Form 2 Volunteer Survey

Baseline Questionnaire for Longitudinal Volunteer Study 03.03.15

An important part of this study is to understand how people like you decide to become volunteers. The next few questions ask about your decision to become a volunteer.

Volunteer Motives:

1. Have you volunteered as a Foster Grandparent / Senior Companion before?

1. Yes ___________________________________ (GO TO Q2)

0. No ____________________________________ (SKIP TO Q3)

9998. DK (don't know)

9999. Prefer not to answer

2. When did you volunteer with the Foster Grandparent / Senior Companion Program?

Month _______

Year _________

9998. Don’t Know / Don’t remember ___

9999. Prefer not to answer/RF (refused) ___

There are many reasons why people become a volunteer. For each reason listed below, indicate how much these factors influenced your decision. You can respond: not at all, a little, somewhat, a lot, a great deal.

3.		1. not at all	2. a little	3. somewhat	4. a lot	5. a great deal	9998. DK	9999. RF
a.	Help another person/children.
b.	Earn extra money.
c.	Keep busy / fill my time.
d.	Learn something new.
e.	Make me feel better.
f.	Make new friends.
g.	Get more experience.
h.	Learn a new skill or hobby.
i.	Have a sense of accomplishment.
j.	Improve my community.
k.	Learn about myself.
l.	Other reason, please specify

4. How did you find out about the Foster Grandparent / Senior Companion Program [CHOOSE ALL THAT APPLY]?

1. Volunteered before with Foster Grandparent / Senior Companion

2. Told by a friend

3. Word of mouth

4. Direct mailing (letters)

5. Community outreach talks

6. Printed brochure or poster

7. Church

8. TV or Public interest articles

9. Internet

10. Other ways, please specify ___________________________

9998. DK (don't know)

9999. Prefer not to answer

5. Have you ever in the past volunteered with any religious, educational, health-related or other charitable organizations other than the Foster Grandparent / Senior Companion Program?

1. Yes ___________________________________ (GO TO Q6)

0. No ___________________________________ (SKIP TO Q7)

9998. DK (don't know)

9999. Prefer not to answer

The study would like to know the amount of physical activity that you do daily.

Self-reported Physical Activity: ⁱ

6. How often do you take part in sports or activities that are moderately energetic such as, gardening, cleaning the car, walking at a moderate pace, dancing, floor or stretching exercises?

1. More than once a week

2. Once a week

3. One to three times a month

4. Hardly ever or never

5. Every day

9998. DK (don't know); NA (not ascertained)

9999. Prefer not to answer/RF (refused)

Life Satisfaction:ⁱⁱ

7. Please think about your life and situation right now; how satisfied are you with …

	1. Completely Satisfied	2. Very Satisfied	3. Somewhat Satisfied	4. Not Very Satisfied	5. Not at All Satisfied
a. The city or town you live in?
b. Your daily life and leisure activities?
c. Your family life?
d. Your present financial situation?
e. Your life-as-a-whole these days?

Self-Rated Healthⁱⁱⁱ

Next there is a question about your health.

8. Would you say your health is excellent, very good, good, fair, or poor?

1. Excellent ___

2. Very good ___

3. Good ___

4. Fair ___

5. Poor ___

9998. DK (don't know); NA (not ascertained)

9999. Prefer not to answer/RF (refused)

Part of this study is to learn about people’s memory, and ability to think about things.

9. How would you rate your memory at the present time? Would you say it is excellent, very good, good, fair, or poor?^iv

1. Excellent ___

2. Very good ___

3. Good ___

4. Fair ___

5. Poor ___

9998. DK (don't know); NA (not ascertained)

9999. Prefer not to answer/RF (refused)

The next few questions will help the study learn about the health of volunteers.

Chronic Conditions:^v

10.	Has a medical doctor ever told you that you have any of the following health conditions?	1.Yes Yes	0. No	8. DK	9. Prefer Not Answer/RF
a.	High blood pressure or hypertension?
b.	Diabetes or high blood sugar?
c.	Cancer or a malignant tumor, excluding minor skin cancer?
d.	Chronic lung disease such as chronic bronchitis or emphysema?
e.	Heart attack, coronary heart disease, angina, congestive heart failure, or other heart problems?
f.	Stroke?
g.	Problems with depression
h.	emotional nervous, or psychiatric problems

Depressive Symptoms: ^vi

Now think about the past week and the feelings you have experienced. For each statement, consider whether the statement was true for you much of the time during the past week.

11. Much of the time during the past week, would you say yes or no?	1. Yes	0. No	9998. Don’t Know	9999. Prefer not to answer
You felt depressed.
You felt that everything you did was an effort.
Your sleep was restless.
You were happy.
You felt lonely.
You enjoyed life.
You felt sad.
You could not get going.
You had a lot of energy.

