IRB Protocol Submission

Attachment C2 IRB Protocol

IRB Package Contents
March 6, 2015
Conduct an Older Adult Mobility Assessment Tool Impact Evaluation
and Develop a Dissemination Plan (OAMAT)
100051149-Task 6
Betsy Payn, Project Director

Page
IRB Review Request .......................................................................................................... 1
Appendix 1: Cognitive Interview Recruitment Flyer and Advertisement ............................ 19
Appendix 2: Cognitive Interview Screener ........................................................................ 22
Appendix 3: Cognitive Interview Reminder Email or Letter ............................................... 26
Appendix 4: Cognitive Interview Script for Reminder Call ................................................. 28
Appendix 5: Cognitive Interview Consent Form ................................................................ 30
Appendix 6: Cognitive Interview Discussion Guide ........................................................... 33
Appendix 7: Cognitive Interview Handout of Survey Questions ........................................ 66
Appendix 8: Evaluation Study – Baseline Survey Screener and Telephone Interview ...... 71
Appendix 9: Evaluation Study – Cover Letter for MPT Mailing ......................................... 80
Appendix 10: Evaluation Study – Follow-Up Survey Telephone Interview ........................ 82
Appendix 11: Evaluation Study – Thank You Letter for Mailing Magnet and MPT ............ 88
Appendix 12: Detailed Analysis Plan for Phase 2 ............................................................. 90
Appendix 13: CITI IRB Training Completion Certificate .................................................. 123

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BATTELLE INSTITUTIONAL REVIEW BOARD
Federal-wide Assurance No. FWA00004696
IRB Registration Number: IRB00000284
APPLICATION for HUMAN SUBJECTS PROTOCOL REVIEW

SECTION 1: COVER SHEET
Name of Battelle Principal Investigator/Project Manager/Project Director: Betsy Payn
Battelle Site Name: Seattle

Phone Number: (206) 528-3138

Full Study Title (and common or short title): Conduct an Older Adult Mobility Assessment Tool Impact
Evaluation and Develop a Dissemination Plan (OAMAT)
IRB Number (if already assigned):
number

NOTE: CPHRE Line of Review studies will NOT be assigned an IRB

1. Project & Activity ID Number (or B&P number): 100051149-Task 6
2. Proposal Number (OP Number) ):

NOTE: NOT required for CPHRE Line of Review studies.

3. Reason for Review. Complete and submit only those sections indicated.
Request for Exemption (Sections 1 & 2)
Continuing Review (Sections 1 & 3)
Modification to IRB approved protocol (Sections 1 & 4)
Pre-award review for proposal (Sections 1 & 5)
Pre-test/Pilot study review only (Sections 1 & 5)
Full study implementation (Sections 1 & 5)
4. Type of Award
Contract/cooperative agreement
PHS grant
Other grant
Subcontract to Battelle from:
Client / Funding Agency: CDC
sources
Agency principal Investigator: Gwen Bergen, PhD
Address: 4770 Buford Highway, NE, Mail Stop F-62; Atlanta, GA 30341
Phone: (770) 488-1394
e-mail Address [email protected]
Agency contract officer: Leanna Fox
Phone: (770) 488-3915
e-mail Address [email protected]
5. Period of Award
Contract/grant start date
Contract/grant end date

08/04/2014
09/08/2016

Procedure Area: Human Subjects Research
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Page 1 of 123

List any additional funding
None

Will another IRB review this study?
Yes __________ / No______X______
If yes, identify the IRB(s):
________________________________

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Date human subject contact begins (or began)

03/23/2015

Signature:

Date:
Battelle Principal Investigator/Project Manager /Project Director

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03/06/2015

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SECTION 5: REQUEST FOR INSTITUTIONAL REVIEW BOARD REVIEW
A. STUDY DESCRIPTION
1. Study aims/hypothesis (200-300 words)
Under a contract with CDC, Battelle is conducting an impact evaluation study for the Mobility Planning
Tool or MPT; see PDF file accompanying this application). The tool is a 4-page brochure that includes a
mobility self-assessment and suggestions to plan for future changes in mobility. This includes changes in
one’s self (e.g., improving balance), changes inside one’s house (e.g., removing tripping hazards), and
changes outside one’s house (e.g., knowing how to get around in the community without a car). The
objective of this evaluation study is to determine whether the MPT is effective in changing older adults in
terms of their attitudes and behaviors about their mobility and their planning behaviors related to their
mobility.
To conduct the evaluation, Battelle will carry out two phases of data collection:
(1) Phase 1 will involve conducting cognitive interviews with up to 9 adults between the ages of 6074 to gather information on the feasibility and validity of the questions to be included in the
evaluation surveys.
(2) Phase 2 will involve conducting a baseline (pre-treatment) telephone survey and, two weeks later,
a follow-up telephone survey (post-treatment) with a sample of 1,000 adults (control group = 500;
treatment group = 500) between the ages of 60-74 with no known mobility limitations. The
study’s treatment (i.e., mailing the MPT to participants) will be sent two days after a participant in
the Treatment arm of the study after he/she has completed the baseline survey. The Phase 2 study
is referred to as the Thinking About My Future Study.
We will use Phase 1 (cognitive interviews) to determine whether any changes need to be made to the data
collection materials that we plan to use in Phase 2 (baseline and follow-up evaluation surveys). We
anticipate there will be only minor changes to the evaluation survey documents. As such, we are
submitting materials on both Phases 1 and 2 in this application. If there are changes to the Phase 2
documents beyond minor wording changes or deletions, we will submit these modifications to the IRB for
review and approval prior to conducting the Phase 2 data collection. After carrying out the evaluation
surveys, we will conduct analyses to evaluate the effectiveness of the MPT, provide recommendations for
changes to the MPT, and develop a dissemination plan for the MPT.
If time and funds permit, we may conduct a focus group(s) after completing the evaluation survey (Phase
2) and prior to final revisions to the MPT. The purpose of the focus group(s) would be to (1) clarify
findings from the survey, including clarifying ways the MPT might be revised to make it maximally useful
for the target population and (2) inform development of the MPT dissemination plan. Before recruiting
for and conducting the focus group(s), we would submit a modification to the IRB for review and approval
of the focus group protocol and related documents.
In this application to the IRB, we are only requesting review and approval of Phase 1 (cognitive
interviews) and Phase 2 (two-wave evalatuion survey) of the project.
2. Does the research intend to collect data from or about vulnerable populations (* as defined by 45
CFR 46 or Battelle Corporate Policy 1.1.1.6)?. Indicate those populations in the chart below. Use
“OTHER to describe any vulnerable populations not identified in the chart.
No data will be collected from vulnerable populations at either phase.
Procedure Area: Human Subjects Research
For additional information, contact the Subject Matter Expert for this procedure area.
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Minors / Children*
Pregnant women*
Fetuses*
Prisoners or parolees*
Battelle staff or families*
Institutionalized
Genetically susceptible/impaired
Cognitively/psychologically/physically
impaired
Socially or economically disadvantaged
Emergency patients

Students
Terminally ill
Comatose
Cancer patients
Non-English speaking
Unable to give informed consent
Military personnel and/or immediate family
Tribal, Hispanic, Asian, or other diverse subjects
Workers/Employees
Secondary Subjects (genetic/medical relationship)
Other:

3. Explain briefly the criteria for inclusion and/or exclusion of certain populations, if applicable.
None
Minors / Children
Pregnant women
Newborns*
Prisoners or parolees
Alcohol, drug or mental health clients
HIV infected individuals
Incompetent
Other (specify) Older adults (60-74)
The inclusion/exclusion criteria will be the same for Phase 1 (cognitive interviews) and Phase
2 (evaluation surveys) of the project:
•
•
•
•

Must be 60 to 74 years old
Must be not in an institution and is living independently (e.g., not in a retirement
community, assisted living, nursing home, etc.)
Must not have self-rated mobility as fair or poor
Must speak English

The inclusion/exclusion criteria are assessed in the screeners for each phase.
4. Describe sampling procedures (sampling plan; power calculations; stratifications) and eligibility
criteria
Phase 1 (cognitive interviews): We will recruit up to 9 participants meeting the study selection
criteria (adults age 60-74 with no known mobility limitations with fair to better self-reported
health and speaks English) in the Seattle metropolitan area who will be scheduled for an
individual in-person cognitive interview at Battelle’s office or in the participant’s home. To the
extent possible, we will recruit a diverse set of participants in terms of age, gender, race and
ethnicity, income level, marital status, and residential location (e.g., urban, rural, and suburban).
Participants will be recruited by posting and distributing fliers, posting information from the flyer
online including through social media, and by networking with individuals and organizations (e.g.,
churches, older adult community centers) in the community that usually include adults ages 60-74.
Procedure Area: Human Subjects Research
For additional information, contact the Subject Matter Expert for this procedure area.
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The information provided in the cognitive interview recruitment flyers (Appendix 1) will be
placed at (or sent to) venues frequented by older adults. Contact information will be included on
each of the flyers along with other information about the cognitive interview study (e.g., purpose,
length, incentive payment, etc.) as appropriate.
Phase 2 (evaluation surveys): The population of interest for the study is older adults age 60-74
with no known mobility limitations. The sampling frame will be an address-based list of telephone
numbers of 10,000 households identified as likely having at least one resident within the target
age range for the study (60-74). This address list will be selected from the universe of all U.S.
households, with approximately 70% of the sample being drawn from addresses in urban or
suburban areas. Non-English speaking residents will be excluded because developing the tool and
survey in multiple languages would be cost prohibitive, and providing the tool in English to those
who are not fluent would not be appropriate.
Individuals meeting the screening criteria and agreeing to participate in the study will be randomly
assigned to one of the two study groups (MPT Group or the Comparison Group).
Based on previous research experience, we expect that contacting 10,000 households will yield a total of
1,000 individuals who meet the study criteria and agree to participate in the study. We anticipate that, of
the individuals who complete an initial interview, 10% will drop out of the study, resulting in a total of
900 respondents completing a follow up interview. We assume that the drop out rate will be similar in
both the MPT and the Comparison Groups.
The proposed sample size of 500 in each of the two study groups (MPT and Comparison) was selected to
provide the analytic team with the flexibility to determine (1) whether there are mean differences across
the two study groups at the Follow-Up interview in terms of each of the Readiness to Change variables,
Behaviors, and Plan Development and (2) whether there are differences on each of these variables by
Interview Time (Baseline vs. Follow-Up) in the MPT Group.
This sample size will provide the statistical power necessary to detect a relatively small difference
between the MPT and Comparison groups, anticipating that there will be wide variation within each
group, as is common in intervention studies similar to that proposed. Taking into consideration a potential
10% dropout rate between the Baseline and Follow-Up Interviews, 500 respondents per group at Baseline
and 450 respondents per group at Follow-Up will provide 80% power to detect an approximately 0.84point mean difference in the Readiness to Change variables, Behaviors, and Plan Development, assuming
a common group standard deviation of 4.5, α = .05. This estimate is based on a simple random sampling
design, and is thus conservative if a stratified sample is conducted. Previous studies with similar measures
and target populations have estimated group standard deviations of closer to 4 points, in which case with
stratified cell sizes of approximately 20 participants in the MPT and Comparison Group this would
marginally confer 80% power to detect differences of around 4 points within the subgroups, while
controlling for Type I error at a rate of 0.05.
5. Sample size(s):
Phase 1 (cognitive interviews): Maximum of 9 cases.
Phase 2 (evaluation surveys): Up to 1,000 cases (500 controls; 500 treatment)

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6. Describe participant recruitment procedures, including advertisements, flyers, brochures,
etc. (50-100 words)
Phase 1 (cognitive interviews): Potential interviewees will be recruited through advertisements in
numerous local venues, including community centers and churches, and through online ads posted
through social media (see Appendix 1 for draft flyer and ad). Contact information will be
included on the flyers and in the ads along with other information about the cognitive interview
study (e.g., purpose, length, incentive payment, etc.) as appropriate. Individuals interested in the
study can call the phone number on the flyer or in the ad to get more information about the study
and to be screened for eligibility (see Section B.1 below).
Phase 2 (evaluation surveys): Interviewers will telephone and screen prospective respondents
(see Sections A and B in in Appendix 8; voicemail message included) at each selected household
until a sample of 1,000 individuals meeting the study selection criteria have been selected.
Individuals will be randomly assigned to either Group 1 (The Treatment MPT Group) or Group 2
(The Control Group). The Treatment MPT Group will receive a copy of the MPT via FEDEX
within 4 days after completing the Baseline interview. The Control Group will not receive a copy
of the tool.
7. Will participants receive monetary or other compensation?
Yes
No
If Yes, describe
a) the conditions that must be fulfilled to receive full or partial payments and b) why the compensation is
reasonable.
Phase 1 (cognitive interviews): At the end of the cognitive interview, each participant will
receive a $50 gift card for completing an interview. This rate is based on what we have paid
participants in other studies and takes into consideration the fact that participants will incur travelrelated costs to travel to a Battelle office to be interviewed.
Phase 2 (evaluation surveys): A refrigerator magnet (worth less than $2) will be mailed to all
respondents in a thank-you letter (see Appendix 11) following completion of their second
interview as a token of appreciation for their participation.
8. Is there any concern of potential conflict of interest? For example, is there a relationship
between the sponsor and the potential participants that could create a conflict of interest (e.g.,
unions, teachers, physicians, employees)?
Yes
No, not for either phase
If Yes, describe.
B. DATA COLLECTION PROCEDURES
1. Provide a brief, sequential description of the overall study design, including any procedures that are
experimental. Include the length of time that it will take for subjects to complete each procedure.
Phase 1 (cognitive interviews): Interested participants can call the toll-free number (listed in the
flyer or ad; see Appendix 1) for more information on the study and to complete a brief (~5minute) eligibility screening (see Appendix 2 for screener). In addition to describing the study,
the eligibility screener includes questions to insure that recruited participants are within the ages
of 60 to 74 and have no known mobility restrictions. In addition, if potential participants cannot
complete the screener in English, they will not be eligible for the cognitive interviews. For those
callers who are eligible and interested in participating, an appointment will be scheduled to
conduct the cognitive interview at the Battelle offices in Seattle or in the participant’s home.
Procedure Area: Human Subjects Research
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Depending on a participant’s preference, we will send a confirmation letter or email (see
Appendix 3 for reminder letter or email) with details regarding the time and location of the
interview. In addition, we will call participants 1 to 2 days before the appointment to confirm
their appointment and answer any questions (see Appendix 4 for script for the reminder call).
When participants arrive at the Battelle Seattle office, we will obtain their informed consent (see
Appendix 5 for consent form) prior to conducting the cognitive interview (see Section C.3 for
consenting details and Section B.3 for details on the cognitive interview). After completing the
coginitive interview, we will provide participants with their incentive ($50 gift card). We expect
the full interview including consenting and incentive payment to take no more than two hours.
Phase 2 (evaluation surveys): Figure 1 below provides a visual representation of the overall study design.
During the Pre-Test Period, all potential participants will be contacted by telephone, told about the study,
consented for screening, screened for eligibility, consented if eligible and interested, and then interviewed
(see Appedix 8). Two days after the baseline telephone interview, the MPT Tool will be mailed to
participants in the Treatment arm (see Appendix 9 for cover letter and Appendix 1 for MPT). Two weeks
after the baseline interview, all participants will re-interviewed by telephone (see Appendix 10 for followup interview). The interview questions in the follow-up interview will be nearly identical for the
Treatment MPT and Control group participants. The exception will be a few additional questions about
the MPT and its dissemination at the end of the interview that will be asked only of the Treatment MPT
group participants. After participants complete the follow-up interview, we will send them a thank-you
letter (see Appendix 11) and a magnet with information printed on it similar to what is included in the
MPT (value less than $2).

