asian  

   4. Native Hawaiian or other Pacific Islander  

   5. American Indian or Alaska Native  

9. Are you currently married, have a partner as if married, separated, divorced, widowed, or never married? ⁱ

1. Married

2. Have partner

3. Separated

4. Divorced

5. Widowed

6. Never Married

7. Other

8. I prefer not to answer

10. INTERVIEWER: Please note if the interview will proceed with the client, an assistant or proxy reporter?

    1. Senior Companion Client completing the survey alone: [START WITH QUESTION 11 AND WORK THROUGH THE ENTIRE SURVEY]

    2. Senior Companion completing the survey with assistance [START WITH QUESTION 11 AND WORK THROUGH THE ENTIRE SURVEY]

IF USING AN ASSISTANT:

1. Reasons an assistant is needed (e.g., specify types of impairment): _______

2. Relationship of assistant to client (e.g., spouse, adult child, another relative, family friend, primary caregiver): ____________________

3. Client has given consent to speak with the assistant: ________ (yes/no) Do not proceed if answer is NO.

3. Proxy for Senior Companion Client, answering the survey on behalf of the Client [START WITH QUESTIONS 13 THROUGH 17; QUESTION 26; QUESTIONS 28 THROUGH 39]

IF USING A PROXY REPORTER:

1. Reasons a proxy is needed (e.g., specify types of impairment): _______

2. Relationship of proxy to client (e.g., spouse, adult child, another relative, family friend, primary caregiver): ____________________

3. Client has given consent for an interview to be conducted with proxy: ________ (yes/no) Do not proceed if answer is NO.

For proxy reporters: Script will replace reference to “You” for reference to client name; and a subset of the questions will be asked. Once information is entered into the CATI system that it is a proxy reported the specific subset of questions to be asked to the proxy reporter will be the only questions the interviewer will see on the screen.

The next question is about how you feel about different aspects of your life

INTERVIEWER: if the interview is with a proxy, skip to question 13.

Life satisfaction

11. Please think about your life-as-a-whole. How satisfied are you with it? Are you satisfied or not satisfied? [Check one box] ⁱⁱ

If satisfied: Are you…

1. Completely satisfied

2. Very satisfied

3. Somewhat satisfied

If not satisfied: Are you…

4. Not very satisfied

5. Not at all satisfied

8. Don’t know

9. Refuse (I prefer not to answer)

Next I have questions about your health.

12. Would you say your health is excellent, very good, good, fair, or poor? [Check one box] ⁱⁱⁱ

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

8. Don’t know

9. Refuse (I prefer not to answer)

13. Has a medical doctor ever told you/CLIENT that you/CLIENT^iv...

	1. Yes	2. No	8. Don’t know	9. Refuse
Have/Has high blood pressure or hypertension?
Have/Has diabetes or high blood sugar?
Have/Has cancer or a malignant tumor, excluding minor skin cancer?
Have/Has chronic lung disease such as chronic bronchitis or emphysema?
Had a heart attack, coronary heart disease, angina, congestive heart failure, or other heart problems?
Had a stroke?

14. Have/Has you/CLIENT ever had or has a doctor ever told you/CLIENT that you/CLIENT^v …

	1. Yes	2. No	8. Don’t know	9. Refuse
Had any emotional, nervous, or psychiatric problems?
Have/Has arthritis, osteoarthritis, or rheumatism?

We would like to understand difficulties people may have with various activities because of an illness or health or physical problem. Please tell me whether you/CLIENT have/has any difficulty doing each of the everyday activities that I am going to read.

15. Because of a health problem do/does you/CLIENT have any difficulty with^vi…

	1. Yes	2. No	3. Can’t do	4. Don’t do	8. Don’t Know	9. Refuse
Walking one block?
Getting up from a chair after sitting for long periods?
Reaching or extending your arms above shoulder level

16. Does any impairment or health problem limit the kind or amount of work you/CLIENT can do around the house?^vii

    1. Yes GO TO Q17

    2. No GO TO Q18 [INTERVIEWER: if the interview is with a proxy

reporter skip to Part 2, question 27]

3. Too old to work GO TO Q18 [INTERVIEWER: if the interview is with a

proxy reporter skip to Part 2, question 27]

8. Don’t know GO TO Q18 [INTERVIEWER: if the interview is with a

proxy reporter skip to Part 2, question 27]

