Screener Interview Guide (Acceptance)

Attachment D1 Screener and Baseline Interviewer Guide

Form Approved

OMB No: 0920-1005
Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 15 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 (0920-1005).

SECTION A: INTRODUCTORY TEXT

[SCRIPT IF SOMEONE ANSWERS THE PHONE:]

Hello, my name is [INTERVIEWER NAME] from Battelle, a research organization that is working with the Centers for Disease Control and Prevention or CDC. We’re working on a study of how people who are age 60 or older plan for their future health. The results of this research will be used to provide information to other older adults to help them stay healthy. We’re looking for people to participate in a brief phone survey that will ask about your plans to protect your health over time. If you are interested, I will ask you a few questions to determine if you are eligible for the study. Your participation is completely voluntary, and all the information you provide will be kept private and secure. We expect this interview to take about 10 minutes today. May we begin?

INTERVIEWER INSTRUCTION: GO TO THE SCREENING QUESTIONS

SECTION B: SCREENER

First, I’d like to ask you a few questions to see if you are eligible for the survey.

1. What is your age? ____Years Old --> IF NOT WITHIN AGE RANGE OF 60 TO 74, NOT ELIGIBLE.  SAY:  “Thank you for your time.  You are not currently eligible to participate in this study,” AND END CALL.

2. How would you describe your ability to get where you need to go on a typical day?  Would you say it is very good, good, fair, or poor?

a.       VERY GOOD

b.      GOOD

c.       FAIR  NOT ELIGIBLE.  SAY:  “Thank you for your time.  You are not currently eligible to participate in this study,” AND END CALL.

d.      POOR  NOT ELIGIBLE.  SAY:  “Thank you for your time.  You are not currently eligible to participate in this study,” AND END CALL.

3. Do you currently live in a retirement community, nursing home, assisted living residence or facility, a skilled nursing facility, or in some other assisted living situation?

a.       Yes  NOT ELIGIBLE.  SAY:  “Thank you for your time.  You are not currently eligible to participate in this study,” AND END CALL.

b.      No  ELIGIBLE. CONTINUE.

SCRIPT IF ELIGIBLE:

Thank you for answering these questions. You are eligible to participate in the study. I’d like to collect some contact information for you.

First, what is your full name? [RECORD FULL NAME.]

In order to send you your thank-you gift at the end of the study, which will involve two interviews, I also need to collect your address. What is your mailing address? [RECORD ADDRESS.]

Do you have time to complete the first study interview now? It should take no more than 10 minutes. [YES/NO]

[IF YES, GO TO CONSENT SCRIPT.]

[IF NO, SAY: No problem. When would be a good time to call you back?

RECORD TIME AND CONFIRM PHONE NUMBER TO USE FOR CALL-BACK.]

SECTION C: CALL-BACKS AND MESSAGES

FOR RESPONDENTS WHO HAVE AN APPOINTMENT:

Hello, may I please speak with [RESPONDENT NAME]?

IF RESPONDENT ANSWERS OR COMES TO PHONE, SAY: This is [INTERVIEWER NAME], calling from Battelle on behalf of the Centers for Disease Control and Prevention or CDC. We are scheduled today to conduct an interview on protecting your health at you age. Is this still a good time to talk?

IF YES, SAY: Great. Let’s get started. GO TO CONSENT SCRIPT

IF NO, SAY: That’s okay. When might be a good time for me to call back?

IF RESPONDENT NOT AVAILABLE, SAY: May I leave a message for [RESPONDENT NAME]?

IF YES, SAY: Please ask [RESPONDENT NAME] to call us toll-free at 1-xxx-xxx-xxxx. We are trying to reach [HIM/HER] to complete a survey that [HE/SHE] agreed to participate in.

IF NO, SAY: Thank you for your time.

VOICEMAIL SCRIPT: Hello, this is [INTERVIEWER NAME]. I’m calling for [RESPONDENT NAME] to conduct a telephone interview. [HE/SHE] thought this would be a good time to talk. Please return our call toll-free at 1-xxx-xxx-xxxx. Thank you.

FOR RESPONDENTS WHO DON’T HAVE AN APPOINTMENT:

Hello, may I please speak with [RESPONDENT NAME]?