Figure 1. Pre-test/post-test design with an untreated control group for the evaluation.
Group 1 (Treatment):
Baseline Interview

Mail MPT
(2 days after Baseline)

Follow-up Interview
(2 weeks after Baseline)

NA

Follow-up Interview
(2 weeks after Baseline)

Group 2 (Control):
Baseline Interview

We expect the baseline screening to take about 5 minutes, and the consenting and interviews at both
baseline and follow-up to take about 10 minutes to complete. We are using a telephone survey
methodology because 90 percent of persons aged 65 and older have a landline 1, and this technique is thus
likely to result in a representative sample, and telephone surveys historically yield better response rates
than mail or internet surveys. In addition, a telephone survey allows for screening prior to the survey,
avoiding administration of the survey to ineligible participants.

2. Type(s) (check all that apply, indicate methods):
Survey:

No

Yes – Phase 2 (evaluation surveys)
Mail return

1

http://www.cdc.gov/nchs/data/nhis/earlyrelease/wireless201212.PDF.

Procedure Area: Human Subjects Research
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Self-administered at site
Telephone/CATI questionnaire
In-person interview/CAPI
Other, specify:
Record Abstraction/Match:

No

Yes
Computerized data
Hard copy data
Other, specify:

Biological Specimen Collection:
No
Yes
Describe Type of Specimen:
Will specimens be obtained directly from subjects
Will specimens be provided by clients or collaborators?
Will specimens be linked to original human donor(s)?
Will specimens be utilized for follow-on research
Will specimens be destroyed after study is completed?
Environmental Specimens/Measures:

No

No
No
No
No
No

Yes
Yes
Yes
Yes
Yes

Yes
Air
Soil
Water
Food
Other, specify:

Laboratory Procedure or Measurement:

No
Yes Phase 1 (cognitive interviews)
Describe Type of Laboratory Procedure:
Psychological
Physical
Focus group
Other, specify: Cognitive interviews

Other (e.g., device, drug)

No

Yes
Describe:

Private Health Information (PHI) Provided by a “HIPAA Covered Entity”:
If Yes, is a Business Associate Agreement (BAA) Required?
BAA)

No

No

Yes
Yes (attach copy of

3. Describe the data collection procedures (200-300 words)
Phase 1 (cognitive interviews): The Cognitive Interview Discussion Guide (see Appendix 6)
provides information on preparation for the interview, the protocol for obtaining consent, and the
questions to be asked when conducting the cognitive interview. The cognitive interviews will
have two phases for each section of the survey, including the screener. First, participants will
Procedure Area: Human Subjects Research
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answer each question or set of questions by using a “think-aloud” approach in which participants
describe what they are thinking as they answer the question(s). Second, the Interviewer will ask a
range of questions and probes from the interview guide about each specific question in the section
in order to assess each participant’s impression and understanding of the content reviewed. The
interviews will seek input from participants regarding level of difficulty, terminology and
language used, and understandability of the survey questions that will be provided to the
participants. The Interviewer may vary the specific questions asked from the Guide depending on
the type of survey questions being reviewed and the responses given by a participant, as well as
ask additional questions to follow-up on unique interpretations of the survey questions by
participants. After asking about the participants’ background (Section 6 in the Cognitive
Interview Guide) and before asking the Dissemination (Section 7 in the Cognitive Interview
Guide), the Interviewer will give the participant a copy of the MPT to review (the MPT is in the
PDF file accompanying this application). Then the Interviewer will continue the cognitive
interview, asking questions about the MPT and its dissemination.
Once the Interviewer has asked questions about every section, the Interviewer will provide the
participants with a handout listing the survey questions (see Appendix 8 for the handout of the
survey questions). The Interviewer will ask general questions regarding the questions (e.g., which
are more or less relevant, any questions that should not be asked, whether there are any missing
questions or topics that should be asked about, etc.). At the end of the cognitive interview, each
participant will receive a $50 gift card for completing an interview.
The Interviewer also will record any final thoughts about the interview process with the
participant that might inform the analysis of the data gathered. As noted above, the cognitive
interview, including the consent process, is expected to last no more than 2 hours. We will
digitally record the cognitive interviews to ensure complete, accurate data capture, and the
interviewer will take detailed notes regarding participant responses.
Initially, we will schedule only 3 interviews to allow the Study Team to review the findings from
the initial interviews and make adjustments to the survey instrument or interview guide if
necessary. A second set of 3 interviews, and then a third set of three interviews, will be conducted
if necessary to obtain additional information. Once the interview themes have been saturated (that
is, once we are hearing the same kinds of remarks from most respondents), we will stop
conducting interviews even if we have not reached the maximum number of 9 interviews.
Phase 2 (evaluation surveys): Telephone interview data will be collected using two telephone
interviews: A baseline interview and a follow up interview (See Appendices 8 and 10,
respectively). The baseline interview contains questions about individuals’ readiness to make
mobility-related changes, mobility-related behaviors, willingness to develop a mobility plan, and
background. Two days after completing the baseline interview, we will send participants in the
Treatment group a copy of the MPT (see cover letter in Appendix 9). Two weeks after the
baseline interview, Battelle will recontact the participants by phone to conduct the follow-up
telephone interview. The questions in the follow-up interview are largely identical to the
questions in the baseline interview. The differences between the two surveys is that the follow-up
interview does not include background questions, but it does include questions only for the
Treatment group on the use and dissemination of the MPT. A thank you letter (see Appendix 11)
will be sent to all participants after the final interviews.

Procedure Area: Human Subjects Research
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4. Describe the methods to control access to the study data during and after the study.
Phase 1 (cognitive interviews): All audio recordings and electronic materials containing study
data will be stored on password-protected Battelle computers during and after the study. All hard
copies of materials containing study data will be stored in locked file cabinets at Battelle. After
completion of the study, the audio recordings and identifiers will be destroyed. Data collected for
this study will be accessible only to authorized Battelle staff. All identifiers will be destroyed
after the data have been reviewed for use in revising the survey items. De-identified data will be
provided to CDC, if requested.
Phase 2 (evaluation surveys): All study data will be stored on password-protected Battelle
computers during and after the study. All hard copies of materials containing study data will be
stored in locked file cabinets at Battelle. After completion of the study, the identifiers will be
destroyed. Data collected for this study will be accessible only to authorized Battelle staff. All
identifiers will be destroyed after the data have been reviewed for use in revising the survey items.
De-identified data will be provided to CDC.
5. Are data being collected that would identify someone who is not the target study participant
No
Yes
If yes, identify:
(“third parties”), e.g., family members, friends?
No third parties in Phase 1 nor Phase 2 data collection.
6. Is there a data analysis plan?

No

Yes

If yes, describe.

Phase 1 (cognitive interviews): After completion of the interview, the Interviewer will review
his/her handwritten notes to identify themes in participants’ responses, noting any issues with the
clarity or organization of survey items and summarizing information relevant to the development
of the dissemination plan. The Interviewer will review the digital recordings, if necessary, to
augment his/her handwritten notes. A brief (2 to 3 pages) summary of the cognitive interview
findings will be prepared and submitted to CDC, along with a list of the most informative
participant comments. After disucssions with CDC, Battelle may make changes to the evaluation
study (Phase 2) protocol and/or related documents. If there are changes to the Phase 2 documents
beyond minor wording changes or deletions, we will submit these modifications to the IRB for
review and approval prior to conducting the Phase 2 data collection.
Phase 2 (evaluation surveys): Effectiveness of the tool will be assessed using two kinds of
comparisons: 1) a comparison between individuals’ attitudes and behaviors related to protecting
their mobility as they age before and after receiving the MPT in the group that received the MPT
and 2) a comparison of mobility-related attitudes and behaviors between the group that received
the MPT (Treatment Group) and the group that did not receive the MPT (Control Group). The
plan for analysis of the survey data will involve creating separate composite scores for mobility
behaviors and attitudes for each respondent. Paired t-tests (or their non-parametric equivalent, as
appropriate) will be used to compare mean composite scores within each group for the Baseline
and Follow-Up surveys. ANOVA (or the non-parametric equivalent) will be used to examine
whether there are differences between the mobility behavior and attitude composite scores for the
two groups, at each of the two survey administrations. Analyses of mobility behaviors and
attitudes by respondent subgroup (e.g., by sex, race/ethnicity, marital status, urban vs. rural,
socioeconomic status) may also be conducted if desired by CDC. The MPT will be revised
following the evaluation and the results summarized in a final evaluation report as well as in an
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article suitable for submission to a peer-reviewed journal. We provide a more detailed analysis
plan in Appendx 12 (Detailed Analysis Plan for Phase 2).
7. Is there a data sharing plan?
No
Yes
If yes, describe what is being done with
the data and who will have access to the data during and after the study.
Phase 1 (cognitive interviews): The de-identified qualitative data (e.g., a list of the comments
made about each survey question) will be shared with the client.
Phase 2 (evaluation surveys): A copy of the data set, along with documentation, will be provided
to the client after all identifiers have been stripped from the data. The results of the study will be
used to develop a Final Report that is internal to CDC and will be used to modify the MPT.
Additionally, findings from this study will be disseminated through the publication of a
manuscript in a peer-reviewed journal. Finally, study findings may also be disseminated through
oral or poster presentations. All data will be de-identified prior to analysis, and the findings will
be reported in aggregate. No published oral or written reports or presentations of the research will
identify any participants
8. If data leave Battelle, are all identifiers removed?

No

Yes

9. Is there a data retention plan?
No
Yes
If yes, describe where samples are being
stored, when the data are destroyed, what data are being returned to the client, etc.
Phase 1 (cognitive interviews): After completion of the study, the audio recordings and
identifiers will be destroyed. All identifiers will be destroyed after the data have been reviewed
for use in revising the survey items. Only de-identified notes from the interviews and summary
information will be retained. Signed consent forms will be stored in locked cabinets.
Phase 2 (evaluation surveys): As noted above in B.6, a copy of the data set (including both
waves of data), along with documentation, will be provided to the client after all identifiers have
been stripped from the data set. The de-identified data set will be encrypted and stored securely at
Battelle. All identifiers will be destroyed at the end of the project period.
C. INFORMED CONSENT PROCEDURES
Informed consent must be obtained (minor assent and parental permission, when applicable).
Attach copies of all versions of the informed consent, assent or parental permission documents
to be used in this research study.
1. Type:
CONSENT # 1
Appendix 2)

Form Title:

Phase 1 (cognitive interview): Screener consent (see

Written and signed
Written, not signed
Verbal, not signed

Procedure Area: Human Subjects Research
For additional information, contact the Subject Matter Expert for this procedure area.
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REVISED:

The OFFICIAL SBMS COPY is the on-line version. Before using a printed copy, verify that it is the most current version by
checking the REVISED date of the on-line version on the SBMS website.

