Form 1 IIE Informant Interview Deaths

Public reporting burden for this collection of information is estimated to average 30 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 (0925-0584). Do not return the completed form to this
address.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL Informant Interview
FORM CODE: IIE
VERSION: 1, 1/15/2014

ID NUMBER:

Contact
Occasion

0

SEQ #

ADMINISTRATIVE INFORMATION
0a.

/

Completion Date:
Month

/
Day

0b.

Staff ID:

Year

Instructions: The informant interview form is completed for each informant for an eligible death as

determined by the HCHS/SOL event investigation protocol.

Decedent’s name: ________________________
Date of death:

/

/

/

/

Informant name: _____________________

Age at death:
Date of birth:

Place of death: __________________________

“Hello, my name is (interviewer’s name) with the HCHS/SOL study. I’m calling (name of informant)
regarding (name of decedent) involvement with the HCHS/SOL study, a medical study in which (name of
decedent) was enrolled.
[Once it is established you are speaking with the informant, continue with the script below. If the informant
is not available determine a time to call back. If the interviewer determines that the person they are
speaking with is knowledgeable of the circumstances surrounding the decedent’s death, the interview with
this person should continue. See procedure manual for more details.]
“I want to express our condolences for your loss. We understand that you have been identified as someone
who can help us complete our documents for (decedent name). I need to ask you a few questions about the
circumstances surrounding (name)’s death. Would now be a good time to talk?”
No

When would be convenient to call back? ___________________________

Yes

Thank you. If you have any questions, please ask me.

ID
NUMBER:

FORM CODE: IIE
VERSION: 1, 1/15/2014

Contact
Occasion

0

SEQ#

1. Before we get started could you please tell me what was your relationship with the (insert name of
decedent? (Respondent was deceased’s…)
Spouse
1
Daughter/Son
2
Parent
3
Friend
4
Workmate
5
Other relative
6
Other
7
Specify relationship of other: ________________________________
A. CIRCUMSTANCES SURROUNDING DEATH
“Now, I would like to ask you about the circumstances surrounding (insert decedent’s name) medical
history.”
2. Please tell me about his/her general health, health on the day s/he died, and about the death itself.
Record a brief synopsis of the events surrounding the death as related by the informant:

“Some of the remaining questions may repeat information you already provided, but it helps us to ask
these items specifically.”
3. Where was (insert decedent’s name) when s/he died? (Mark only one response.)
Home
0
Work
1
Public building
2
Bus or public transportation 3
In a car
4
Nursing home
5
In an emergency room
6
In an ambulance
7
In a hospital
8
Unknown
9
Other
10
Specify: _______________
4. Was anyone present when s/he died?
No
Yes
Unknown

0
1

skip to question 7

9

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ID
NUMBER:

FORM CODE: IIE
VERSION: 1, 1/15/2014

Contact
Occasion

0

SEQ#

5. Was anyone close enough to hear (insert decedent’s name) if s/he had called out?
No
0
Yes
1
Unknown 9
6. How long was it between the time (insert decedent’s name) was last known to be alive and the time
s/he was found dead?
Less than 5 minutes
1
5 minutes to 1 hour
2
1 to 24 hours
3
Longer than 24 hours 4
Unknown
9
(All responses above Skip to question 8)
7. Please tell me who was present. (Mark all that apply.)
Self
Health care person(s)
Other person(s)

No 0
No 0
No 0

Yes 1
Yes 1
Yes 1

Skip to question 9

8. When was the last time you saw (insert decedent’s name) prior to his/her death?
Less than 5 minutes
1
5 minutes to 1 hour
2
1 to 24 hours
3
Longer than 24 hours 4
Unknown
9
B. MEDICAL HISTORY
“The next few questions concern (insert decedent’s name) medical history.”
9. Was s/he restricted to home, able to leave home only with assistance or great effort, or was his/her
activity unrestricted?
Restricted to home
Able to leave home only with assistance or great effort
Unrestricted

1
2
3

10. Was s/he hospitalized within the four weeks prior to death?
No
0
Skip to question 14
Yes
1
Unknown 9
Skip to question 14

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ID
NUMBER:

FORM CODE: IIE
VERSION: 1, 1/15/2014

Contact
Occasion

0

SEQ#

11. What was the reason for the hospitalization? (Select all that apply.)
a. Unknown
No
b. Heart attack or heart disease
No
c. Stroke
No
d. Heart surgery
No
e. Surgical procedure (other than heart)
No
f. Emphysema, chronic bronchitis, or chronic
obstructive pulmonary disease (COPD)
No
g. Pneumonia
No
h. Infection
No
i. Other condition
No
j. If other, specify: ________________

