Form 1 Comparison Group Care Recipient Survey

OMB No. 0985-00xx

Exp. Date. xx/xx/xx

Appendix N

Comparison Group Care Recipient Survey:

Survey of the National Family Caregiver Support Program

Comparison Group Care Recipient Survey

Thank you very much for agreeing to participate in this study. The first few questions are about how you feel and how things have been for you.

As I read each statement, please give me the one answer that comes closest to the way you feel.

1. In general, would you say your quality of life is . . . [READ RESPONSE OPTIONS].

Excellent 5

Very Good 4

Good 3

Fair 2

Poor 1

REFUSED -7

DON’T KNOW -8

2. In general how would you rate your mental health, including your mood and your ability to think?

[READ RESPONSE OPTIONS]

Excellent 5

Very Good 4

Good 3

Fair 2

Poor 1

REFUSED -7

DON’T KNOW -8

3. In general, how would you rate your satisfaction with your social activities and relationships?

[READ RESPONSE OPTIONS]

Excellent 5

Very Good 4

Good 3

Fair 2

Poor 1

REFUSED -7

DON’T KNOW -8

4. In the past 7 days, how often have you been bothered by emotional problems such as feeling anxious,

depressed, or irritable ? [READ RESPONSE ALOUD]

Always 5

Often 4

Sometimes 3

Rarely 2

Never 1

REFUSED -7

DON’T KNOW -8

The last question is about your caregiver.

5. To what extent does having a caregiver help you to remain at home? [READ RESPONSE OPTIONS]

Not at all helpful 1

A little helpful 2

Somewhat helpful 3

Mostly helpful 4

Very helpful 5

REFUSED -7

DON’T KNOW -8

Comparison Group Caregiver Identification

This module asks OAA services recipients, who have stated they have a family caregiver, if we can have permission to contact and interview these caregivers. These caregivers will constitute the NFCSP evaluation’s comparison group.

PF16a. You have said that {you need /NAME OF PARTICIPANT needs} the help of another person with [READ LIST OF ACTIVITIES]. We would like to know if family or friends provide help with these activities. If so, which family member or friend helps {you/him/her} the most with [READ LIST OF ACTIVITIES]?

(WHOHELPS)

(INTERVIEWER NOTE: MARK ONLY ONE. )

SON .............................................................................................. 1

DAUGHTER .................................................................................. 2

HUSBAND ..................................................................................... 3

WIFE.............................................................................................. 4

PARENT ........................................................................................ 5

OTHER RELATIVE ....................................................................... 6

FRIEND/NEIGHBOR...................................................................... 7

OTHER NONRELATIVE (NOT PAID STAFF)............................... 8

DID NOT RECEIVE HELP FROM FAMILY/FRIEND..................... 9 (GO TO MODULE 2)

REFUSED...................................................................................... -7 (GO TO MODULE 2)

DON’T KNOW................................................................................ -8 (GO TO MODULE 2)

PROGRAMMER NOTE:

If PF16a = 1 through 8 (a relationship), create a caregiver interview and then go to question PF16b.

Else, if PF16a = 9 (no help), DO NOT create a caregiver interview. Go to Module 2.

Else, if PF16a = -7 or -8, create a caregiver interview, assign a result code of RC to the cg interview and go to Module 2.

At PF16b (is cg 18+),

If PF16b = yes, go to PF16c.

Else, if PF16b = 2, -7, or -8, assign a result code of IC to the cg interview and go to Module 2.

At PF17 (collect name and phone for cg),

If first and last name are both = -7 or -8, assign a result code of RC to the cg interview and go to Module 2.

Else, if first or last name is not missing, collect phone number.

If phone number is -7 or -8, assign a result code of RC to the cg interview and go to Module 2.

Else, go to Module 2.

The caregiver's name can be entered as a descriptor (female/54, son/43, etc.) and this will NOT finalize the cg interview. Interviewers will be trained to try to collect a descriptor rather than entering -7 or -8.

The participant's name will be used as the care recipient's name in the cg interview.

16b. Is this person at least 18 years old?

(HELPADLT)

YES............................................ 1 (GO TO 16C)

NO.............................................. 2 GO TO MODULE 2)

REFUSED..................................-7 (GO TO MODULE 2)

DON’T KNOW............................-8 (GO TO MODULE 2)

92

16c. Can I reach that person at this telephone number?

(SAMEPHON)

YES............................................ 1 (GO TO Q17INTROA)

NO.............................................. 2 (GO TO Q17INTROB)

REFUSED..................................-7 (GO TO Q17INTROB)

DON’T KNOW............................-8 (GO TO Q17INTROB)

Q17 INTROA. We are also interested in speaking with the person who helps {you/NAME OF PARTICIPANT}. We are trying to find out what services they may need. Can I have the name of the person who helps {you/NAME OF PARTICIPANT}?

(ADCGSMPH)

_________________ ____________________

FIRST NAME LAST NAME

REFUSED..................................-7 GO TO MODULE 2.

DON’T KNOW............................-8 GO TO MODULE 2.

Q17 INTROB. We are also interested in speaking with the person who helps {you/NAME OF PARTICIPANT}. We are trying to find out what services they may need. Can I have the name, address, and telephone number of the person who helps {you/NAME OF PARTICIPANT}?

(ADCGDFPH)

[VERIFY SPELLING]

FIRST NAME: ____________________ LAST NAME: ________________________________

[DO NOT ENTER P.O. BOX]

# & STREET:_________________________________________________________________

APT. # _______________________

CITY:______________________________STATE:______ ZIP CODE: ___________________

What is [FIRST NAME/LASTNAME]’s home telephone number?

HOME TELEPHONE NUMBER: (XXX) XXX-XXXX (GO TO MODULE 2)

REFUSED..................................-7 GO TO MODULE 2.

DON’T KNOW............................-8 GO TO MODULE 2. PROGRAMMER NOTE: ADD NEW CAREGIVER INTERVIEW FOR NAMES IN Q17INTROA AND Q17INTROB. PHONE NUMBER FOR NAMES IN Q17INTROA IS THE SAME AS PHONE NUMBER WE REACHED THIS RESPONDENT ON. THIS CAREGIVER INTERVIEW SHOULD BE AVAILABLE AS SOON AS THIS INFO IS ENTERED, SO INTERVIEWER CAN ASK FOR A CAREGIVER AT THE SAME PHONE NUMBER AS SOON AS THIS INTERVIEW ENDS (AFTER MODULE 4). THERE IS A DIFFERENT TELEPHONE NUMBER FOR CAREGIVER IN Q17INTROB. A CAREGIVER INTERVIEW WITH A CAREGIVER AT A DIFFERENT PHONE NUMBER SHOULD BE AVAILABLE IN THE CATI QUEUE AS SOON AS IT IS ENTERED HERE.

CLOSE1. Those are all the questions I have for you today. We may want to call you back in the future to ask if there are any changes in your answers to these questions at that time. Thank you very much for your help with this important national survey. We appreciate your time.