CONSENT # 2
Appendix 5)

Form Title:

Phase 1 (cognitive interview): participant consent (see

Written and signed
Written, not signed
Verbal, not signed
CONSENT # 3
Sections A and B)

Form Title:

Phase 2 (evaluation-baseline): screener (see Appendix 8,

Written and signed
Written, not signed
Verbal, not signed
CONSENT # 4
Form Title:
Appendix 8, Section D)

Phase 2 (evaluation-baseline): telephone interview (see

Written and signed
Written, not signed
Verbal, not signed
CONSENT # 5
Form Title:
Appendix 10, Section B)

Phase 2 (evaluation-follow-up): telephone interview (see

Written and signed
Written, not signed
Verbal, not signed
2. Is/are copy(ies) of the consent form(s) left with the respondent? :
Phase 1 (cognitive interviews):
Phase 2 (evaluation surveys):

No
No

Yes
Yes

3. Informed consent is a process. Describe how participants will be informed and how their questions
will be answered (200-300 words)
Phase 1 (cognitive interviews): For the cognitive interviews, the consent process begins with the
Screener (Appendix 2) in which the Interviewer provides a preliminary description of the study
before asking permission to ask the screening questions. The Interviewer also will assure
potential participants that their information will be kept confidential and their participation in
answer the screener is voluntary. Participants who are eligible for the study and interested in
participating will be given two copies of the written consent (Appendix 5) when they arrive at the
Battelle offices for their cognitive interview. Again, participants will have the opportunity to ask
questions of Battelle staff. Participants will also be provided with two phone numbers if they
have any questions.
Phase 2 (evaluation surveys): For the evaluation surveys, the consent process for the baseline
survey begins with the Screener (Appendix 8, Sections A and B) in which the Interviewer
provides a preliminary description of the study before asking for their verbal consent to ask the
Procedure Area: Human Subjects Research
For additional information, contact the Subject Matter Expert for this procedure area.
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REVISED:

The OFFICIAL SBMS COPY is the on-line version. Before using a printed copy, verify that it is the most current version by
checking the REVISED date of the on-line version on the SBMS website.

screening questions. The Interviewer also will assure potential participants that their information
will be kept confidential and their participation in answer the screener is voluntary. For
participants who are eligible for the study and interested in participating, the Interviewer will
describe the study, noting the follow-up survey, as well as the voluntary nature of the study, that
they can refuse to answer any question, all the information will be kept confidential, possible
risks, and two phone numbers if they have any questions about the study or their rights as a human
subject (see Appendix 8, Section D). The Interviewer will then ask participants for their verbal
consent to participate. The Interviewer also will obtain verbal consent from participants for
participation in the follow-up survey (see Appendix 10, Section B). At both the baseline and
follow-up surveys, participants will have the opportunity to ask questions about their participation.
4. How and by whom will it be determined if the subjects or their legally authorized
representatives understand the information provided in informed consent/assent/parental
permission documents?
Phase 1 (cognitive interviews): The Interviewer will determine if participants understand the
information provided in the informed consent. This will be determined during several stages of the
informed consent process, including: when the Interviewer provides an overview of the study and
the purpose of the interview (prior to reviewing the consent form); when the participants review
the consent form, read the consent to participate statement, and sign the consent form; and, if
applicable, when the participants ask questions about the study and their role in it.
Phase 2 (evaluation surveys): The Interviewer will ask participants if they would like to consent
to participate after they have been told about the study and their rights as a human subject (e.g.,
right to refuse to answer, right to confidentiality). The participants will be asked if they have
questions so as to ensure they understand what their participation involves.
5. Is translation of the informed consent/assent/parental permission documents required?
No, only English-speaking participants will be enrolled in the two phases.
If yes, a translation certificate must be provided to the IRB.
6. Will any information about the research study be withheld from potential or participating
subjects? If so, explain the deception, why it is necessary to accomplish the research aims and
describe the plans for a post-study debriefing of the subjects?
No, no information will be withheld from participants (neither at Phase 1 or 2).
7. If third parties may be identified during the research study, will consent be obtained from
the third party(ies)? If so, how?
No. No third-party data will be collected. Third-party consenting is not necessary.

D.

POTENTIAL RISKS
1. Type (check all that apply)
Minimal physical

Procedure Area: Human Subjects Research
For additional information, contact the Subject Matter Expert for this procedure area.
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REVISED:

The OFFICIAL SBMS COPY is the on-line version. Before using a printed copy, verify that it is the most current version by
checking the REVISED date of the on-line version on the SBMS website.

Minimal psychological/social/legal
Substantial physical
Substantial psychological/social/legal
2. Description of potential risks, including breach of confidentiality (100-200 words)
For both Phase 1 (cognitive interviews) and Phase 2 (evaluation surveys): To the best of our
knowledge, the cognitive interviews and evaluation surveys will pose very minimal physical,
psychological, social, legal, or other risk to the participants. One potential risk is the possibility
of a breach of confidentiality of participants’ identities and responses. To assure participants that
the privacy and confidentiality of their personal identities and responses will be maintained, we
indicate in the consent information that all information they share with us will be kept
confidential and that we will not include names or any information that might identify them in our
notes or any written reports. Each participant will be given a unique participant ID code. Any
data leaving Battelle will have participant names and any other personally identifiable
information replaced by participant ID codes or removed entirely. An additional risk is that some
participants may experience discomfort in answering questions related to function or to their
planning (or lack of planning) related to mobility. Given that the survey questions will be similar
to ones that are asked by health care providers, we expect that most respondents will have only
slight discomfort in answering the questions.
3. What specific steps will be taken to prevent/minimize potential risks or discomfort?
Phase 1 (cognitive interviews): We will follow a number of procedures to eliminate or reduce
any discomfort a respondent may have while participating in this study. All audio recordings and
electronic materials containing study data will be stored on password-protected computers during
and after the study. All hard copies of materials containing study data will be stored in locked file
cabinets. We will make it clear to participants that participation in the study is completely
voluntary, and they may refuse to answer any questions or leave at any point without penalty. We
will also inform participants that Battelle will protect all personally identifying information
gathered through this project so that what they say will be used in a confidential manner. To
protect their confidentiality and privacy, any materials that have personally identifiable
information will not be shared with anyone outside the project staff, and any reports or
publications that result from this project will not quote participants by name or contain any
statements attributable to them.
Phase 2 (evaluation surveys): As described above, there is very little risk to the participants,
except for the possibility that some participants may find certain questions uncomfortable to
answer and a possibility for a breach of confidentiality. The data collection procedures will be
designed to prevent or redress any discomfort from responding to a survey and to minimize the
risk of breach of confidentiality. We will follow a number of procedures to eliminate or reduce
any discomfort a respondent may have. First, we will make clear that responding to the baseline
and follow-up surveys is completely voluntary and that the participants may refuse to answer any
or all questions. Second, the Interviewers will be trained to deal with sensitive issues and to detect
when a respondent is feeling discomfort. In that event, the Interviewers will encourage the
respondent to move on to another question if necessary. With respect to the risk of breach of
confidentiality, when mailing packages with survey information to the participants, we will ensure
that the packages are addressed to the participant and that the packaging does not display
information that might compromise confidentiality (e.g., study objectives).
Procedure Area: Human Subjects Research
For additional information, contact the Subject Matter Expert for this procedure area.
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REVISED:

The OFFICIAL SBMS COPY is the on-line version. Before using a printed copy, verify that it is the most current version by
checking the REVISED date of the on-line version on the SBMS website.

4. Unforeseen Events (including Adverse Events / Unanticipated Problems / Non-conformance). How
will unforeseen events be handled and by whom?
For both Phase 1 (cognitive interviews) and Phase 2 (evaluation surveys): All unforeseen events
(UE) will be reported by project staff to the Battelle Project Manager as soon as it is known that
an UE has occurred. The Battelle Project manager will report the UE to the IRB. She will then
resolve or address the UE, providing the IRB a report on the event and resolution.
E. POTENTIAL BENEFITS
1. Information provided to study participants – For both phases:
No direct benefit
Medical or physical data
Sociological data
Psychological data
Environmental data
Other, specify:
2. Services provided to study participants—For both phases:
No direct services provided
Medical or rehabilitation treatment
Social/economic service
Psychological counseling
Environmental cleanup or correction
Other, specify:
3. What are the benefits, if any, to society that may be expected from this research study?
For both Phase 1 (cognitive interviews) and Phase 2 (evaluation surveys): The population of
older adults in the U.S. is growing rapidly. In 2014, there were more than 46 million adults aged
65 or older in the U.S., representing approximately 14.5% of the population. By 2030, this
segment of the population will increase to an estimated 72 million (20% of the population). A
critical public health issue for the older adult population is mobility – how well people are able to
get to places they need to go. There is widespread agreement that older adults in the U.S. do not
adequately plan for their future mobility needs, nor are most aware of existing mobility resources
in their communities. Thus, when individuals’ mobility becomes impaired, they are often poorly
prepared to adapt their lifestyle to their changing needs. Development of the 4-page informational
brochure -- the Mobility Planning Tool (MPT)—may help in promoting readiness to adopt
mobility-protective behaviors among older adults.
F. PROTECTION OF SUBJECTS
1. Guarantees, as applicable
Anonymity (no link between individual and data)
Confidentiality – for both phases
2. Special procedures to reduce or alleviate risks, as applicable
Procedure Area: Human Subjects Research
For additional information, contact the Subject Matter Expert for this procedure area.
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REVISED:

The OFFICIAL SBMS COPY is the on-line version. Before using a printed copy, verify that it is the most current version by
checking the REVISED date of the on-line version on the SBMS website.

None—for both phases
Medical treatment
Counseling
Environmental remediation
Certificate of Confidentiality (CoC) has been applied for.
Certificate of Confidentiality (CoC) has been received.
Other, specify:
3. Describe any other procedures to reduce or alleviate risks including measures to protect
confidentiality (100-200 words)
For both Phase 1 (cognitive interviews) and Phase 2 (evaluation surveys): Interviewers will
be required to sign an extensive confidentiality statement. This assurance will contain a listing
of requirements to maintain confidentiality and will include a signed pledge indicating that
staff will comply with these procedures. The signed assurance of confidentiality legally binds
the person never to disclose any information regarding the data collected. It also ensures that
she or he will abide by Battelle terms of shipping or handling confidential materials.
Furthermore, a staff member or interviewer is prohibited from interviewing or handling the
confidential data of any person that she or he may know. If an interviewer receives an
assignment that includes someone she or he knows, it is to be returned to the supervisor for
reassignment.
G. RISK/BENEFIT RATIO
1. Weigh the potential risks and benefits of participation (100-200 words)
For both Phase 1 (cognitive interviews) and Phase 2 (evaluation surveys): There are no direct
benefits to participation. Indirectly, the information and feedback provided by cognitive interview
participants will be used to improve survey data collection for the MPT evaluation study. In turn,
the MPT may aid older adults in planning for changes in their mobility. The main potential risk of
participation is the potential for breaches of confidentiality. As described earlier, we will
implement procedures not only to protect the confidentiality of the data and materials, but also to
assure participants that we will protect the privacy and confidentiality of their identities and
interview responses in any reports we produce or data we share outside of Battelle. Overall,
Phases 1 and 2 of the study present minimal risks to participants, with potential benefits
outweighing the potential risks of participation.
2. Special issues or types of risk, as applicable
None – for both phases
Collaborative research
Multi-site research
Follow-on studies
Required to release information to authorities (e.g., reporting suspected child abuse)
International research
Other, specify:
3. What is the level of risk to participants
Procedure Area: Human Subjects Research
For additional information, contact the Subject Matter Expert for this procedure area.
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The OFFICIAL SBMS COPY is the on-line version. Before using a printed copy, verify that it is the most current version by
checking the REVISED date of the on-line version on the SBMS website.

Minimal risk, minimal benefit – for both phases
Minimal risk, substantial benefit
Substantial risk, substantial individual benefit
Substantial risk, substantial research/society benefit
Other, describe:
H. INVOLVEMENT OF OTHER INSTITUTIONS
1. Name other institutions involved in this study. Indicate which institution has the lead.
There are no other institutions engaged in the research. CDC is funding the study but is not
engaged in the research.
2. Describe the human subjects research activities that will be conducted at or by Battelle.
All the data collection activity will be conducted by Battelle. This includes all the cognitive
interviews of Phase 1 and the baseline and follow-up telephone surveys of Phase 2.
3. Describe the human subject research activities that will be conducted at or by the other
institution(s)
None.

I . OTHER CONSIDERATIONS
Other Considerations—FOR BOTH PHASES
Will the results of this research study be held for inspection by the U.S. Food
and Drug Administration for a future permit for marketing or researc h?
Does the research study involve recombinant DNA?
Does the research study involve use of radioactive materials or radiation
producing devices?
Does the research study involve any use of animals in research?
Does the study involve the participation of Battelle staff members as the
research subject population?

Yes

If yes to any, explain below:

ATTACH COPIES OF (check all that apply):
Research Protocol/Study Plan, that specifically pertain to Human Subjects Research
Proposed informed consent and assent forms
Contact letters
Interview scripts, screener scripts, etc.
Data collection instruments
Focus group guides, draft questions or description of questions
Recruitment materials (e.g., posters, brochures, flyers, e-mailers)
PI human subjects protection training documentation (e.g., CITI or NIH certificate)
Procedure Area: Human Subjects Research
For additional information, contact the Subject Matter Expert for this procedure area.
Page 17 of 123

No
X
X
X
X
X

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REVISED:

The OFFICIAL SBMS COPY is the on-line version. Before using a printed copy, verify that it is the most current version by
checking the REVISED date of the on-line version on the SBMS website.

IRB approvals from other institutions
Any other relevant documents that will be helpful to the IRB for this review
As it deems necessary, the IRB can request other study-related documents, e.g., information about subcontractor(s), e.g., CV or resume, Statements of Work, or a complete Research Protocol/Study Plan.
APPENDICES:
Appendix 1: Cognitive Interview Recruitment Flyer and Advertisement
Appendix 2: Cognitive Interview Screener
Appendix 3: Cognitive Interview Reminder Email or Letter
Appendix 4: Cognitive Interview Script for Reminder Call
Appendix 5: Cognitive Interview Consent Form
Appendix 6: Cognitive Interview Discussion Guide
Appendix 7: Cognitive Interview Handout of Survey Questions
Appendix 8: Evaluation Study – Baseline Survey Screener and Telephone Interview
Appendix 9: Evaluation Study – Cover Letter for MPT Mailing
Appendix 10: Evaluation Study – Follow-Up Survey Telephone Interview
Appendix 11: Evaluation Study – Thank You Letter for Mailing Magnet and MPT
Appendix 12: Detailed Analysis Plan for Phase 2
Appendix 13: CITI IRB Training Completion Certificate for Betsy Payn
Send completed application to IRB Manager for the appropriate line of review: Gary Sapp, (614) 4247648, [email protected]

Procedure Area: Human Subjects Research
For additional information, contact the Subject Matter Expert for this procedure area.
Page 18 of 123

APPENDIX 1:
COGNITIVE INTERVIEW
RECRUITMENT FLYER AND ADVERTISEMENT

19

Cognitive Interview
Recruitment Flyer

Are you 60 to 74 years old and able to get to places you
need to go?
Are you able to get around and do the things you want to do
without assistance?
Would you like to take part in a research interview about
mobility among older adults?
•

What will I do in the study?
You will meet with an interviewer at Battelle, a non-profit research firm, near South
Lake Union. You will be asked your opinions on survey questions that may be used by
the Center for Disease Control (CDC).
The interview will take about 2 hours. You will receive a $50 gift card at the end of the
interview.

