0920-1030 Attachment C Second call script-sampling interview and p

Attachment C

Second call script-sampling, interview, and debriefing/probing

Form Approved

OMB No. 0920-1030

Exp. Date 10/31/2017

NOTICE – Public reporting burden of this collection of information is estimated to average 55 minutes per response. 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-74, Atlanta, GA 30333, ATTN: PRA (0920-1030).

Assurance of Confidentiality – All information which would permit identification of an 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 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).

(Text in all caps are instructions to the interviewer. Text in sentence case are to be read to the respondent)

IF YOU ARE CONDUCTING THE INTERVIEW DURING THE SAME CALL THAT THE SCREENING WAS COMPLETED, SAY: Now I would like to walk you through the steps to identify three (residents / participants) currently (living / enrolled) at this (residential care community / adult day services center) to select. Please have your list of your current residents age 18 or older (living at this community/ enrolled at this adult day services center) as of midnight yesterday.

IF YOU ARE COMPLETING THE SAMPLING DURING A SCHEDULED FOLLOW-UP APPOINTMENT (A SEPARATE CALL FROM THE SCREENING) ASK: Do you have your list of current (residents / participants) age 18 or older (living / enrolled) at this (residential care community / adult day services center) as of midnight yesterday?

IF YES: Using your list that you have prepared, I will talk you through a few steps to determine which (residents / participants) currently (living / enrolled) at this (residential care community / adult day services center) to select. PROCEED TO SAMPLING INSTRUCTIONS.

IF NO: Please get your list of current (residents / participants) age 18 or older (living / enrolled) at this (residential care community / adult day services center) as of midnight yesterday. PROCEED TO SAMPLING INSTRUCTIONS.

SAMPLING INSTRUCTIONS

1. If there are any (residents / participants) under age 18, please cross them out.

2. Starting at the top of the list, number each resident/participant age 18 or older. How many (residents/participants) are on your list?

3. BASED ON THE NUMBER OF RESIDENTS/PARTICIPANTS REPORTED BY THE RESPONDENT, GENERATE A LIST IN RANDOM ORDER USING THE EXCEL RANDOM FUNCTION. Circle the three (residents / participants) that correspond with [PROVIDE THE RESPONDENT WITH THE 3 NUMBERS THAT ARE AT THE TOP OF THE LIST YOU RANDOMLY GENERATED].

4. Please record the initials of the three (residents / participants) that you circled.

5. I will ask you questions about these (residents / participants) that we have just selected using their initials. You may need to access their records to answer some of the questions. OFFER TO WAIT WHILE R RETRIEVES RECORDS.

COMPLETE QUESTIONNAIRES FOR EACH RESIDENT/PARTICIPANT SELECTED AND RECORD THE ANSWERS ON THE RESIDENT/PARTICIPANT DATA SPREADSHEET. DO NOT RECORD PII LIKE NAMES, SSN, OR OTHER PII IN THIS SPREADSHEET.

Survey questions

1. What is [resident/participant Initials] gender? Male or Female, Don’t know, Refused

2. What is the resident/participant's age? Age, Don’t know, Refused

3. Is [resident/participant Initials] of Hispanic or Latino origin? Yes, No, Don’t know, Refused

4. Which one or more of the following five race categories is [resident/participant Initials] race?

   1. White

   2. Black

   3. Asian

   4. Native Hawaiian or other Pacific Islander

   5. American Indian or Alaska Native

Don’t know, Refused

5. During the last 30 days did [resident/participant Initials] have any of (his/her) long-term care services received at this residential care community/adult day services center paid by Medicaid? Yes or No

6. Has [resident/participant Initials] been diagnosed with any of the following conditions (REFER TO SHOWCARD)? Yes, No, Don’t know, Refused for each condition

   1. Alzheimer's disease or other dementia

   2. Anemia

   3. Arthritis or rheumatoid arthritis

   4. Asthma

   5. Cancer or malignant neoplasm of any kind

   6. Cerebral palsy

   7. Chronic bronchitis

   8. Congestive heart failure

   9. COPD

   10. Coronary heart disease

   11. Depression

   12. Diabetes

   13. Emphysema

   14. Glaucoma

   15. Gout, lupus, or fibromyalgia

   16. Heart attack (myocardial infarction)

   17. High blood pressure or hypertension

   18. Intellectual of developmental disability, such as mental retardation, severe autism, or Down syndrome

   19. Kidney disease

   20. Macular degeneration

   21. Muscular dystrophy

   22. Nervous system disorders, including multiple sclerosis, Parkinson's disease, and epilepsy

   23. Osteoporosis

   24. Other mental, emotional, or nervous condition

   25. Partial or total paralysis

   26. Serious mental problems such as schizophrenia or psychosis

   27. Spinal cord injury

   28. Stroke

   29. Traumatic brain injury

   30. Any other kind of heart condition or heart disease (other than listed above)

   31. Other

7. During the past 90 days, has [resident/participant Initials] been treated in a hospital emergency room? Yes or No, Don’t know, Refused

8. During the past 90 days, has [resident/participant Initials] been a patient in a hospital overnight or longer? Exclude trips to the hospital emergency department that did not result in an overnight hospital stay. Yes or No, Don’t know, Refused

9. During the past 90 days, has [resident/participant Initials] had a fall? Yes or No, Don’t know, Refused

10. Next, I would like to ask about everyday activities and whether [resident/participant Initials] needs any assistance in doing them. By assistance, we mean help from special equipment, another person or both.

    1. Does [Resident/participant Initials] need any assistance in bathing or showering? Yes or No, Don’t know, Refused

    2. Does [Resident/participant Initials] need any assistance in dressing? Yes or No, Don’t know, Refused

    3. Does [Resident/participant Initials] need any assistance in eating, such as cutting up food or cueing? Yes or No, Don’t know, Refused

    4. Does [Resident/participant Initials] need any assistance in transferring in and out of a bed or a chair? Yes or No, Don’t know, Refused

    5. Does [Resident/participant Initials] need any assistance in walking? Yes or No, Don’t know, Refused

    6. Does [Resident/participant Initials] need any assistance in using the bathroom? Yes or No, Don’t know, Refused

11. Does [Resident/participant Initials] need any assistance in taking medication--this includes opening the bottle, remembering to take medication on time, and taking the prescribed dosage? Yes or No, Don’t know, Refused

Probes

Sampling Probes:

• When did you generate the list of current residents/participants? How clear do you think the instructions for creating the list are? What, if anything, would make the instructions clearer?

• How did you generate the list of current residents/participants? (IF NEEDED: Did you print the list o or did you have to manually create it?)

• Do you have any suggestions that you think will help make the process to randomly select residents/participants easier?

Interview Question Probes (will be asked for only Questions 6 and 7):

• Did you have to look at resident/participants records for this information? Was this information easy or difficult to locate?

• How did you come up with your answer? How easy or difficult is it for you to answer this question? Why?

End of Interview Debriefing Probes:

• Compared to your expectations, was this interview longer or shorter than expected?

• Were there any questions you found particularly difficult to understand? Which ones? Can you explain what made the question difficult to understand? / What was it about the question that you did not understand?

• Was it challenging to complete this interview over the telephone? What made it challenging?

• NCHS plans to use this protocol to conduct a national survey with providers like you. Would you have been willing to complete all 3 of the resident/participant questionnaires on your own via web rather than with me over the telephone? Do you think most residential care/adult day directors would prefer to complete this activity by web on their own or with an interviewer over the telephone?

• Do you have any recommendations for improving the interview experience?

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