0
0
0
0
0

Yes
Yes
Yes
Yes
Yes

1
1
1
1
1

0
0
0
0

Yes
Yes
Yes
Yes

1
1
1
1

12. What was the date of the hospitalization?

/
Month

/
Day

Year

13. What was the name and location of the hospital?
14. Was (insert decedent’s name) seen by a doctor any other time in the last four weeks prior to death?
No
Yes
Unknown

0
1
9

Skip to question 16
Skip to question 16

15. What was the name and address of this doctor?
_____________________________________________
_____________________________________________

C. SYMPTOMS
“The next set of questions deals specifically with acute symptoms such as pain, discomfort that (insert
decedent’s name) may have experienced at the time of his/her death.”
16. Did s/he experience pain, discomfort or tightness in the chest, left arm or jaw?
No
Yes
Unknown

0
1
9

Skip to question 23
Skip to question 23

17. Did the pain, discomfort or tightness specifically involve the chest?
No
Yes
Unknown

0
1
9

17a. Did (insert decedent’s name) ever take nitroglycerin for this pain?
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ID
NUMBER:

FORM CODE: IIE
VERSION: 1, 1/15/2014

Contact
Occasion

0

SEQ#

No
0
Yes
1
Unknown 9
18. Were these episodes new or had they occurred previously?
New symptoms
Previous symptoms
Unknown

1
2
9

Skip to question 23

19. Were the episodes getting longer or more frequent?
No
Yes
Unknown

0
1
9

**

20. Were the episodes getting more severe?
No
Yes
Unknown

0
1
9

**

**If No or Unknown to Questions 19 and 20, skip to Question 22**
21. Over what period of time did these episodes become longer, more frequent, or more severe?
Days
1
Weeks
2
Months
3
Unknown 9
22. Did s/he experience shortness of breath?
No
Yes
Unknown

0
1
9

Skip to item 23
Skip to item 23

22a. Did s/he have shortness of breath while at rest?
No
Yes
Unknown

0
1
9

“I apologize if this question sounds hard or if it makes you uncomfortable. Please be assured we respect
your feelings about this unfortunate event.”

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ID
NUMBER:

FORM CODE: IIE
VERSION: 1, 1/15/2014

Contact
Occasion

0

SEQ#

23. How long was it from (insert decedent’s name) last episode of symptoms to the time that s/he stopped
breathing on his/her own?
Less than 5 minutes
Less than 1 hour
Less than 24 hours
Greater than 24 hours
Unknown

1
2
3
4
9

D. EMERGENCY MEDICAL CARE
“The next few questions are concerned with emergency medical care (insert decedent’s name) 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.”
24. Was a physician, ambulance or other emergency medical team called?
No
Yes
Unknown

0
1
9

Skip to question 25
Skip to question 25

24a. How long was it from the time the last episode of symptoms started to the time that medical
assistance was called for?
5 minutes or less
10 minutes or less
1 hour or less
6 hours or less
24 hours or less
More than 24 hours
Unknown

1
2
3
4
5
6
9

24b. How long was if from the time medical care was called to the time when it arrived?
5 minutes or less
10 minutes or less
1 hour or less
6 hours or less
24 hours or less
More than 24 hours
Unknown

1
2
3
4
5
6
9

25. Were resuscitation measures, such as CPR attempted?
No
Yes
Unknown

0
1
9

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ID
NUMBER:

FORM CODE: IIE
VERSION: 1, 1/15/2014

Contact
Occasion

0

SEQ#

26. Was (insert decedent’s name) taken to the hospital, emergency room or any other emergency car
facility?
No
Yes
Unknown

0
1
9

E. ADDITIONAL INFORMANTS
27. Is there anyone else we could contact who might be able to provide additional information about the
circumstances surrounding (insert decedent’s name) death or his/her usual state of health?
No
Yes
Unknown

0
1
9

Skip to Closing Script
Skip to Closing Script

28. How is s/he related to (insert decedent’s name)?
Spouse
1
Daughter/Son
2
Parent
3
Friend
4
Workmate
5
Other relative
6
Other
7
Specify relationship of other: _____________________________
29. What is the name and address of this person?
___________________________________________
___________________________________________
F. CLOSING SCRIPT
“Thank you very much for your assistance in this study. Do you have any questions? Thanks again for
your help.”
G. RELIABILITY (To be completed after the interview)
30. On the basis of these questions, give your rating of reliability of the interview.
Poor
Fair
Good

1
2
3

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