IF RESPONDENT ANSWERS OR COMES TO PHONE, SAY: This is [INTERVIEWER NAME], calling from Battelle on behalf of the Centers for Disease Control and Prevention or CDC. We are calling today to see if this might be a good time to conduct an interview on protecting your health at you age. Is this a good time to talk?

YES, SAY: Great. Let’s get started. GO TO CONSENT SCRIPT

NO, SAY: That’s okay. When might be a good time for me to call back?

IF RESPONDENT NOT AVAILABLE, SAY: May I leave a message for [RESPONDENT NAME]?

IF YES, SAY: Please ask [RESPONDENT NAME] to call us toll-free at [1-xxx-xxx-xxxx]. We are trying to reach [HIM/HER] to complete a survey that [HE/SHE] agreed to participate in.

IF NO, SAY: Thank you for your time.

VOICEMAIL SCRIPT: Hello, this is [INTERVIEWER NAME]. I’m calling for [RESPONDENT NAME] to conduct a telephone interview. Please return our call toll-free at 1-xxx-xxx-xxxx. Thank you.

SECTION D: CONSENT

As I said before, we expect this interview to take about 10 minutes today. Just to remind you of some of the things I mentioned before, your participation is voluntary. You can decide whether or not to complete the interview, and you may end the interview at any time. Nothing will happen to you if you choose not to participate. You may experience a level of discomfort in answering some questions. You may also choose not to answer any questions you wish.  All the information you share with us will be kept private and secure. Only Battelle project staff will have access to any personally identifiable information about you. Although steps will be in place to protect the security of your responses, there is a small possibility that the information you provide could be connected with your name. Any identifiable information about you will be destroyed at the end of the study.  In addition to today’s survey, we will contact you again in about two weeks for a 10-minute follow-up interview. At the end of the study, we will send you a thank-you gift for participating in both interviews for our study.

If you have any questions about this research study, you can call Betsy Payn at 206-528-3138. If you have any questions about your rights as a study participant, you can call the Battelle IRB at 1-877-810-9530, ext. 500. I may also be able to address your questions.

Do you have any questions before we begin? ADDRESS ANY QUESTIONS.

Okay, let’s begin the interview.

PROGRAMMER INSTRUCTION: RECORD START TIME _________________

SECTION E: TTM STAGES OF CHANGE

In thinking about the future, many people make plans for what they will do when there are big changes in their life, such as changes in their employment, such as retirement, changes in their home or where they live, or changes in their physical ability.

In this section of the interview, I will read several statements to you about what you might be doing to prepare for changes in your life. For each statement, please tell me how strongly you disagree or agree with each statement. On a scale from 1 to 5, where 1 is strongly disagree and 5 is strongly agree, how much do you agree with the following statements?

[REPEAT RESPONSE OPTIONS AS NEEDED.]

[IF RESPONDENT HAS DIFFICULTY REMEMBERING THE RESPONSE CATEGORIES, SUGGEST THAT HE/SHE WRITE DOWN THE RESPONSES WITH A NUMBER BY EACH:

1 = STRONGLY DISAGREE

2 = DISAGREE

3 = NEITHER DISAGREE NOR AGREE

4 = AGREE

5 = STRONGLY AGREE

RESPONDENTS CAN STATE NUMBER RATHER THAN RESPONSE CATEGORY.]

1. I am currently engaging in a physical activity program on a regular basis.

2. I have started making changes to my home so as to protect me from tripping or falling in my home as I get older.

3. I have been thinking about my ability to get around as I get older.

4. I don't need to do anything to maintain or improve my physical strength or balance as I get older.

5. I am very motivated to conduct a safety check of my home to protect me from trips and falls as I get older.

6. I really think I should get started with a plan to make my home safe from the risk of tripping and falls.

7. I have been successful in making changes to eliminate trip and fall hazards in my home.

8. I am preparing to start a regular physical activity program in the next few weeks.

9. I could make changes to make my home safer from trips and falls as I get older, but I don't currently have plans to.

10. I have been talking with my family and friends about how I will get around as I get older.

11. I have made some changes to make sure I can get around as I get older, and I plan to continue.

12. I don't have the time or energy to think about how I will get where I need to go outside of my home as I get older.

13. I am doing something about the things that might limit my ability to get around as I get older, such as being active or getting a vision checkup.