8. Refuse (I prefer not to answer) GO TO Q18 [INTERVIEWER: if the

interview is with a proxy reporter skip to Part 2, question 27]

17. Does this limitation keep you/CLIENT from working around the house altogether?^viii

    1. Yes

    2. No

8. Don’t know

9. Refuse (I prefer not to answer)

[INTERVIEWER: if the interview is with a proxy reporter skip to Part 2, question 27]

18. Part of this study is concerned with people's memory, and ability to think about things. First, how would you rate your memory at the present time? Would you say it is excellent, very good, good, fair or poor?^ix

1. Excellent

2. Very good

3. Good

4. Fair

5. Poor

8. Don’t know

9. Refuse (I prefer not to answer)

Now think about the past week and the feelings you have experienced. Please tell me if each of the following was true for you much of the time during the past week.

19. Much of the time during the past week^x…

	1. Yes	2. No	8. Don’t Know	9. Refuse
a. you felt depressed.
b. you had a lot of energy.

Self-Efficacy

Now please tell me how much you agree or disagree with the following:

20. I can do just about anything I really set my mind to. Do you agree or disagree with this statement?^xi

If disagree: Do you

1. Strongly disagree

2. Somewhat disagree or

3. Slightly disagree

If agree: Do you

4. Slightly agree

5. Somewhat agree or

6. Strongly agree

21. I can do the things that I want to do. Do you agree or disagree with this statement?^xii

If disagree: Do you

1. Strongly disagree

2. Somewhat disagree or

3. Slightly disagree

If agree: Do you

4. Slightly agree

5. Somewhat agree or

6. Strongly agree

Social Loneliness

22. How much of the time do you feel that you are alone? Would you say often, some of the time, or hardly ever or never [Check one box] ^xiii

1. Often

2. Some of the time

3. Hardly ever or never

8. Don’t know

9. I prefer not to answer

23. How much of the time do you feel that you lack companionship? Would you say often, some of the time, or hardly ever or never [Check one box] ^xiv

1. Often

2. Some of the time

3. Hardly ever or never

8. Don’t know

9. I prefer not to answer

Emotional Loneliness

24. How much of the time do you feel that there are people you feel close to? Would you say often, some of the time, or hardly ever or never [Check one box]^xv

1. Often

2. Some of the time

3. Hardly ever or never

8. Don’t know

9. I prefer not to answer

25. How much of the time do you feel that there are people you can turn to? Would you say often, some of the time, or hardly ever or never [Check one box] ^xvi

1. Often

2. Some of the time

3. Hardly ever or never

8. Don’t know

9. I prefer not to answer

Part 2: Performance Measure

INTERVIEWER: SKIP PART 2 (QUESTIONS 22 AND 23a-l) ON THE PRE-TEST.

The next question is about how many hours of service you receive in a typical week from your senior companion.

Tell us how many TOTAL HOURS in a typical week you received services.

Here is an example of how Mrs. Jones would answer question #1:

Her Senior Companion usually spends one hour on Monday with Mrs. Jones and two hours on Wednesday. Therefore, the total hours a week that she receives services is 3 hours a week.

26. In a typical week, how many hours is your/CLIENT Senior Companion Volunteer is with you/CLIENT?

27. Because I Have a Senior Companion Volunteer …

	If Disagree, Do you…		If Agree, Do you…
	1. Strongly Disagree	2. Somewhat Disagree	3. Somewhat Agree	4. Strongly Agree
I feel less lonely. Do you agree or disagree?
I feel I have close ties to more people. Do you agree or disagree?
I am able to do more of the things I need to do. Do you agree or disagree?
I am able to do more things I want to do. Do you agree or disagree?
I can remain living in my own home. Do you agree or disagree?
I am eating regularly scheduled meals. Do you agree or disagree?
I am able to get to medical appointments. Do you agree or disagree?
I am able to get to the grocery store. Do you agree or disagree?
I am able to take care of other necessary errands/appointments Do you agree or disagree?
I am more satisfied with my life. Do you agree or disagree?
Overall, I am satisfied with my Senior Companion volunteer. Do you agree or disagree?
Overall, the Senior Companion Program has met my expectations. Do you agree or disagree?

Part 3: Background questions about the client

I want to ask a few more questions about yourself/CLIENT. Your answers will help us understand the characteristics of the people who participated in this survey.