•

Who do you want to participate in the study?
We are looking for adults ages 60 to 74 who are able to get around on their own and who
do not have any mobility limitations.

•

Who do I contact if I want more information or would like
to participate?
Please contact Betsy Payn at 206-528-3138 or [email protected] to volunteer or learn
more about the study.

20

Cognitive Interview
Advertisement
Battelle, a non-profit research firm, is recruiting adults ages 60 to 74 who can get around without
assistance to participate in a study funded by the Centers for Disease Control and Prevention
(CDC). Participants will meet with an interviewer at the Battelle office (near South Lake Union)
and provide their opinions on survey questions about older adult mobility that may be used in a
future survey. The interview will take about 2 hours. Participants will receive a $50 gift card at
the end of the interview. If you would like more information or want to participate, contact
Betsy Payn at 206-528-3138 or [email protected] to volunteer or learn more about the study.

21

APPENDIX 2:
COGNITIVE INTERVIEW
SCREENER

22

Cognitive Interview
Screener
[Purpose of script/screener: Potential participants may call the number in the flyer or
advertisement. Battelle will provide information about the study and will obtain information
from potential participants to determine whether they meet the eligibility criteria and help
ensure a diverse sample. Responses to all questions and information gathered will be recorded
on the form below and then entered into an Excel spreadsheet.]
Script for incoming calls:
My name is [NAME], and I work for Battelle. Thank you for your interest in The Older
Adult Mobility Planning Study for the Centers for Disease Control and Prevention or CDC.
Battelle is a research organization that is currently assisting the CDC. Battelle has been asked to
conduct cognitive interviews on survey questions that ask about plans to protect physical mobility
as people age, such as their ability to get to places they need to go as they get older. The purpose
of the interviews is to learn if the survey questions are easy to understand and answer. We are
currently recruiting adults who are 60 to 74 years old and who can get around without assistance
to participate in these interviews.
In a moment, I will ask you a series of questions to determine if you are eligible to
participate. If eligible, you will be asked to participate in a 2-hour cognitive interview. During
the cognitive interview, we will ask you to answer survey questions and then will ask you about
your understanding of those questions. We will audio record the discussion to help with our
analysis. The audio recording will be destroyed after the research study is completed.
Your participation is completely voluntary, and all the information you provide will be
kept confidential. If you are eligible for the study and choose to participate, you will receive a
$50 gift card as a thank you for participating. Does this sound like something you are interested
in participating in? Do you have any questions?

IF PARTICIPANT DOES NOT SPEAK ENGLISH, THEY ARE NOT ELIGIBLE. THANK
THEM AND END CALL.
INTERVIEWER INSTRUCTIONS: CIRCLE THE LETTER OF THE RESPONSE
CATEGORY OR FILL IN AS INDICATED.
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.

23

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. GO TO Q4
4. GENDER: RECORD WITHOUT ASKING, IF POSSIBLE
a. Female
b. Male
5. Are you of Hispanic or Latino/Latina origin or descent?
a. Yes, Hispanic or Latino/Latina
b. No, Not Hispanic nor Latino/Latina
6. Which of the following best describes your race? [READ RESPONSES]
a. White,
b. Black or African American,
c. Asian,
d. Native Hawaiian or Other Pacific Islander, or
e. American Indian or Alaska Native.
7. What is the highest level of education you have completed? [READ RESPONSES]
a. Less than high school,
b. High School diploma or GED,
c. Some college but no degree,
d. Associates Degree or Trade School Certification
e. Bachelor’s Degree, or
f. Post graduate degree, such as a Master’s or PhD?
8. Of these income groups, which category best represents your total combined family
income during 2014? Just tell me the letter. Is it…[READ RESPONSES]
a. Less than $30,000,
b. $30,000-$49,000,
c. $50,000-$99,000, or
d. $100,000 or more.
24

e. REFUSED
f. DON’T KNOW
9. Do you live in an area that is: [READ RESPONSES]
a. Rural,
b. Suburban, or
c. Urban.
10. Which best describes your Marital Status? [READ RESPONSES]
a. Married,
b. Not married but living with a partner,
c. Never been married,
d. Divorced,
e. Separated, or
f. Widowed.
I’d now like to gather contact information for you.
Name: ___________________________________________________
Address: _________________________________________________
Telephone Number: _________________________________________
Is that (CIRCLE ONE):
Home
Work
Cell
Email: _____________________________________________________
SCHEDULING:
[DETERMINE SCHEDULING BASED ON NEED FOR A DIVERSE SAMPLE. IF
SCHEDULING NOW:]
Thank you for answering these questions. You are eligible for the study. We would like to set up a
time to conduct the cognitive interview with you at our Battelle office or your home.
[IF NOT SCHEDULING NOW:]
Thank you for answering these questions to help us determine if you are eligible for this study. If
you are selected to participate in a cognitive interview, we will contact you soon by phone to
schedule a time.
[THANK PARTICIPANTAND END.]
ASSIGN POTENTIAL PARTICIPANTS A THREE-DIGIT ID NUMBER
SEQUENTIALLY BEGINNING WITH 100. ASSIGN ID NUMBER:
25

APPENDIX 3:
COGNITIVE INTERVIEW
REMINDER EMAIL OR LETTER

26

Reminder Email or Letter
[Battelle Letter head if letter]
Dear [PARTICIPANT NAME],
Thank you for agreeing to participate in the Older Adult Mobility Planning Study. I am writing
to remind you of your scheduled appointment at Battelle on [DATE] at [TIME] to participate in a
cognitive interview. Battelle is located on the 1100 Dexter Avenue North, Seattle, WA 98109. Please
take the elevator to the 4th floor (Suite 400). The interview will take about 2 hours to complete. At the
end of the interview, you will receive a $50 gift card as a thank you for participating. If you have
questions, please contact me at 206-528-3138 or by email at [email protected].

Best wishes,

Betsy Payn
Health Researcher

27

APPENDIX 4:
COGNITIVE INTERVIEW
SCRIPT FOR REMINDER CALL

28

Script for Reminder Call

Hi! Is [PARTICIPANT NAME] there?
[IF PARTICIPANT IS ON OR COMES TO THE PHONE, SAY:] I’m calling from Battelle about
your participation in the Older Adult Mobility Planning Study and to remind you of your appointment at
Battelle on [DATE] at [TIME]. Battelle is located on the 1100 Dexter Avenue North, Seattle, WA
98109. Please take the elevator to the 4th floor (Suite 400). The interview will take about 2 hours to
complete. At the end of the interview, you will receive a $50 gift card as a thank you for participating.
Do you have any questions? [ANSWER QUESTIONS] Thank you. Good bye.
[IF PARTICIPANT IS NOT AVAILABLE, SAY:] May I leave a message? I’m calling to remind
[PARTICIPANT NAME] of {his/her} appointment at Battelle on [DATE] at [TIME]. If
[PARTICIPANT NAME] has any questions, {he/she} can contact Betsy Payn at 206-528-3138. Thank
you. Good bye.

29

APPENDIX 5:
COGNITIVE INTERVIEW
CONSENT FORM

30

Cognitive Interview
Consent Form

The Older Adult Mobility Planning Study
Consent Form
What is the purpose of this study?
The Centers for Disease Control and Prevention (CDC) has asked Battelle, a nonprofit research
company, to develop a brochure or pamphlet that can help people ages 60 or older protect their
ability to get places they need to go as they age. The study we are asking you to participate in is a
cognitive interview to obtain your opinion about survey questions that will be used to evaluate the
tool that is being developed. The purpose of the cognitive interview is to make sure the survey
questions are relevant and understandable. Cognitive interview participants will be asked to
provide feedback on potential questions for future use by the CDC.
What will I have to do if I am in this study?
If you are in this study, you will take part in a one-on-one interview at the Battelle Seattle office.
Your interview will take no more than 2 hours of your time, not including time to and from the
interview location. During the interview session, you may be asked to answer survey questions
about what you are doing or are planning to do about your ability to get to get around in the future.
You then will be asked about your understanding of the survey items.
What are the risks to being in this study?
There may be a level of discomfort for you in sharing your thoughts and opinions regarding the
survey measures. Although steps will be in place to protect the confidentiality of your responses,
there is a small possibility that the information you provide could be connected with your name.
What are the benefits to being in this study?
You will not benefit directly from this study. However, the information you provide will be used
to improve tools to assist people in planning for changes in their mobility.
What about our privacy and the confidentiality of the information I provide?
All the information you share with us will be kept confidential. Only Battelle project staff will
have access to any personally identifiable information about you. If you or someone else is in
danger, we will need to tell people who can help. When conducting the study, we will not include
in our notes or in any written reports your name or any other information that might identify you.
In order to make sure our notes are correct, we will audio record the interview with you. The
recording will only be used by members of the research team to confirm what is said during the
discussion. The audio recordings will be destroyed after we are finished summarizing the
information. Any other identifiable information about you also will be destroyed at the end of the
study.
Do we have to agree to participate in the interview?
You can decide whether or not to take part in this cognitive interview. You may also choose not to
answer any questions you wish. Nothing will happen to you if you choose not to participate. You
will receive a $50 gift card when we are finished today to thank you for your participation no
matter how many questions you answer.
31

What if I have questions?
If you have any questions about this research study, you may call the Battelle Project Leader, Ms.
Betsy Payn at (206) 528-3138. If you have questions about your rights as a research participant,
please call the Battelle Institutional Review Board Chair (toll-free) at (877) 810-9530, ext. 500.
Participant’s Consent to Participate
I understand the nature and purpose of the study, The Older Adult Mobility Planning Study, as
described above. I understand the activities involved in the study and my rights as a research
participant. I agree to participate in the cognitive interview.

Name of Participant (Print)

Signature of Participant

Date

32

APPENDIX 6:
COGNITIVE INTERVIEW
DISCUSSION GUIDE

33

Cognitive Interview
Discussion Guide
General Instructions and Guidelines for Conducting the Cognitive Interview:
In order to assess respondent understanding and interpretation of each item, you will review the
survey question by question with the interviewee and utilize a “think aloud” strategy for all the
questions in a section, followed by probing for each question as described below. So, there will
be two distinct “phases”: Think Aloud for all questions in a section (Phase I) and Verbal
Probing separately for each question in the section (Phase II).
PHASE I: Think Aloud
In Phase I, you will read the survey questions to interviewees and ask them to think out loud as
they answer the questions. After reading a survey question, you will inject little other than a
prompt to “tell me what you are thinking” if the respondents pause. You are not asking any
specific questions or probes at this point. The main purpose of this “phase” is to gather the
interviewees’ thought process they first hear the question.
As the interviewees “think aloud” after hearing each question, it will be helpful for you to jot
down some notes about words/phrases the interviewees find confusing/unclear, information they
think is helpful, inappropriate, out of place, etc. This will help you to target your specific
questions and probes in Phase II.
PHASE II: Verbal Probing
This is the phase of the interview after interviewees answer questions and let you know what
they are thinking as they do so. The purpose is to:

Try to understand further the reasons behind comments interviewees made during the “thinkaloud” that are not clear to you;


Assess the participants’ understanding of the question;



Determine their impressions of the clarity and level of difficulty of the question; and,


Ask (as appropriate) some item specific probes about the content that you and the participant
have not discussed yet.

To accomplish this, read each survey question again with the participant and ask the following
general questions:
•
Participants’ Understanding/Comprehension of the Content: E.g., – Can you repeat
this question in your own words?
•

Level of Difficulty: E.g. –Was that easy or hard to answer?

34

•
Unclear/Confusing Content: E.g. – Was there anything about this particular question
you found confusing? or What does the term “X” mean to you?
•
Confidence Judgment: E.g. – How sure are you that the answer you picked accurately
reflects how you really feel about this statement?
In addition, follow up with interviewees about anything they mentioned during the Phase I
review/“think aloud” that you feel you need a better understanding of (e.g., “What was your
reason for mentioning [XX] again? I just want to make sure I understand.”), and, as appropriate
or needed, ask any item-specific probes for a particular question (examples of specific probes to
consider asking are listed below throughout the remainder of the interview guide). Not all
questions listed for Phase 2 should be asked. Use the questions as a reminder for what might be
asked or probed given a participant’s answer and understanding of the question.
Finally, as you move through the questions, (and/or other appropriate times during the
interview), remember not only to provide some occasional encouragement and praise to
interviewees about how helpful their feedback is but also some occasional reminders about how
there are no right or wrong answers, this is not a test, they are the “expert” today, etc. (as will be
mentioned in the sample pre-interview script below).
Also pay attention to your time to make sure you get through all of the questions if possible.
This may mean skipping some of the Phase 2 probing questions if you have enough information
on particular survey questions.
General Questions on the Instrument
After completing Phases I and II for all the survey items, you will ask participants some general
questions about the instrument as a whole. This will be followed by a question about the
interview experience. This will conclude the interview. You will then provide the incentive
($50) to the participant.
Prior to Each Interview:

Call the participant 1 – 2 days prior to the interview, and again on the day of the
interview if needed, to remind the participant about the interview date, time, and place. We
expect the cognitive interview to last approximately 2 hours.