Functional Status: ^vii

12. Do you have any long lasting conditions like blindness, deafness, or a severe vision or hearing impairment?

1. Yes

0. No

9998. DK (Don't Know); NA (Not Ascertained)

9999. PREFER NOT TO ANSWER/RF (Refused)

13. Do you have any condition that substantially limits basic physical activities like walking, climbing stairs, reaching, lifting, or carrying?

1. Yes

0. No

9998. DK (Don't Know); NA (Not Ascertained)

9999. PREFER NOT TO ANSWER/RF (Refused)

The study would like to understand the activities volunteers are able or not able to do because of a health or physical problem. For each statement, please indicate if you are able or not able to do that activity. The responses are: yes, no, can’t do, and don’t do. You should not report any problems that you expect to last less than three months.

Functional Status: ^viii

14. Because of a health problem do you have any difficulty with:		1.Yes	0.No	2.Can’t Do	3.Don’t Do	9998.DK	9999.Prefer Not Answer/RF
a.	Walking one block?
b.	Getting up from a chair after sitting for long periods?
c.	Climbing several flights of stairs without resting?

The next questions will help the study better support you in serving your community. All responses will be used in combination with other respondents. Please answer how much you agree or disagree with the following:

Self-efficacy: ^ix

15. Please answer how much you agree or disagree with each of the following statements. (MARK (X) ONE BOX FOR EACH LINE.)

	1. Strongly Disagree	2. Somewhat Disagree	3. Slightly Disagree	4. Slightly Agree	5. Somewhat Agree	6. Strongly Agree
a. I can do just about anything I really set my mind to.
b. I can do the things that I want to do.

The next questions reflect people’s thoughts and feelings. Please answer how you feel about each question. The responses are: often, some of the time, hardly ever or never.

Social/Emotional Loneliness: ^xxi

16.		1. Often	2. Some of the time	3. Hardly ever or never	9998. DK	9999. Prefer not to answer
a.	How much of the time do you feel that you are alone?
b.	How much of the time do you feel that you lack companionship?
c.	How much of the time do you feel left out?
d.	How much of the time do you feel isolated from others?
e.	How much of the time do you feel that there are people you feel close to?
f.	How much of the time do you feel that there are people you can turn to?

17. How many of your friends would you say you have a close relationship with?

Please write a number on the line. ___________

9998. Don’t Know ___

9999. I prefer not to answer ___

18. The next question is about your friends, please check the answer that shows how you feel about each statement. The responses are: a lot, some, a little, not at all.

	1. A lot	2. Some	3. A little	4. Not at All
How much can you rely on them if you have a serious problem?
How much do they let you down when you are counting on them?

The next questions are about employment and retirement. This information will help the study better understand the people who took the survey.

Employment, Retirement:^xii

19. Are you [ANSWER EACH ONE]:

	1. Yes	0. No	9999. Refused
a. Working now?
b. Unemployed and looking for work?
c. Temporarily laid off, on sick or other leave?
d. Disabled?
e. Retired?
f. Homemaker?

20. What sort of work did (or do) you do?^xiii For example, electrical engineer, stock clerk, typist, farmer, secretary, teacher.

____________________________________

9998. Don’t Know _____

9999. I Prefer Not to Answer _____

The next few questions are about you. Your answers will help us understand the volunteers who took the survey.

Demographics:

21. In what month and year were you born?

a. 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

b. Year _____

9998. Don’t Know____

9999. I prefer not to answer ___

22. Do you consider yourself:

1. Hispanic or Latino origin____

2. Not Hispanic Latino origin_____

23. What is your race? Please select one or more. ^xiv

1. American Indian or Alaska Native___

2. Asian ___

3. Black or African American____

4. Native Hawaiian or Other Pacific Islander____

5. White

24. What is your Veteran Status [CHOOSE ALL THAT APPLY]

1. Active duty or Reserve Component ___

2. Military family ____

3. Veteran ____

4. Family of veteran ____

5. None, not a veteran ____

9998. Don’t Know ____

9999. I prefer not to answer ____

25. What is the highest grade of school or year of college that you completed?

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 ___

9998. I don’t know ___

9999. I prefer not to answer ___

26. Are you currently married, or do you have a partner as if you are married, separated, divorced, widowed, or not married?

1. Married ____

2. Have a partner ____

3. Separated ___

4. Divorced ___

5. Widowed ___

6. Never Married ___

7. Other ___

9999. I prefer not to answer ___

27. Are you male or female ?

0. Male ___

1. Female ___

9999. I prefer not to answer ___

28. Do you generally live alone or with others

1. Live alone ___ (SKIP TO Q30)

2. With others ___ (GO TO Q29)

9999. I prefer not to answer ___ (SKIP TO Q30)

29. IF LIVING WITH OTHERS: Including yourself, how many people live in your

household?

