Telephone Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 27 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 NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

Older Adult Safe Mobility Assessment Tool Development:

Telephone Survey

Screening questions to be asked during recruitment so that we capture “pre-exposure” answers:

1. What is the first thing that comes to mind when you think about challenges you might face in getting to the places you need to go to, as you get older? [WRITE IN AND CHECK BELOW. WRITE IN “OTHER SPECIFY”]

2. On a scale of 1 to 5 with one being not at all, and 5 being very much, how much have you been recently thinking about your ability to get around in your home and community as you age?

3. On a scale of 1 to 5 with one being not at all, and 5 being very much, how much have you been recently thinking about protecting your ability to get around your home and community as you age?

4. Again on a scale of 1-5 with one being “not at all”, and 5 being “very much”, how confident do you feel that you know what to do to protect your mobility as you age?

5. Again on a scale of 1-5, how motivated are you to protect your ability to get around your home and community as you age?

Know what to do to protect your mobility

Telephone Survey (12 MINUTES)

We would like your help with developing an assessment tool aimed at helping people understand and maximize their ability to get where they need to go as they get older. I have a few introductory questions to get us started…

Prior to our call, you were sent (via mail or email) the assessment to complete.

1. Did you get the assessment?

Yes No [PUT ON REMAIL LIST AND RESCHEDULE FOR FOLLOWUP INTERVIEW ABOUT ONE WEEK FROM TODAY].

2. Do you still have it?

Yes No – [PUT ON REMAIL LIST AND RESCHEDULE FOR FOLLOWUP INTERVIEW ABOUT ONE WEEK FROM TODAY].

3. Did you read it and complete it today?

Yes No [IF NO, SAY, “PLEASE TAKE A MOMENT TO READ IT OVER AGAIN NOW.”]

4. If you were describing this to a friend, what would you call this thing? [OPEN END]

[FILL IN, THEN ASK CLOSE ENDED]

Would you call it:

An assessment
Brochure
Booklet
Quiz

Other [FILL IN]

Think about what you’d normally do if you saw this on a counter at the drug store or at your doctor’s office.

5. How likely would you to pick it up and read it based on the cover? On a scale of 1 to 5, 1 being “not at all” and 5 being “very.”

PROBE: What is the main reason why you would or would not pick it up?

PROBE: What would make you more likely to pick it up?

6. How eye-catching is the front cover to you? On a scale of 1 to 5, 1 being “not at all eye catching” and 5 being “very eye catching.”

PROBE: What’s the main thing that caught your eye?

7. Think about the different places this document might be. Where would you most likely stop and pick it up? [RECORD TOP OF MIND RESPONSE VIA FOLLOWING LIST OR FILL IN IF THEY SAY SOMETHING OTHER THAN BELOW]

Doctor’s office

Drug store

Grocery store

Other retail store

Booth at a convention or outdoor event

Church

Senior Center or other place serving older adults
Bank

Gym

Other (specify) ________________

SELF-ASSESSMENT SECTION

8. Did you answer the self-assessment questions? Y/N

[IF NO, PLEASE ASK THEM TO TAKE A MOMENT TO DO SO NOW]

9. I’m going to ask you to rate the assessment on a few different things. Please rate the assessment on a 1-5 scale where “1” means “not at all” where 5 means “completely” on if it is:

FACTOR	RATING 1-5
Easy to complete
[IF “EASY TO COMPLETE” IS “1” OR “2” OR “3” ASK:] In which of the following ways was it not easy to complete? Following the instructions? [PROBE AND CLARIFY, E.G., ASK “IN WHAT WAY?” AND “WHAT PART OF THE ASSESMENT WAS CONFUSING”] The format? [PROBE AND CLARIFY, E.G., ASK “IN WHAT WAY?” AND “WHAT PART OF THE ASSESMENT WAS THE FORMAT A PROBLEM?”] Being too long?
Understandable
[IF “UNDERSTANDABLE” IS “1” OR “2” OR “3” ASK:] In what way was it hard to understand? Did you find the wording vague or confusing? [PROBE AND CLARIFY, E.G., ASK “IN WHAT WAY?” AND “WHAT PART OF THE ASSESMENT WAS CONFUSING”] Did you find the format hard to understand? [PROBE AND CLARIFY, E.G., ASK “IN WHAT WAY?” AND “WHAT PART OF THE ASSESMENT HAD CONFUSING FORMATTING?]
Described issues I care about
[IF “DESCRIBED ISSUES I CARE ABOUT” IS “1” OR “2” OR “3” ASK:] What issues could we have described that you would care about in terms of your mobility? [OPEN END]
Helped me think more about protecting my mobility
[IF “LIKELY TO CHANGE THE WAY I THINK ABOUT PROTECTING MY ABILITIES” IS “1” OR “2” OR “3” ASK:] What could we have included here that would have helped you think about protecting your mobility? [OPEN END]
Made me want to read further
[IF “LIKELY TO MAKE ME WANT TO READ FURTHER” IS “1” OR “2” OR “3” ASK:] What other assessment questions could we have included that would have enticed you to read further? [OPEN END]

10. Thinking about what you might normally do with this document if you saw it at the drug store, how likely would you be to complete the self-assessment section—with 1 being “not at all” and 5 being “very likely”

11. How effective was the self-assessment in motivating your interest in protecting your mobility? 1 is “not at all” effective, and 5 is “very effective”.

TIPS & RESOURCES SECTION

Ok, now let’s talk a little bit about the tips and resources section. Again, thinking about what you might normally do with this document if you saw it at the drug store,

12. Would you be most likely to:

1. skip over and not read the Tips & Resources section at all

2. just skim through the Tips & Resources section or

3. read thoroughly the Tips & Resources section?

13. How effective would you say these tips are in motivating you to think about ways you can protect your abilities? 1 is “not at all” effective, and 5 is “very effective”.

PLAN SECTION

Ok, we’re going to repeat what we just did with the last section with the next section—Having a Plan. Again, thinking about what you might normally do with this document if you saw it at the drug store,

14. Would you be most likely to:

4. skip over and not read the Plan section at all

5. just skim through the Plan section or

6. read thoroughly the Plan section?

15. How effective would you say the Plan is in motivating you think about ways you can protect your abilities? 1 is “not at all” effective, and 5 is “very effective”.

EFFECTIVENESS OF THE TOOL ON DESIRED OUTCOMES

Since you have read and completed this document…

16. How much have you been thinking about your mobility in your home and community as you age?—on a scale of 1 to 5 with one being “not at all”, and 5 being “very much”

17. Again, on a scale of 1 to 5, Now having read and completed this document, how much are you thinking about protecting your mobility as you age?

18. Again on a scale of 1-5 with one being “not at all”, and 5 being “very much”, Now having read the document, how confident do you feel that you know what to do to protect your mobility as you age?

19. How effective would you say this document is in raising your awareness of the kinds of things you should think about as you age in order to protect your mobility? 1 being “not at all” and 5 being “very effective”.

20. On a scale from 1 to 5 with 1 being “not at all” and 5 being “a lot”, do you feel you now know more about ways of protecting your current mobility than before using this document?

21. On a scale from 1 to 5 with 1 being “Not at all” and 5 being “A lot”, now that you’ve completed the assessment, how motivated are you to protect your ability to get around your home and community as you age?

22. Would you consider passing the document on to your parent, another relative, a friend or someone else?

Yes

No

Because______________________________________________________

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