Complete the table below with pertinent information about the interview (e.g., unique
participant ID code, interview date/time, interviewer)







Remember to bring the following important items to the interview:
Audio recorder
Cognitive Interviewer Guide
At least two copies of consent form (one for participant to sign and return, one to keep)
Extra pens and batteries
Welcome and Consent and Assent Process:

 Point out location of restroom if/when needed.
 When ready, obtain consent for participation.
35

Participant ID:
Interview Date/Time:
Interviewer:
Pre-Interview Script:
Note: The pre-interview script is to be used as a guide to help make sure the important
points are covered and doesn’t need to be recited verbatim. Practice before the interview
so it comes across as more conversational and try not to read from the script.
Welcome, and thanks again for agreeing to participate in our study, The Older Adult Mobility
Planning Study. My name is [NAME] and I work for Battelle. Battelle is a non-profit research
organization that is currently assisting the Centers for Disease Control and Prevention, or
“CDC,” to develop a brochure or pamphlet to help people who are 60 years or older protect
their mobility, such as their ability to get to places they need to go as they get older.
CDC has contracted with Battelle to collect feedback on survey questions to be used in
evaluating the brochure that CDC is developing. To accomplish this, we’re identifying
individuals from diverse backgrounds to participate in interviews to ensure that the survey
questions are relevant and understandable.
The specific purpose of today’s interview is to get your feedback on potential survey questions to
be used in an evaluation study of a brochure developed by CDC to help older adults plan for
future changes in their mobility. We’re hoping to get your opinions about the content of the
questions on a range of topics, including how understandable you think the questions are and
how difficult they are to answer, as well as any particular word, phrases or concepts you think
are confusing. There is no right or wrong answer – you are the expert. The feedback we receive
from you and others who we interview about this will certainly help improve the content of the
survey questions and the overall experience for individuals who will answer the future survey.
Basically, we are interested in what you are thinking when you hear the survey question. In
order to find out what you are thinking, I want you to think out loud as much as you can as I ask
you the questions. In other words, when you hear the question, I want you to say out loud
everything you say to yourself silently, for example, about things you find confusing, things you
think go against what you believe to be true, or any other impressions or thoughts you have that
you feel are important to know.
I know this is kind of different. It's not what people usually do. Usually people would just
answer the question asked. So, I may have to remind you from time to time to let me know what
you’re thinking. OK?
Before we begin, I’ll also need to get your consent to participate in today’s interview. Here’s a
copy of the consent form for our study for you to review and sign.

36

Hand consent form to the participant, have him/her read the form, and then answer any
questions he/she has. Once all questions have been answered, ask the participant to sign
the consent form for his/her participation. Provide the participant a blank copy of the
consent to keep.
OK, great! I also want to mention before we begin that, although I will be taking some notes, I
don’t write that fast, so as was mentioned in the consent form, we’ll need to have an audio
record of what we discuss today, OK? I’m going to turn the recorder on now, and then we can
start. We’ll work through the questions until we finish, no later than [TIME 2 hours from time
you began].
As I mentioned earlier, please try to “think aloud” as much as possible as I read you each
question and you respond. Although I’ll be asking you a bunch of general and item-specific
questions to see what you think about each question, it’s also very helpful to get your initial
thoughts and impressions.

***Remember to turn on audio recorder***

37

SECTION 1, PHASE 1-THINK ALOUD: SCREENER QUESTIONS
First, I’d like to ask you a few questions to see if you are eligible for the survey.
1. What is your age?
2. Do you have any disability, handicap, or chronic condition that keeps you from participating
in work, school, housework, or other activities?
3. Where 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?
NOTES:

SECTION 1, PHASE 2-VERBAL PROBING: SCREENER QUESTIONS
Now I’d like to ask you some specific questions about each item. We’ll start with Question 1.
1. What is your age?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?
The next question is:
2. Do you have any disability, handicap, or chronic condition that keeps you from participating in
work, school, housework, or other activities?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?
The next question is:
38

3. Where 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. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

SECTION 2, PHASE 1-THINK ALOUD: TTM QUESTIONS
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.
1. I am preparing to start a regular exercise program in the next few weeks.
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 could make changes to make my home safer from trips and falls as I get older, but I don't
currently have plans to.
9. I have been talking with my family and friends about how I will get around as I get older.
10. I have made some changes to make sure I can get around as I get older, and I plan to continue.
39

11. 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.
12. I am doing something about the things that might limit my ability to get around as I get older,
such as exercising or getting a vision checkup.
13. 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.
14. I have been thinking about whether I will be able to do the things I want to do as I get older.
15. I know how to get around as I get older and will continue to look for opportunities or support as I
need them.

NOTES:

40

SECTION 2, PHASE 2-VERBAL PROBING: TTM QUESTIONS
Now I’d like to ask you some specific questions about each item. The first question in this section is:
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.
1. I am preparing to start a regular exercise program in the next few weeks. [Do you strongly
disagree, disagree, neither disagree nor agree, agree, or strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:
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. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or
strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:
3. I have been thinking about my ability to get around as I get older. [Do you strongly disagree,
disagree, neither disagree nor agree, agree, or strongly agree?]
41

a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:
4. I don't need to do anything to maintain or improve my physical strength or balance as I get older.
[Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:
5. I am very motivated to conduct a safety check of my home to protect me from trips and falls as I
get older. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly
agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:

42

6. I really think I should get started with a plan to make my home safe from the risk of tripping and
falls. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:
7. I have been successful in making changes to eliminate trip and fall hazards in my home. [Do
you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:
8. 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. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or
strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

43

The next question is:
9. I have been talking with my family and friends about how I will get around as I get older. [Do
you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:
10. I have made some changes to make sure I can get around as I get older, and I plan to continue.
[Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:
11. 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. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or
strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?
44

The next question is:
12. I am doing something about the things that might limit my ability to get around as I get older,
such as exercising or getting a vision checkup. [Do you strongly disagree, disagree, neither
disagree nor agree, agree, or strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:
13. 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. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or
strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:
14. I have been thinking about whether I will be able to do the things I want to do as I get older. [Do
you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
45

g. Is there anything else you’d like to say about this statement?

The next question is:
15. I know how to get around as I get older and will continue to look for opportunities or support as I
need them. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly
agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

46

SECTION 3, PHASE 1-THINK ALOUD: BEHAVIORS IN THE PAST 2 WEEKS
Now I’d like to ask several questions about things you may have done in the last 2 weeks. For each
activity, please tell me if in the last two weeks:
•
•
•
•

You did not think about doing it,
You thought about doing it,
You made plans to do it, or
You did the activity.

1. The first activity is, had a physical checkup. In the last 2 weeks, did you not think about doing it,
did you think about doing it, did you make plans to do it, or did you do it?
2. [The next activity is…] Had all your medicines reviewed by your health care provider or
pharmacist
3. [The next activity is…] Had a vision checkup
4. [The next activity is…] Participated in an exercise program to increase your physical strength
5. [The next activity is…] Participated in an exercise program to increase your balance
6. Checked your home for tripping hazards
7. [The next activity is…] Made any changes for safety in your home, such as putting handrails on
the stairs, grab bars in your bathroom, a lamp within reach of your bed, or any other changes for
safety
8. [The next activity is…] Took a driving refresher course
9. [The next activity is…] Got your car checked to see how well it fits you
10. [The next activity is…] Gathered information on transportation options other than driving
yourself

47

SECTION 1, PHASE 2-VERBAL PROBING: BEHAVIORS IN THE PAST 2 WEEKS
Now I’d like to ask several questions about things you may have done in the last 2 weeks. For each
activity, please tell me if in the last two weeks: You did not think about doing it; you thought about
doing it; you made plans to do it; or, you did the activity.
1. The first activity is, had a physical checkup. In the last 2 weeks, did you not think about doing it,
did you think about doing it, did you make plans to do it, or did you do it?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?
[The next activity is…].
2. Had all your medicines reviewed by your health care provider or pharmacist? In the last 2 weeks,
did you not think about doing it, did you think about doing it, did you make plans to do it, or did you
do it?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?
[The next activity is…].
3. Had a vision checkup? In the last 2 weeks, did you not think about doing it, did you think about
doing it, did you make plans to do it, or did you do it?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
48

e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?
[The next activity is…].
4. Participated in an exercise program to increase your physical strength? In the last 2 weeks, did
you not think about doing it, did you think about doing it, did you make plans to do it, or did you do
it?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?
[The next activity is…].
5. Participated in an exercise program to increase your balance? In the last 2 weeks, did you not
think about doing it, did you think about doing it, did you make plans to do it, or did you do it?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?
[The next activity is…].
6. Checked your home for tripping hazards? In the last 2 weeks, did you not think about doing it, did
you think about doing it, did you make plans to do it, or did you do it?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
49

f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?
[The next activity is…].
7. Made any changes for safety in your home, such as putting handrails on the stairs, grab bars in
your bathroom, a lamp within reach of your bed, or any other changes for safety? In the last 2 weeks,
did you not think about doing it, did you think about doing it, did you make plans to do it, or did you
do it?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?
[The next activity is…].
8. Took a driving refresher course? In the last 2 weeks, did you not think about doing it, did you
think about doing it, did you make plans to do it, or did you do it?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?
[The next activity is…].
9. Got your car checked to see how well it fits you? In the last 2 weeks, did you not think about
doing it, did you think about doing it, did you make plans to do it, or did you do it?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?
50

[The next activity is…].
10. Gathered information on transportation options other than driving yourself? In the last 2 weeks,
did you not think about doing it, did you think about doing it, did you make plans to do it, or did you
do it?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

51

SECTION 4, PHASE 1-THINK ALOUD: DEVELOPING PLAN
For each statement, please tell me how strongly you agree or disagree with each statement.
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. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or
strongly agree?]
2. I have a plan for how I will make my home safe so I can avoid tripping and falling in my home.
[Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree?]
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. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or
strongly agree?]

SECTION 4, PHASE 2-VERBAL PROBING: DEVELOPING PLAN
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. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly
agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?
The next statement is:
2. I have a plan for how I will make my home safe so I can avoid tripping and falling in my home.
[Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
52

g. Is there anything else you’d like to say about this statement?
The next statement is:
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. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly
agree?]
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

53

SECTION 5, PHASE 1-THINK ALOUD: BACKGROUND QUESTIONS
Now I’d like to ask you some general questions about your background.
1. How long have you lived in your current residence?
2. How many adults, age 18 years or older, live in your home with you?
3. Are you of Hispanic or Latino/Latina origin or descent?
4. Which of the following best describes your race: White; Black or African American; Asian,
Native Hawaiian or Other Pacific Islander; or, American Indian or Alaska Native?
5. What is your current marital status? Are you currently married, widowed, divorced, separated, or
never married?
6. ASK IF NOT OBVIOUS: Are you male or female?
7. What is the highest grade or year of school that you completed?
8. Last week were you working full time at least 35 hours, working part time less than 35 hours,
retired, going to school, keeping house, or doing something else?
9. How strongly do you disagree or agree with the following statement?: “I can count on my
friends and family to listen when I need to talk.” Do you strongly disagree, disagree, neither
disagree nor agree, agree, or strongly agree?
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?
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?
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?

SECTION 5, PHASE 2-VERBAL PROBING: BACKGROUND QUESTIONS
Now I’d like to ask you some general questions about your background.
1. How long have you lived in your current residence?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

54

The next question is:
2. How many adults, age 18 years or older, live in your home with you?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

The next question is:
3. Are you of Hispanic or Latino/Latina origin or descent?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

The next question is:
4. Which of the following best describes your race: White; Black or African American; Asian,
Native Hawaiian or Other Pacific Islander; or, American Indian or Alaska Native?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

The next question is:
5. What is your current marital status? Are you currently married, widowed, divorced, separated, or
never married?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
55

d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

The next question is:
6. ASK IF NOT OBVIOUS: Are you male or female?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

The next question is:
7. What is the highest grade or year of school that you completed?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

The next question is:
8. Last week were you working full time at least 35 hours, working part time less than 35 hours,
retired, going to school, keeping house, or doing something else?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

56

The next question is:
9. How strongly do you disagree or agree with the following statement?: “I can count on my friends
and family to listen when I need to talk.” Do you strongly disagree, disagree, neither disagree nor
agree, agree, or strongly agree?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:
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?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next question is:
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?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
57

g. Is there anything else you’d like to say about this statement?

The next question is:
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?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

58

THE OLDER ADULT MOBILITY PLANNING TOOL
The last section is about the brochure that we are developing. [HAND PARTICIPANT THE
BROCHURE.] Please take a few minutes to look through the brochure, then I’ll continue with the
cognitive interview.
[AFTER 5 MINUTES, TELL THE PARTICIPANT THAT YOU’LL START THE COGNITIVE
INTERVIEW AGAIN, STARTING WITH THINK-ALOUD SECTION.]

SECTION 6, PHASE 1-THINK ALOUD: DISSEMINATION AND FEEDBACK ON USE OF
BROCHURE
I would like to ask you some questions about the brochure.
1. Using a scale from 1 to 5, where 1 is not at all likely and 5 is very likely, how likely are you to
download the brochure if it is on the Web or Internet?
2. How likely are you to use the brochure if it is given to you by your medical provider?
3. How likely are you to read the rest of the brochure if you only saw the first page?
4. Did you use the chart on page 2 of the brochure, Mobility Plan for Myself, to develop a mobility
plan for yourself?
5. Which parts of the Mobility Plan for Myself on page 2 did you find most helpful?
6. Which parts of the Mobility Plan for Myself on page 2 did you find least helpful?
7. Did you use the chart on page 3 of the brochure, Mobility Plan for Inside My Home, to develop a
plan to reduce the risk of trips and falls in your home?
8. Which parts of the Mobility Plan for Inside My Home on page 3 did you find most helpful?
9. Which parts of the Mobility Plan for Inside My Home on page 3 did you find least helpful?
10. Did you use the chart on page 4 of the brochure, Mobility Plan for Outside My Home, to develop
a plan for how you would get around if you could not do what you usually do?
11. Which parts of the Mobility Plan for Outside My Home on page 4 did you find most helpful?
12. Which parts of the Mobility Plan for Outside My Home on page 4 did you find least helpful?

SECTION 6, PHASE 2-VERBAL PROBING: DISSEMINATION AND FEEDBACK ON USE
OF BROCHURE
I would like to ask you some questions about the brochure.
1. Using a scale from 1 to 5, where 1 is not at all likely and 5 is very likely, how likely are you to
download the brochure if it is on the Web or Internet?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
59

d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next statement is:
2. How likely are you to use the brochure if it is given to you by your medical provider?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next statement is:
3. How likely are you to read the rest of the brochure if you only saw the first page?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. Were the response categories easy to use in answering the question? If not, what made them
difficult to use?
e. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
f. Is there anything about this particular statement you found confusing or unclear?
g. Is there anything else you’d like to say about this statement?