Please write a number in the line _______

9999. I prefer not to answer

30. How many children do you have?

0. NO CHILDREN SKIP TO Next section

___________ [enter number of children]

9999. I prefer not to answer SKIP TO Next section

31. IF HAS CHILDREN: Do any of your children live within 10 miles of you?

0. No ____

1. Yes ____

9999. I prefer not to answer ____

Income:

32. Which category best describes your total annual household income?

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

1. Less (SKIP TO GIFT CARD SECTION)

2. Greater                     (GO TO Q33)

9998. Don’t Know            (SKIP TO GIFT CARD SECTION)

9999. Refuse (I prefer not to answer) (SKIP TO GIFT CARD SECTION)

33. 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 ___

                        3. More than $40,000 ___

9998. Don’t Know ___

9999. Refuse (I prefer not to answer) ___

Gift Card

Thank you again for taking the time to participate in this survey. Would you prefer to get a $20 check or a $20 gift card?

_____ Gift card (Visa/Mastercard/American Express)

______ Check

Just to make sure that you receive the $20, could you provide your contact information.

First Name: ________________ Last Name: ____________________

Street Address: ____________________________________________________

____________________________________________________

City: ____________________ State: ___________ Zip: ____________

Phone: ____________________________________

E-mail: ___________________________________

34. How would you prefer we contact you in the future?

1. Phone ____

2. Email ____

3. Mail ____

35. What is the best phone number, email address, or physical address where you can be reached?

________________________________________

Contact Information for Relative and Friend:

In order for the research team to reach you for the next survey, please answer the next two questions about how to find you.]

Is there a relative or friend, who does not live in this household, who will always know how to get in touch with you? The research team will only contact this person if it cannot locate you for the next interview.

NO.............................................................. 0 (END THE SURVEY)

YES............................................................. 1 (GO TO 36)

DON’T KNOW ............................................. 8 (END THE SURVEY)

I prefer not to answer ................................................... 9 (END THE SURVEY)

36. What is the name, address, and telephone number of that person? (GO TO 37)

First Name: ________________ Last Name: ____________________

Street Address: ____________________________________________________

____________________________________________________

City: ____________________ State: ___________ Zip: ____________

Phone: (_____)__________________

Email: _________________________

37. What is this person’s relationship to you?

RELATIVE (SPECIFY)_________________ 2

NEIGHBOR (SPECIFY)________________ 3

FRIEND (SPECIFY)___________________ 4

OTHER (SPECIFY)___________________ 7

I PREFER NOT TO ANSWER ................................................... 9

Is there another relative or friend, who does not live in this household, who will always know how to get in touch with you? The research team will only contact this person if it cannot locate you for the next interview.

NO.............................................................. 0 (END SURVEY)

YES............................................................. 1 (GO TO 38)

DON’T KNOW ............................................. 8 (END SURVEY)

REFUSED ................................................... 9 (END SURVEY)

38. What is the name, address, and telephone number of that person? (GO TO 39)

First Name: ______________________ Last Name: ____________________

Street Address: ____________________________________________________

____________________________________________________

City: ____________________ State: ___________ Zip: ____________

Phone: (_____) ________________________

39. What is this person’s relationship to you?

RELATIVE (SPECIFY)_________________ 2

NEIGHBOR (SPECIFY)________________ 3

FRIEND (SPECIFY)___________________ 4

OTHER (SPECIFY)___________________ 7

I PREFER NOT TO ANSWER ................................................... 9

i Health and Retirement Study, Core Section, Section C NC223-NC225

ii Health and Retirement Study, Core Section, Section LB, Q36

iii Health and Retirement Study, Core Section, Section NC001

iv Health and Retirement Study, Cognition Section, Section D D101

v Health and Retirement Study, Core Section, Section NC005, NC010, NC018, NC030, NC036, NC053, NC066, NC070

vi Health and Retirement Study, Core Section, Section D ND110-ND118

vii http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1187&context=edicollect; table 1

viii Health and Retirement Study, Core Section, Section G, G01 through G013

ix Health and Retirement Study, Core Section LB, Q22

x Health and Retirement Study, Core, section LB*, Q20a,i Hughes, M. E., Waite, L. J., Hawkley,

L. C., & Cacioppo, J. T. (2004)

xi Health and Retirement Study, Core, Section LB*, Q20i Hughes, M. E., Waite, L. J., Hawkley, L. C., & Cacioppo, J. T. (2004)

xii Health and Retirement Study, Core Section, Section J NJ005M1, NJ007, NJ011, NJ017

xiii Health and Retirement Study, Employment Section, Section J NJ062M

xiv Office of Management and Budget, Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity Federal Register, Notice October 30, 1997

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