14. I have made the changes I need to make so I will have the physical ability to do the things I want to do as I get older.

15. I have been thinking about whether I will be able to do the things I want to do as I get older.

16. I know how to get around as I get older and will continue to look for opportunities or support as I need them.

SECTION F: DOCTOR VISIT

1. How often do you see a doctor for a regular check-up? Would you say at least once a year, once a year, once every two years, less than once every two years?

2. When is your next appointment to see your doctor? _______

3. How often do you get your vision checked? Would you say at least once a year, once a year, once every two years, less than once every two years?

SECTION G: DEVELOPING PLAN

Using the same scale of 1 to 5 as earlier, where 1 is strongly disagree and 5 is strongly agree, how much do you agree with the following statements?

1. I have a plan for how I will maintain or increase my ability to do the things I want to do as I get older, including increasing my physical strength, improving my balance, and monitoring my vision and health.

2. I have a plan for how I will make my home safe so I can avoid tripping and falling in my home.

3. I have a plan for how I will get to where I want to go when I can no longer use my usual ways of getting around.

SECTION H: BACKGROUND

Now I’d like to ask you some general questions about your background.

1. How long have you lived in your current residence? [RECORD NUMBER OF YEARS/ MONTHS]

2. How many adults, age 18 years or older, live in your home with you? [RECORD NUMBER]

3. Are you of Hispanic or Latino/Latina origin or descent?

   1. Yes

   2. No

4. Which of the following best describes your race? [READ LIST:]

1. White,

2. Black or African American,

3. Asian,

4. Native Hawaiian or Other Pacific Islander, or

5. American Indian or Alaska Native.

5. What is your current marital status? Are you currently married, widowed, divorced, separated, or never married? [CURRENTLY MARRIED, WIDOWED, DIVORCED, SEPARATED, OR NEVER MARRIED]

6. ASK IF NOT OBVIOUS: Are you male or female? [MALE/FEMALE]

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

RECORD RESPONSE:

___ Less than High School Degree or GED

___ High School Degree or GED only

___ Some college (no degree)

___ Completed associate or other technical 2-year degree

___ Completed Bachelor’s degree (but not graduate or professional degree)

___ Completed graduate or professional degree (Master’s degree or higher)

8. Last week were you working full time at least 35 hours, working part time less than 35 hours, retired, volunteering, going to school, keeping house, or doing something else? [CHECK ALL THAT APPLY]

[RECORD ONE ONLY. IF MORE THAN ONE RESPONSE, GIVE PREFERENCE TO FIRST MENTIONED. IF “DOING SOMETHING ELSE”, ASK RESPONDENT TO SPECIFY AND RECORD ANSWER.]

9. On a scale from 1 to 5 where 1 is strongly disagree and 5 is strongly agree, how strongly do you agree with the following statement:

“I can count on my friends and family to listen when I need to talk.”

10. In a typical month, how often do you drive a car to get to a destination? Would you say: Every day; more than once a week; once a week; 2-3 times a month; once a month; less than once a month; never; or, you do not have a car to drive?

[RECORD ANSWER]

11. How about taking public transit? In a typical month, how often do you take public transit, such as take the bus or use the subway, to get to a destination? [IF NECESSARY, SAY:] Would you say: Every day; more than once a week; once a week; 2-3 times a month; once a month; less than once a month; never; or, there is no public transportation in your area? [RECORD ANSWER]

12. And, in a typical month, how often do you walk to get to a destination? [IF NECESSARY, SAY:] Would you say: Every day; more than once a week; once a week; 2-3 times a month; once a month; or, never? [RECORD ANSWER]

13. And, in a typical month, how often do you ride a bicycle to get to a destination? [IF NECESSARY, SAY:] Would you say: Every day; more than once a week; once a week; 2-3 times a month; once a month; or, never? [RECORD ANSWER]

Those are all the questions I have for you. Thank you very much for participating in the Thinking About My Future Study. We will contact you again in about two weeks for the follow-up survey. Goodbye.

Those are all the questions I have for you. Thank you very much for participating in the Thinking About My Future Study. We will contact you again in about two weeks for the follow-up survey. Goodbye.