The next statement is:
4. Did you use the chart on page 2 of the brochure, Mobility Plan for Myself, to develop a mobility
plan for yourself?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
60

f. Is there anything else you’d like to say about this statement?

The next statement is:
5. Which parts of the Mobility Plan for Myself on page 2 did you find most helpful?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

The next statement is:
6. Which parts of the Mobility Plan for Myself on page 2 did you find least helpful?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

The next statement is:
7. Did you use the chart on page 3 of the brochure, Mobility Plan for Inside My Home, to develop a
plan to reduce the risk of trips and falls in your home?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

The next statement is:
8. Which parts of the Mobility Plan for Inside My Home on page 3 did you find most helpful?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
61

c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

The next statement is:
9 Which parts of the Mobility Plan for Inside My Home on page 3 did you find least helpful?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

The next statement is:
10. Did you use the chart on page 4 of the brochure, Mobility Plan for Outside My Home, to develop
a plan for how you would get around if you could not do what you usually do?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

The next statement is:
11. Which parts of the Mobility Plan for Outside My Home on page 4 did you find most helpful?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

62

The next statement is:
12. Which parts of the Mobility Plan for Outside My Home on page 4 did you find least helpful?
a. What do you think of when you hear this question? PROBE: What images or experiences come
to mind?
b. Can you repeat this statement in your own words? PROBE: How would you suggest rephrasing
this statement to make it more understandable or clearer?
c. Was this easy or hard to answer? PROBE: What made it [hard or easy]?
d. How sure are you that the answer you picked accurately reflects how you really feel about this
statement?
e. Is there anything about this particular statement you found confusing or unclear?
f. Is there anything else you’d like to say about this statement?

63

GENERAL QUESTIONS ABOUT THE INSTRUMENT:
•

Overall, what would you say is the main purpose of the questions you were asked today?

[HAND PARTICIPANT THE SURVEY ITEMS HANDOUT]
1. Were there any questions that now standout as being particularly difficult to answer? If so, what
made them difficult?
2. The response categories for several of the questions are: “Do you strongly disagree, disagree,
neither disagree nor agree, agree, or strongly agree?” Other possible responses patterns could
be:
a. “Do you disagree, are neutral, or agree with the statement?” OR
b. “Using a scale from 1 to 5, where 1 is strongly disagree and 5 is strongly agree, please
tell your level of agreement with the statement.”
If you were answering these questions on the phone, how would you prefer to answer these
questions?
o “Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree?”,
o “Do you disagree, are neutral, or agree with the statement?”, OR
o “Using a scale from 1 to 5, where 1 is strongly disagree and 5 is strongly agree, please
tell your level of agreement with the statement.”
3. Which of these questions seems most relevant to older adults without known mobility
limitations?
Probe: Can you give me an example of this?
4. Which of these seem least relevant to older adults without known mobility limitations?
Probe: Can you give me an example of this?
5. Were there questions that we didn’t ask that you think we should? What specifically?
6. If these questions were asked over the telephone, are there any that would be difficult to answer
over the phone? Which ones and why would they be difficult?
7. Were there any questions that you would recommend we not ask of older adults without known
mobility limitations? Why?
8. Before we wrap up, is there anything else you feel would be important for us to know about and
consider as we work to improve and finalize this set of survey questions?

Interview Conclusion:
•

Well, we’ve finished…Do you have any questions?

•

What did you think of the experience?

Thank you very much for participating. Your input will be very helpful in improving the survey
instrument.
64

[Remember to hand the interviewee the $50 gift card for participating, have participant sign
the incentive payment receipt form, walk with participant to the exit, and thank them again
for providing valuable feedback.]

INTERVIEWER OBSERVATIONS
1. Which questions did the participant not understand?
2. Which questions did the participant have difficulty answering and why?
3. Did the participant have difficulty using the response categories? If yes, how so?
4. Please provide any other information about the participant and/or the interview might
help in analyzing the interview results.

65

APPENDIX 7:
COGNITIVE INTERVIEW
HANDOUT OF SURVEY QUESTIONS

66

COGNITIVE INTERVIEW
HANDOUT OF SURVEY QUESTIONS
Developing the OAMAT Evaluation Study
Cognitive Interview Participant Handout

SECTION 1: SCREENER QUESTIONS
First, I’d like to ask you a few questions to see if you are eligible for the survey.
1. What is your age?
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?
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?

SECTION 2: TTM QUESTIONS
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.
[Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree?]
1. I am preparing to start a regular exercise program in the next few weeks.
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.
67

8. 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.
9. I have been talking with my family and friends about how I will get around as I get older.
10. I have made some changes to make sure I can get around as I get older, and I plan to continue.
11. 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.
12. I am doing something about the things that might limit my ability to get around as I get older, such
as exercising or getting a vision checkup.
13. 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.
14. I have been thinking about whether I will be able to do the things I want to do as I get older.
15. I know how to get around as I get older and will continue to look for opportunities or support as I
need them.

SECTION 3: BEHAVIORS IN THE PAST 2 WEEKS
Now I’d like to ask several questions about things you may have done in the last 2 weeks. For each
activity, please tell me if in the last two weeks:
•
•
•
•

You did not think about doing it,
You thought about doing it,
You made plans to do it, or
You did the activity.

1. The first activity is, had a physical checkup. In the last 2 weeks, did you not think about doing it,
did you think about doing it, did you make plans to do it, or did you do it?
2. [The next activity is…] Had all your medicines reviewed by your health care provider or pharmacist
3. [The next activity is…] Had a vision checkup
4. [The next activity is…] Participated in an exercise program to increase your physical strength
5. [The next activity is…] Participated in an exercise program to increase your balance
6. Checked your home for tripping hazards
7. [The next activity is…] Made any changes for safety in your home, such as putting handrails on the
stairs, grab bars in your bathroom, a lamp within reach of your bed, or any other changes for safety
8. [The next activity is…] Took a driving refresher course
68

9. [The next activity is…] Got your car checked to see how well it fits you
10. [The next activity is…] Gathered information on transportation options other than driving yourself

SECTION 4: DEVELOPING PLAN
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. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly
agree?]
2. I have a plan for how I will make my home safe so I can avoid tripping and falling in my home. [Do
you strongly disagree, disagree, neither disagree nor agree, agree, or strongly agree?]
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. [Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly
agree?]

SECTION 5: BACKGROUND
Now I’d like to ask you some general questions about your background.
1. How long have you lived in your current residence?
2. How many adults, age 18 years or older, live in your home with you?
3. Are you of Hispanic or Latino/Latina origin or descent?
4. Which of the following best describes your race: White; Black or African American; Asian, Native
Hawaiian or Other Pacific Islander; or, American Indian or Alaska Native?
5. What is your current marital status? Are you currently married, widowed, divorced, separated, or
never married?
6. ASK IF NOT OBVIOUS: Are you male or female?
7. What is the highest grade or year of school that you completed?
8. Last week were you working full time at least 35 hours, working part time less than 35 hours,
retired, going to school, keeping house, or doing something else?
9. How strongly do you disagree or agree with the following statement?: “I can count on my friends
and family to listen when I need to talk.” Do you strongly disagree, disagree, neither disagree nor
agree, agree, or strongly agree?

69

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?
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?
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?

SECTION 6: DISSEMINATION AND FEEDBACK ON USE OF BROCHURE
Finally, I would like to ask you some questions about the brochure that was sent to your home 2 weeks
ago.
1. Using a scale from 1 to 5, where 1 is not at all likely and 5 is very likely, how likely are you to
download the brochure if it is on the Web or Internet?
2. How likely are you to use the brochure if it is given to you by your medical provider?
3. How likely are you to read the rest of the brochure if you only saw the first page?
4. Did you use the chart on page 2 of the brochure, Mobility Plan for Myself, to develop a mobility plan
for yourself?
5. Which parts of the Mobility Plan for Myself on page 2 did you find most helpful?
6. Which parts of the Mobility Plan for Myself on page 2 did you find least helpful?
7. Did you use the chart on page 3 of the brochure, Mobility Plan for Inside My Home, to develop a
plan to reduce the risk of trips and falls in your home?
8. Which parts of the Mobility Plan for Inside My Home on page 3 did you find most helpful?
9. Which parts of the Mobility Plan for Inside My Home on page 3 did you find least helpful?
10. Did you use the chart on page 4 of the brochure, Mobility Plan for Outside My Home, to develop a
plan for how you would get around if you could not do what you usually do?
11. Which parts of the Mobility Plan for Outside My Home on page 4 did you find most helpful?
12. Which parts of the Mobility Plan for Outside My Home on page 4 did you find least helpful?

70

APPENDIX 8:
EVALUATION STUDY – BASELINE SURVEY
SCREENER AND TELEPHONE INTERVIEW

71

Evaluation Study – Baseline Survey
Screener and Telephone Interview

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 on a study of
how people who are age 60 or older protect their physical mobility as they age, including
being able to get to places they need to go. We’re looking for people to participate in a
brief phone survey that will ask about your plans to protect your mobility 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 confidential. May we begin?
INTERVIEWER INSTRUCTION: GO TO THE SCREENING QUESTIONS
UNLESS PARTICIPANT DOES NOT SPEAK ENGLISH. IF DOES NOT SPEAK
ENGLISH, THANK THEM AND END CALL.

[VOICE MAIL SCRIPT IF NO ONE ANSWERS THE PHONE:]
Hi, 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 looking
for people age 60 or older to participate in a brief phone survey that asks about their
plans to protect their mobility over time, including being able to get to places they need
to go. If you are interested, please contact our research office at XXX-XXX-XXXX for
more information. Thank you and we look forward to hearing from you soon.

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.
72

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, I also need to collect your address. What is
your mailing address? [RECORD ADDRESS.]
Do you have time to complete the 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 CALLBACK.]
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 mobility 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 1xxx-xxx-xxxx. Thank you.
73

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 mobility 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 confidential. Only
Battelle project staff will have access to any personally identifiable information about
you. Although steps will be in place to protect the confidentiality 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 our study.
If you have any questions about this research study, you can call Betsy Payn at 206-5283138. 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 _________________
74

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.
[AFTER READING THE FIRST STATEMENT, SAY: Do you strongly disagree,
disagree, neither disagree nor agree, agree, or strongly agree?]
[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 preparing to start a regular exercise program in the next few weeks.
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 could make changes to make my home safer from trips and falls as I get older, but I
don't currently have plans to.
9. I have been talking with my family and friends about how I will get around as I get
75

older.
10. I have made some changes to make sure I can get around as I get older, and I plan to
continue.
11. 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.
12. I am doing something about the things that might limit my ability to get around as I
get older, such as exercising or getting a vision checkup.
13. 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.
14. I have been thinking about whether I will be able to do the things I want to do as I get
older.
15. 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: BEHAVIORS IN THE PAST 2 WEEKS
Now I’d like to ask several questions about things you may have done in the last 2 weeks.
For each activity, please tell me if in the last two weeks:
• You did not think about doing it,
• You thought about doing it,
• You made plans to do it, or
• You did the activity.
[IF RESPONDENT HAS DIFFICULTY REMEMBERING THE RESPONSE
CATEGORIES, SUGGEST THAT THEY WRITE DOWN THE RESPONSES
WITH A NUMBER BY EACH:
1 = YOU DID NOT THINK ABOUT DOING IT
2 = YOU THOUGHT ABOUT DOING IT
3 = YOU MADE PLANS TO DO IT
4 = YOU DID THE ACTIVITY
RESPONDENTS CAN STATE NUMBER RATHER THAN RESPONSE
CATEGORY.]
1. The first activity is, had a physical checkup. In the last 2 weeks, did you not think
about doing it, did you think about doing it, did you make plans to do it, or did you do
it?
[ASK FOR EACH OF THE FOLLOWING ACTIVITIES:]
2. [The next activity is…] Had all your medicines reviewed by your health care provider
or pharmacist
3. [The next activity is…] Had a vision checkup
76

4. [The next activity is…] Participated in an exercise program to increase your physical
strength
5. [The next activity is…] Participated in an exercise program to increase your balance
6. [The next activity is…] Checked your home for tripping hazards
7. [The next activity is…] Made any changes for safety in your home, such as putting
handrails on the stairs, grab bars in your bathroom, a lamp within reach of your bed,
or any other changes for safety
8. [The next activity is…] Took a driving refresher course
9. [The next activity is…] Got your car checked to see how well it fits you
10. [The next activity is…] Gathered information on transportation options other than
driving yourself
SECTION G: DEVELOPING PLAN
[CONTINUE DIRECTLY FROM PAST SECTION. NO INTRODUCTION TO
THIS SECTION.]
[AFTER READING THE FIRST STATEMENT, SAY: Do you strongly disagree,
disagree, neither disagree nor agree, agree, or strongly agree?]
[REPEAT RESPONSE OPTIONS AS NEEDED.]
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?
a. Yes
b. No
4. Which of the following best describes your race? [READ LIST:]
77

a.
b.
c.
d.
e.

White,
Black or African American,
Asian,
Native Hawaiian or Other Pacific Islander, or
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, going to school, keeping house, or doing something else?
[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. How strongly do you agree with the following statement?:
“I can count on my friends and family to listen when I need to talk.”
Do you strongly disagree, disagree, neither disagree nor agree, agree, or strongly
agree?
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]
SECTION I: END
78

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.