28. Do/does you/CLIENT consider yourself/HIMSELF/HERSELF Hispanic or Latino^xvii

1. Yes

2. No

8. Don’t know

9. Refuse (I prefer not to answer)

29. What is your/CLIENT Veteran Status [Check all that apply]

1. None, not a veteran

2. Active duty or Reserve Component

3. Military family

4. Veteran

5. Family of veteran

8. Don’t Know

9. I prefer not to answer

30. What is the highest grade of school or year of college you/CLIENT completed^xviii

1. No formal education

2. Grades 1- 11

3. Grade 12 (High School Diploma or GED)

4. Some College

5. Associate’s Degree

6. Bachelor’s Degree/ College Graduate

7. Some graduate school

8. Completed a graduate/professional degree

9. Other

10. I don’t know

11. Refuse (I prefer not to answer)

INTERVIEWER: DO NOT ASK QUESTION 30 ON POST-TEST.

31 Are/IS you/CLIENT male or female^xix? (INTERVIEWER Ask only if you do not know from Q3 above; or there is a discrepancy with what is listed as the respondent’s gender.)

1. Female

2. Male

8. Not answered/Don’t Know

9. Refused

Household

32 Do/Does you/CLIENT generally live alone or with others?

1. Alone GO TO Q34

2. With others GO TO Q33

8. Don’t Know GO TO Q34

9. Refuse (I prefer not to answer) GO TO Q34

33 IF LIVING WITH OTHERS: Including yourself/CLIENT, how many people live in your/CLIENT household?

Number ___________________________

INTERVIEWER: DO NOT ASK QUESTIONS 33 ON POST-TEST.

34 How many children do/does you/CLIENT have?

Number of children _____________ GO TO Q35

0. None GO TO Q36

8. Don’t Know GO TO Q36

9. Refuse (I prefer not to answer) GO TO Q36

35 IF HAS CHILDREN: Do any of your/CLIENT children live within 10 miles of you/CLIENT^xx?

1. Yes

2. No

8. Don’t Know

9. Refuse (I prefer not to answer)

Medicare and Medicaid

The next question is about health insurance. Medicare is a public health insurance program for people 65 or older and for disabled persons. (Medicaid/STATE NAME FOR MEDICAID) is a public health insurance program for people with low incomes.

36 Are/Is you/CLIENT currently covered by Medicare health insurance^xxi?

0. Yes

1. No

8. Don’t Know

9. Refuse (I prefer not to answer)

37 Are/Is you/CLIENT currently covered by (Medicaid/STATE NAME FOR MEDICAID) ^xxii?

1. Yes

2. No

8. Don’t Know

9. Refuse (I prefer not to answer)

Income

38 Which category best describes your/CLIENT total annual household income?

Is your total annual household income greater than $20,000 or less than that?

1. Less

2. Greater GO TO Q39

8. Don’t Know

9. Refuse (I prefer not to answer)

39 IF MORE THAN $20,000: Would you say it is......

1. Between $20,000 but less than $30,000

2. Between $30,000 but less than $40,000 or

3. more than $50,000

8. Don’t Know

9. Refuse (I prefer not to answer)

HRS References http://hrsonline.isr.umich.edu/index.php?p=concord

i Core Section, Section B, MB063

ii Core, section B, B000 Campbell et al (1976)

iii Core, section C, C001 Standard Survey Question

iv Core, section C, C005, C010, C018, C030, C036, C053, C069, C065, C070

v Core, Section C, C065, C070

vi Core, Section G, G003, G005, G009

vii Core, Section M, M006

viii Core, Section M, M008

ix Core, Section D, D101

x Core, Section D, D110, D118

xi Core, Section LB, Q23

xii Core, Section LB, Q23

xiii Core, section LB*, Q20a,i Hughes, M. E., Waite, L. J., Hawkley, L. C., & Cacioppo, J. T. (2004)

xiv Core, Section LB*, Q20a Hughes, M. E., Waite, L. J., Hawkley, L. C., & Cacioppo, J. T. (2004)

xv Core, Section LB*, Q20i Hughes, M. E., Waite, L. J., Hawkley, L. C., & Cacioppo, J. T. (2004)

xvi Core, Section LB*, Q20g

xvii Core Section, Section B , B028

xviii Core Section, Section B, MB014

xix Core Section, Section A, MA008

xx Core Section, Section E, E012

xxi Core Section, Section N, N001

xxii Core Section, Section N, N006

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