79

APPENDIX 9:
EVALUATION STUDY – COVER LETTER
FOR MPT MAILING

80

Evaluation Study – Cover Letter
for MPT Mailing
[On CDC letterhead]

[Date]
[Name]
[Address]
[City, State, Zip]
Dear [Name],
Thank you very much for agreeing to participate in the Thinking About My Future Study being
conducted by the Centers for Disease Control and Prevention (CDC). The purpose of this study is to
collect information about how people who are age 60 or older protect their physical mobility as they
age, including being able to get places they want to go. As our interviewer mentioned on the phone,
your participation in the study is completely voluntary.
At your convenience please review the materials enclosed in this packet. In about one week, an
interviewer from Battelle (the research company assisting CDC with the study) will call to ask you
some follow up questions. At the end of the study we will send you a thank you gift for participating.
If you have any questions regarding the study, please call Betsy Payn, M.A., Task Leader, Battelle, at
206-528-3138. If you have any questions regarding your rights as a study subject, please contact the
Chair of the Battelle Institutional Review Board, at 1-877-810-9530, ext. 500.
Thank you in advance for your time and participation in this important study.
Sincerely,

Gwen Bergen, PhD, MPH, MS
Behavioral Scientist, Division of Unintentional Injury Prevention
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention

81

APPENDIX 10:
EVALUATION STUDY – FOLLOW-UP SURVEY
TELEPHONE INTERVIEW

82

Evaluation Study – Follow-Up Survey
Telephone Interview

SECTION A: INTRODUCTORY TEXT
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’ study, Thinking About My Future Study, that you
recently participated in. We are calling today to see if you are available to complete the
follow-up interview that you agreed to be contacted for after our last interview. 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? TRY
TO SCHEDULE AN APPOINTMENT WITH THE RESPONDENT

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-xxxxxx-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 tollfree at 1-xxx-xxx-xxxx. Thank you.
SECTION B: CONSENT
We expect the call today to take about 10 minutes. 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 confidential. Only Battelle
project staff will have access to any personally identifiable information about you.
Although steps will be in place to protect the confidentiality 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. We will
send you a small gift when we are finished with this interview to thank you for your
participation no matter how many questions you answer.
If you have any questions about this research study or your rights as a study participant,
I can provide you with the names and the numbers of the people you can call. I may also
83

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 C: 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.
[AFTER READING THE FIRST STATEMENT, SAY: Do you strongly disagree,
disagree, neither disagree nor agree, agree, or strongly agree?]
[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 preparing to start a regular exercise program in the next few weeks.
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.
84

7. I have been successful in making changes to eliminate trip and fall hazards in my
home.
8. 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.
9. I have been talking with my family and friends about how I will get around as I get
older.
10. I have made some changes to make sure I can get around as I get older, and I plan to
continue.
11. 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.
12. I am doing something about the things that might limit my ability to get around as I
get older, such as exercising or getting a vision checkup.
13. 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.
14. I have been thinking about whether I will be able to do the things I want to do as I get
older.
15. I know how to get around as I get older and will continue to look for opportunities or
support as I need them.
SECTION D: BEHAVIORS IN THE PAST 2 WEEKS
Now I’d like to ask several questions about things you may have done in the last 2 weeks.
For each activity, please tell me if in the last two weeks:
• You did not think about doing it,
• You thought about doing it,
• You made plans to do it, or
• You did the activity.
[IF RESPONDENT HAS DIFFICULTY REMEMBERING THE RESPONSE
CATEGORIES, SUGGEST THAT THEY WRITE DOWN THE RESPONSES
WITH A NUMBER BY EACH:
1 = YOU DID NOT THINK ABOUT DOING IT
2 = YOU THOUGHT ABOUT DOING IT
3 = YOU MADE PLANS TO DO IT
4 = YOU DID THE ACTIVITY
RESPONDENTS CAN STATE NUMBER RATHER THAN RESPONSE
CATEGORY.]
1. The first activity is, had a physical checkup. In the last 2 weeks, did you not think
about doing it, did you think about doing it, did you make plans to do it, or did you do
it?
85

[ASK FOR EACH OF THE FOLLOWING ACTIVITIES:]
2. [The next activity is…] Had all your medicines reviewed by your health care provider
or pharmacist
3. [The next activity is…] Had a vision checkup
4. [The next activity is…] Participated in an exercise program to increase your physical
strength
5. [The next activity is…] Participated in an exercise program to increase your balance
6. [The next activity is…] Checked your home for tripping hazards
7. [The next activity is…] Made any changes for safety in your home, such as putting
handrails on the stairs, grab bars in your bathroom, a lamp within reach of your bed,
or any other changes for safety
8. [The next activity is…] Took a driving refresher course
9. [The next activity is…] Got your car checked to see how well it fits you
10. [The next activity is…] Gathered information on transportation options other than
driving yourself
SECTION E: DEVELOPING PLAN
[CONTINUE DIRECTLY FROM PAST SECTION. NO INTRODUCTION TO
THIS SECTION.]
[AFTER READING THE FIRST STATEMENT, SAY: Do you strongly disagree,
disagree, neither disagree nor agree, agree, or strongly agree?]
[REPEAT RESPONSE OPTIONS AS NEEDED.]
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.
[IF IN CONTROL GROUP, GO TO SECTION G. IF IN TREATMENT GROUP,
GO TO SECTION F.]
SECTION F: DISSEMINATION AND FEEDBACK ON USE OF MPT
Finally, I would like to ask you some questions about the brochure that was sent to your
home 2 weeks ago. [INSERT DESCRIPTION OF BROCHURE AFTER TOOL IS
FINALIZED.]
[INTERVIEWER INSTRUCTIONS: IN THIS SECTION, DO NOT PROVIDE
86

PROMPTS TO THE RESPONDENT EVEN IF HE/SHE DOES NOT REMEMBER
THE CONTENTS OF THE BROCHURE. DO NOT DESCRIBE THE
CONTENTS OF THE BROCHURE.]
1. Using a scale from 1 to 5, where 1 is not at all likely and 5 is very likely, how likely
are you to download the brochure if it is on the Web or Internet? [RECORD
RESPONSE]
2. How likely are you to use the brochure if it is given to you by your medical provider?
[RESTATE RESPONSE SCALE IF NECESSARY. RECORD RESPONSE.]
3. How likely are you to read the rest of the brochure if you only saw the first page?
[RESTATE RESPONSE SCALE IF NECESSARY. RECORD RESPONSE.]
4. Did you use the chart on page 2 of the brochure, Mobility Plan for Myself, to develop
a mobility plan for yourself? [yes/no]
5. Which parts of the Mobility Plan for Myself on page 2 did you find most helpful?
6. Which parts of the Mobility Plan for Myself on page 2 did you find least helpful?
7. Did you use the chart on page 3 of the brochure, Mobility Plan for Inside My Home,
to develop a plan to reduce the risk of trips and falls in your home? [yes/no]
8. Which parts of the Mobility Plan for Inside My Home on page 3 did you find most
helpful?
9. Which parts of the Mobility Plan for Inside My Home on page 3 did you find least
helpful?
10. Did you use the chart on page 4 of the brochure, Mobility Plan for Outside My Home,
to develop a plan for how you would get around if you could not do what you usually
do? [yes/no]
11. Which parts of the Mobility Plan for Outside My Home on page 4 did you find most
helpful?
12. Which parts of the Mobility Plan for Outside My Home on page 4 did you find least
helpful?
SECTION G: END
Those are all the questions I have for you. Thank you very much for answering our
survey. Goodbye

87

APPENDIX 11:
EVALUATION STUDY – THANK YOU LETTER
FOR MAILING MAGNET AND MPT

88

Evaluation Study – Thank You Letter
For Mailing Magnet and MPT

[On CDC letterhead]
[Date]
[Name]
[Address]
[City, State, Zip]
Dear [Name],
Thank you very much for participating in the Thinking About My Future Study conducted by the
Centers for Disease Control and Prevention (CDC). The purpose of this study is to collect
information about how people who are age 60 or older protect their physical mobility as they age,
including being able to get places they want to go.
In appreciation for the time you spent participating in the study, we are providing you with the
enclosed thank you gift.
Sincerely,

Gwen Bergen, PhD, MPH, MS
Behavioral Scientist, Division of Unintentional Injury Prevention
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention

89

APPENDIX 12:
DETAILED ANALYSIS PLAN FOR PHASE 2

90

Detailed Analysis Plan for Phase 2

Analytic Plan
Hypotheses
There are six hypotheses that will be tested using this survey. They are organized into three parts
as follows:
Stage of Change
1. Was the treatment group in a more advanced stage of change at follow-up as compared
with baseline?
2. Was the treatment group more likely to have an increase in stage of change compared
with the control group?
Behaviors
1. Was the treatment group more likely to have thought about, planned or done one of the
mobility-planning behaviors at follow-up as compared with baseline?
2. Was the treatment group more likely to have an increase post-treatment in thinking about,
planning or doing one of the mobility-planning behaviors compared with the control
group?
Plan
1. Was the treatment group more likely to have a plan for self, a plan for their home, and a
plan for travel at follow-up as compared with baseline?
2. Was the treatment group more likely to have an increase in having the three plans posttreatment compared with the control group?
Creation of Data Variables
Stage of Change
A stage of change will be determined for each of the three dimensions of mobility (individual,
home, community) measured on the questionnaire for both the baseline and follow-up survey.
The latest stage that the respondent strongly agreed or agreed with the appropriate statement will
be selected as the respondent’s stage. Table 1 shows the order of precedence for selecting the
stage along with the question number for the questionnaire item used to measure that stage for
each dimension. It also shows an example of how the stage would be assigned for the individual
stage of change; the same logic would be used for home and community.

91

Table 1. Determining Stage of Change based on Questionnaire*
Dimension of Mobility

Stage

Questions for Measuring
Individual Stage

Questions for
Measuring
Home Stage

Questions for
Measuring
Community Stage

Maintenance

Ex: If response to question 13
= strongly agree or agree then
Individual Stage=Maintenance
(value=5); else…

7

15

Action

If question 12 = strongly agree
or agree then Individual
Stage=Action (value=4);
else…

2

10

Preparation

If question 1 = strongly agree
or agree then Individual
Stage=Preparation (value=3);
else

5

9

Contemplation

If question 14 = strongly agree
or agree then Individual
Stage=Contemplation
(value=2); else

6

3

Pre-contemplation

If question 4 = strongly agree
or agree then Individual
Stage=Pre-contemplation
(value=1)

8

11

*Question numbers referenced in this table pertain to the section of the Baseline and Follow-Up Surveys labeled
TTM Stages of Change

The results of this will be the following six variables:
-

Individual baseline stage of change

- Individual follow-up stage of change

-

Home baseline stage of change

- Home follow-up stage of change

-

Community baseline stage of change

- Community follow-up stage of change

92

Two additional composite variables will be created:
Composite baseline stage of change = Individual baseline stage of change + Home baseline stage
of change + Community baseline stage of change
Composite follow-up stage of change=Individual post-intervention stage of change + Home postintervention stage of change + Community post-intervention stage of change
For each of the three dimensions and the composite, the difference in stages of change from base
line to post-intervention will be calculated:
Individual Stage = Individual follow-up stage of change – Individual baseline stage of change
Home Stage = Home follow-up stage of change-Home baseline stage of change
Community Stage =Community follow-up stage of change-Community baseline stage of change
Composite Stage =Composite follow-up stage of change-Composite baseline stage of change
These four variables (Individual, Home, Community, Composite) will be used for the remaining
analysis.
Behaviors in the Past 2 Weeks. A composite Behavior score will be calculated for each
respondent for each interview (Baseline and Follow-up) based on their responses to the 10 items
indicative of mobility activities they performed in the past 2 weeks. Scores will range from 1040, where lower scores are indicative of a low level of effort to changes and 40 is indicative of a
high level of effort. A Behavior Change score will be calculated by subtracting the Baseline
Behavior score from the Follow-up Behavior score.
Plan Development. Three (Individual, Home, Community) Plan Development scores will be
calculated for each participant for each interview based on their responses to the 3 items in the
section labeled Developing Plan. Scores will range from 1-5, where 1 is indicative of a low level
of plan development and 5 is indicative of a high level of development. Three Change scores
(Individual Plan Change, Home Plan Change, Community Plan Change) will be calculated by
subtracting the respective baseline score from the respective follow-up score.
Analysis
Univariate Analyses
We will begin the analysis process by calculating frequency distributions for each of the
variables in both the Baseline and Follow-Up Interview Guides. Descriptive statistics (means
and standard deviations [SDs] will be obtained for each of the continuous variables. As
appropriate, statistics will be reported separately for each group (MPT vs. Comparison Group) at
each time point (Baseline vs. Follow-Up; see sample table shells, below).

93

Bivariate Analyses
Mean differences between the two respondent groups (MPT and Comparison) on continuous
variables such as age will be explored using a series of t-tests. Differences by respondent group
and interview time will be explored using a series of chi square tests. Group differences in
variables with ordinal scaling (e.g., frequency of driving a car within the last month; level of
agreement on Transtheoretical Model [TTM] Behaviors and Planning items) will be explored
using a series of Mann-Whitney U tests.
Multivariate Analyses
Repeated measures analyses of variance (ANOVAs) will be used to explore whether there are
mean differences in the composite and individual scores for Behaviors, and Plan Development
by Respondent Group (MPT vs. Comparison) and Interview Time (Baseline vs. Follow Up).
A series of logistic regressions will be used to examine whether respondent characteristics such
as gender, race/ethnicity, rural/urban, level of social support, MPT respondent (where relevant)
at Baseline predict the following outcomes:
1. A positive change in the Composite Stage
2. Whether an MPT respondent reports developing a Mobility Plan for self
3. Whether an MPT respondent reports developing a Mobility Plan for Inside My Home
4. Whether an MPT respondent reports developing a Mobility Plan for Outside My Home at
Follow Up.
Potential Statistical Concerns
This study will be sufficiently powered to detect between and within-group differences of the
magnitude expected. Thus, there are no concerns about statistical power.
Many of the planned inferences that result from the statistical analyses described in Part A rely
on distributional assumptions of normality. While these procedures are moderately robust to
departures from normality, some outcomes of interest are ordinal in nature as opposed to
continuous, so we will assess this assumption via probability plots and the Shapiro-Wilk test.
Non-parametric equivalents will be used if these assumptions are grossly violated, such as the
Wilcoxon signed-rank test for within-group comparisons at the two time-points and the KruskalWallis ANOVA for between-group comparison of medians.
Qualitative Analysis
The section of the Follow Up survey labelled Dissemination and Feedback on Use of the MPT
contains several open ended questions (items 5,6,8,9,11 and 12). The responses from these
questions will be grouped and presented by overall themes. These questions will apply to the
MPT group only.

94

Illustrative Table Shells

Table 2. Respondent Characteristics (continuous variables)
Respondent Group
All

Characteristic

Mean
(SD)

MinMax

MPT
Mean
(SD)

MinMax

Comparison
Mean
(SD)

P*

MinMax

Age
Length of time in current
residence
Number of adults age 18+
living in home with
respondent
*Group differences will be assessed either with T-test(s) or Mann-Whitney U test(s).

95

Table 3. Respondent Characteristics (nominal variables)
Respondent Group
All
Characteristic

Number

Percent

MPT
Number

Percent

Comparison
Number

P*

Percent

Gender
Male
Female
Ethnicity: Of Hispanic or
Latino Origin
Yes
No
Race
White
Black or AfricanAmerican
Asian
Native Hawaiian or
Other Pacific Islander
American Indian or
Alaska Native
Education
(highest grade completed)
Less than High School
or GED
High school degree or
GED
Some college
2 year college degree
Bachelor’s degree
Graduate or
professional degree

96

Respondent Group
All
Characteristic

Number

Percent

MPT
Number

Percent

Comparison
Number

P*

Percent

Employment status
Work full time
(> 35 hours/week)
Work part time
(< 35 hours/week)
Retired
Going to school
Keeping house
Other
Urban/Rural
Urban
Rural
Social support**
(assessed by degree of
agreement with the
statement “I can count on
friends and family when I
need to talk”)
Strongly agree
Agree
Neither agree nor
disagree
Disagree
Strongly disagree
*Chi square will be used to explore all associations except for social support.
**Mann-Whitney U test

97

Table 4. Transportation Habits
Respondent Group
All
Item

Number

Percent

MPT
Number

Percent

Comparison
Number

P*

Percent

Drive a car
(frequency in a typical
month)
Every day
More than 1 time per
week
Once per week
2-3 times per month
Once per month
Less than once per
month
Never
Not applicable (do not
have a car to drive)
Use public transportation
(frequency in typical month)
Every day
More than 1 time per
week
Once per week
2-3 times per month
Once per month
Less than once per
month
Never
Not applicable (no
public transportation in
my area)

98

Respondent Group
All
Item

Number

Percent

MPT
Number

Percent

Comparison
Number

P*

Percent

Walk to get to a
destination
(frequency in typical month)
Every day
More than 1 time per
week
Once per week
2-3 times per month
Once per month
Less than once per
month
Never
*Mann-Whitney U tests

99

Table 5. Dissemination and Feedback on Use of Brochure (MPT Group Only)
MPT
Respondents
Item

Number

P*

Percent

Likelihood of
downloading the brochure
from the Web or Internet
1 (Not at all likely)
2
3
4
5 (Very likely)
Likelihood of using the
brochure if given to
respondent by medical
provider
1 (Not at all likely)
2
3
4
5 (Very likely)
Likelihood of reading the
rest of the brochure based
on seeing just the first
page
1 (Not at all likely)
2
3
4
5 (Very likely)
Used Mobility Plan for
Myself to develop a
mobility plan
Yes
No

100

MPT
Respondents
Item

Number

P*

Percent

Used Mobility Plan for
Inside My Home to
develop a mobility plan
Yes
No
Used Mobility Plan for
Outside My Home to
develop a mobility plan
Yes
No
*Mann Whitney U or chi-square tests

101

Table 6. TTM Behaviors, by Time of Interview and Respondent Group
Respondent Group and Time of Interview
Pre-Test
All Respondents
TTM Behaviors

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

I am preparing to start a
regular exercise program
in the next few weeks
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly
disagree
I have started making
changes to my home so
as to protect me from
tripping or falling in my
home as I get older
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree

102

Percent

Respondent Group and Time of Interview
Pre-Test
All Respondents
TTM Behaviors

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

I have been thinking
about my ability to get
around as I get older
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree
I don’t need to do
anything to maintain or
improve my physical
strength or balance as I
get older
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree

103

Percent

Respondent Group and Time of Interview
Pre-Test
All Respondents
TTM Behaviors

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

I am very motivated to
conduct a safety check of
my home to protect me
from trips and falls as I
get older
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree
I really think I should get
started with a plan to
make my home safe from
the risk of tripping and
falls
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree

104

Percent

Respondent Group and Time of Interview
Pre-Test
All Respondents
TTM Behaviors

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

I have been successful in
making changes to
eliminate trip and fall
hazards in my home
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree
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
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree

105

Percent

Respondent Group and Time of Interview
Pre-Test
All Respondents
TTM Behaviors

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

I have been talking with
my family and friends
about how I will get
around as I get older
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree
I have made some
changes to make sure I
can get around as I get
older, and I plan to
continue
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree

106

Percent

Respondent Group and Time of Interview
Pre-Test
All Respondents
TTM Behaviors

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

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
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree
I am doing something
about the things that
might limit my ability to
get around as I get older,
such as exercising or
getting a vision checkup
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree

107

Percent

Respondent Group and Time of Interview
Pre-Test
All Respondents
TTM Behaviors

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

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
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree
I have been thinking
about whether I will be
able to do the things I
want to do as I get older
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree

108

Percent

Respondent Group and Time of Interview
Pre-Test
All Respondents
TTM Behaviors

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

I know how to get around
as I get older and will
continue to look for
opportunities or support
as I need them
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree

109

Percent

Table 7. Stage of Change: Individual
Respondent Group and Time of Interview
Pre-Test
All Respondents
Stage of Change

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

Percent

Pre-contemplation
Contemplation
Preparation
Action
Maintenance

110

Table 8. Stage of Change: Home
Respondent Group and Time of Interview
Pre-Test
All Respondents
Stage of Change

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

Percent

Pre-contemplation
Contemplation
Preparation
Action
Maintenance

111

Table 9. Stage of Change: Community
Respondent Group and Time of Interview
Pre-Test
All Respondents
Stage of Change

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

Percent

Pre-contemplation
Contemplation
Preparation
Action
Maintenance

112

Table 10. Stage of Change: Composite
Respondent Group and Time of Interview
Pre-Test
All Respondents
Stage of Change

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

Percent

Pre-contemplation
Contemplation
Preparation
Action
Maintenance

113

Table 11. Type of Change in Stage of Readiness, By Mobility Dimension and Respondent Group
Respondent Group and Type of Change
All Respondents

Dimension
of Mobility

Positive
change
Number

%

No change
Number

%

MPT
Negative
change
Number

%

Positive
change
Number

%

Comparison

No change
Number

%

Negative
change
Number

%

Positive
change
Number

%

No change
Number

%

Negative
change
Number

%

Individual
Home
Community
Composite

114

Table 12. Behaviors in the Past Two Weeks, by Interview Time and Respondent Group
Pre-Test
All Respondents
Behavior in the Past Two
Weeks

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

Percent

Had a physical check up
Did not think about
doing
Thought about doing
Made plans to do
Did the activity
Had all your medicines
reviewed by your health
care provider or
pharmacist
Did not think about
doing
Thought about doing
Made plans to do
Did the activity
Had a vision check up
Did not think about
doing
Thought about doing
Made plans to do
Did the activity

115

Pre-Test
All Respondents
Behavior in the Past Two
Weeks

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

Percent

Participated in an exercise
program to increase your
physical strength
Did not think about
doing
Thought about doing
Made plans to do
Did the activity
Participated in an exercise
program to increase your
balance
Did not think about
doing
Thought about doing
Made plans to do
Did the activity
Checked your home for
tripping hazards
Did not think about
doing
Thought about doing
Made plans to do
Did the activity

116

Pre-Test
All Respondents
Behavior in the Past Two
Weeks

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

Percent

Made any changes for
safety in your home (e.g.,
putting handrails on the
stairs)
Did not think about
doing
Thought about doing
Made plans to do
Did the activity
Took a driving refresher
course
Did not think about
doing
Thought about doing
Made plans to do
Did the activity
Got your car checked to
see how well it fits you
Did not think about
doing
Thought about doing
Made plans to do
Did the activity

117

Pre-Test
All Respondents
Behavior in the Past Two
Weeks

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

Percent

Gathered information on
transportation options
other than driving
yourself
Did not think about
doing
Thought about doing
Made plans to do
Did the activity

118

Table 13. Plan Development
Respondent Group and Time of Interview
Pre-Test
All Respondents
Planning Behaviors

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

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
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree
I have a plan for how I will
make my home safe so I
can avoid tripping and
falling in my home
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree

119

Percent

Respondent Group and Time of Interview
Pre-Test
All Respondents
Planning Behaviors

Number

Percent

MPT
Number

Percent

Follow-Up
Comparison
Number

Percent

All Respondents
Number

Percent

MPT
Number

Percent

Comparison
Number

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
Disagree or strongly
disagree
Neither agree nor
disagree
Agree or strongly agree

120

Percent

Table 14. Readiness to Change and Composite Scores for Behaviors and Plan Development,
by Interview Time and Respondent Group
Pre-Test
All Respondents
Characteristic

Mean

SD

MPT
Mean

SD

Follow-Up
Comparison
Mean

SD

All Respondents
Mean

SD

MPT
Mean

SD

Comparison
Mean

SD

Behaviors
(composite score)
Plan Development
(composite score)
Individual Plan
Development
Home Plan Development
Community Plan
Development

121

Table 15. Plan Development Change, By Respondent Group
Respondent Group
All
Characteristic

Mean

SD

MPT
Mean

SD

Comparison
Mean

P

SD

Behavior Change
Individual Plan Change
Home Plan Change
Community Plan Change

122

APPENDIX 13:
CITI IRB TRAINING COMPLETION CERTIFICATE

123

COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI PROGRAM)
COURSEWORK REQUIREMENTS REPORT*
* NOTE: Scores on this Requirements Report reflect quiz completions at the time all requirements for the course were met. See list below for details.
See separate Transcript Report for more recent quiz scores, including those on optional (supplemental) course elements.
•  Name:
•  Institution Affiliation:
•  Institution Unit:
•  Phone:

Betsy Payn (ID: 1099614)
Battelle Memorial Institute (ID: 1221)
CPHRE Seattle
206-528-3138

•  Curriculum Group:
Basic/Refresher Course - Human Subjects Research
•  Course Learner Group: Investigators - Data or Specimens Only Research
•  Stage:
Stage 1 - Basic Course
•  Report ID:
•  Completion Date:
•  Expiration Date:
•  Minimum Passing:
•  Reported Score*:

12658596
03/24/2014
03/23/2016
80
97

REQUIRED AND ELECTIVE MODULES ONLY
Belmont Report and CITI Course Introduction
History and Ethics of Human Subjects Research
Basic Institutional Review Board (IRB) Regulations and Review Process
Privacy and Confidentiality - SBE
Records-Based Research
Internet-Based Research - SBE
Research and HIPAA Privacy Protections
Battelle Memorial Institute
Research with Children - SBE

DATE COMPLETED
03/24/14
03/24/14
03/24/14
03/24/14
03/24/14
03/24/14
03/24/14
03/24/14
03/24/14

SCORE
3/3 (100%) 
7/7 (100%) 
5/5 (100%) 
5/5 (100%) 
2/2 (100%) 
4/5 (80%) 
5/5 (100%) 
No Quiz 
4/4 (100%) 

For this Report to be valid, the learner identified above must have had a valid affiliation with the CITI Program subscribing institution
identified above or have been a paid Independent Learner. 
CITI Program
Email: [email protected]
Phone: 305-243-7970
Web: https://www.citiprogram.org

COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI PROGRAM)
COURSEWORK TRANSCRIPT REPORT**
** NOTE: Scores on this Transcript Report reflect the most current quiz completions, including quizzes on optional (supplemental) elements of the
course. See list below for details. See separate Requirements Report for the reported scores at the time all requirements for the course were met. 
•  Name:
•  Institution Affiliation:
•  Institution Unit:
•  Phone:

Betsy Payn (ID: 1099614)
Battelle Memorial Institute (ID: 1221)
CPHRE Seattle
206-528-3138

•  Curriculum Group:
Basic/Refresher Course - Human Subjects Research
•  Course Learner Group: Investigators - Data or Specimens Only Research
•  Stage:
Stage 1 - Basic Course
•  Report ID:
•  Report Date:
•  Current Score**:

12658596
12/18/2014
98

REQUIRED, ELECTIVE, AND SUPPLEMENTAL MODULES 
History and Ethics of Human Subjects Research
Students in Research
Defining Research with Human Subjects - SBE
Belmont Report and CITI Course Introduction
Records-Based Research
Assessing Risk - SBE
Privacy and Confidentiality - SBE
Research with Children - SBE
Internet-Based Research - SBE
Battelle Memorial Institute
Research and HIPAA Privacy Protections
Hot Topics
Conflicts of Interest in Research Involving Human Subjects
Basic Institutional Review Board (IRB) Regulations and Review Process
Stem Cell Research Oversight (Part I)

MOST RECENT
03/24/14 
03/24/14 
01/01/09 
03/24/14 
03/24/14 
01/01/09 
03/24/14 
03/24/14 
03/24/14 
03/24/14 
03/24/14 
03/24/14 
03/24/14 
03/24/14 
03/24/14 

SCORE
7/7 (100%) 
No Quiz 
5/5 (100%) 
3/3 (100%) 
2/2 (100%) 
5/5 (100%) 
5/5 (100%) 
4/4 (100%) 
4/5 (80%) 
No Quiz 
5/5 (100%) 
No Quiz 
No Quiz 
5/5 (100%) 
No Quiz 

For this Report to be valid, the learner identified above must have had a valid affiliation with the CITI Program subscribing institution
identified above or have been a paid Independent Learner. 
CITI Program
Email: [email protected]
Phone: 305-243-7970
Web: https://www.citiprogram.org