Form 0920-17HO Att B-10. Monthly Update Survey 09 26 17

77269501 – Telephone

Form Approved

OMB No: 0920-xxxx

Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-xxxx).

Standard demographic preloads:

Variable Name	Variable Type	Variable Label
AGE	Numeric	Age
GENDER	String	Gender
RACETHNICITY	Numeric	Race/ethnicity
EDUC	Numeric	Education
MARITAL	Numeric	Marital Status
EMPLOY	Numeric	Current employment status
INCOME	Numeric	Household income
STATE	String	State
METRO	Numeric	Metropolitan area flag
INTERNET	Numeric	Household internet access
HOUSING	Numeric	Home ownership
HOME_TYPE	Numeric	Building type of panelist’s residence
PHONE_SERVICE	Numeric	Telephone service for the household
HHSIZE	Numeric	Household size (including children)
HH01	Numeric	Number of HH members age 0-1
HH25	Numeric	Number of HH members age 2-5
HH612	Numeric	Number of HH members age 6-12
HH1317	Numeric	Number of HH members age 13-17
HH18OV	Numeric	Number of HH members age 18+

*These variables are populated as a pre-load when the panelists get sampled into the survey

Standard sample preloads

Variable Name	Variable Type	Variable Label
Username	Numeric	Analogous to Member_PIN
P_Batch	Numeric	Batch Number (if only one assignment, then everyone will be 1)
Dialmode	Numeric	CATI Dialmode (predictive, preview, etc)
P_LCS	Numeric	Life cycle stage, 0=released but not touched
LANG	String	Survey language (EN, ES)
Y_FCELLP	String
S_RES	Numeric
Surveylength	Numeric	Estimated length of survey
SurveyId	Numeric	Survey ID# in A4S
Incentwcomma	String	1,000 or 2,000
P_Hold01	Numeric	Prevents dialing cases without phone numbers

This survey will use the following RND_xx variables:

Note, these are randomized in the script (NOT preloads)

RND_xx	Associated survey Qs
RND_00
RND_01
RND_02
RND_03
RND_04
RND_05
RND_06

PHONE SCRIPTS

[CATI - OUTBOUND]

INTRO

Hello, my name is $I. I'm calling from AmeriSpeak by NORC. May I please speak with [FIRSTNAME]?

[IF RESPONDENT IS AVAILABLE]

Thank you for your continued participation in AmeriSpeak. I am calling to let you know that your next survey is available. The survey takes approximately [SURVEYLENGTH] minutes to complete. If you complete the survey, you will receive [INCENTWCOMMA] AmeriPoints for your time. We will keep all of your answers confidential. Shall we proceed?

Great. As always, for quality assurance purposes, this call may be recorded or monitored.

[CATI-INBOUND]

INTRO

Thank you for calling AmeriSpeak by NORC.  My name is $I.  How are you today?

And are you calling to take your next survey?

I just need to confirm that I'm speaking with [FIRSTNAME] [LASTNAME]. Is that you?

Great. This survey takes approximately [SURVEYLENGTH] minutes to complete over the phone and you will earn [INCENTPOINTS] AmeriPoints for your time.  We will keep all of your answers confidential. 

As always, for quality assurance purposes, this call may be recorded or monitored.

Shall we proceed?

[CATI-CALLBACK]

CBINTRO

Hello, my name is $I. I'm calling from AmeriSpeak by NORC. We previously spoke with [FIRSTNAME] about completing an AmeriSpeak survey. Is [FIRSTNAME] available?

[IF RESPONDENT IS AVAILABLE]

Hello, my name is $I, calling from AmeriSpeak by NORC. We previously spoke with you about completing an AmeriSpeak survey. Are you available now to continue?

As always, for quality assurance purposes, this call may be recorded or monitored.

[DISPLAY THIS AM LANGUAGE IF SurveyAccessEnd-CALLDATE>1 DAY]

[CATI-MISSED OUTBOUND, ANSWERING MACHINE]

AM1

Hello, this message is [FIRSTNAME] [LASTNAME]. I'm calling from AmeriSpeak from NORC to let you know that you have a survey waiting for you. The survey will take approximately [surveylength] minutes and you will receive [INCENTWCOMMA] AmeriPoints for your time. Call us toll-free at 888-326-9424 and enter your PIN number, [MEMBER_PIN], to complete your survey and earn rewards. Thank you.

[DISPLAY THIS AM LANGUAGE IF SurveyAccessEnd-CALLDATE>1 DAY]

[CATI-ANSWERING MACHINE MISSED APPOINTMENT CALLBACK]

AMHARD

Hello, this message is for [FIRSTNAME] and I'm calling from AmeriSpeak from NORC. When we spoke previously, you requested that we call you back <at this time>. I'm sorry that we've missed you. We'll try to contact you again soon but please feel free to return our call any time at 888-326-9424 and enter your PIN number, [MEMBER_PIN], to complete your survey and earn rewards. Thank you.

[DISPLAY THIS AM LANGUAGE IF SurveyAccessEnd-CALLDATE>1 DAY]

[CATI-ANSWERING MACHINE MISSED CALLBACK]

AMSOFT

Hello, this message is for [FIRSTNAME]. I am calling from AmeriSpeak from NORC. We are calling you back to complete your AmeriSpeak survey. Remember, you will earn rewards for completing this survey. I'm sorry that we've missed you. We'll try to contact you again soon but please feel free to return our call any time at 888-326-9424 and enter your PIN number, [MEMBER_PIN], to complete this survey. Thank you.

[DISPLAY THIS AM LANGUAGE IF SurveyAccessEnd-CALLDATE=1 DAY]

[CATI-NEARING END OF FIELD, ANSWERING MACHINE]

AMEND

Hello, this message is for [FIRSTNAME]. I'm calling from AmeriSpeak from NORC to let you know that a survey will be ending tomorrow. We’d love to hear from you so please call us toll-free at 888-326-9424 and enter your PIN number, [MEMBER_PIN], to complete your survey and earn rewards. Thank you.

Please include the following options for all questions:

77 DON’T KNOW

99 REFUSED

Text shown includes programming language, interviewer script and interview instructions.

Text shown in boxes includes researcher notes and should not be included in the programming.

[START OF SURVEY]

CREATE DATA-ONLY VARIABLE: QUAL

1=Qualified Complete

2=Not Qualified

3=In progress

AT START OF SURVEY COMPUTE QUAL=3 “IN PROGRESS”

CDC Falls Tools Monthly Follow-up Survey Draft

Date: 11/02/2016

[DISPLAY – WINTRO_1]

Thank you for agreeing to participate in our AmeriSpeak survey! To thank you for sharing your opinions, we will give you a reward of [INCENTWCOMMA] AmeriPoints after completing the survey. Remember, if you complete all of the Health and Stability Surveys including this survey, each monthly survey, and the final survey you will earn a bonus of [INCENTWCOMMA] AmeriPoints. As always, your answers are confidential.

DISPLAY – FALLS

For purposes of this survey, you will be asked a series of questions about your health with a particular focus on falls.  If you have your Health and Stability Survey calendar and log nearby, it would be helpful to use that to complete the survey, but if it’s not available, please report on what you can remember.

In this survey, a fall is being defined as an event that resulted in a person unintentionally coming to rest on the ground, floor, or other lower level.  Please keep this definition in mind as you complete the survey.

Domain	Instrument/Source	Question as written in instrument
Falls screener – falls history	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Number of falls in the past 12 months? • No falls • 1 fall • 2 falls • 3 or more

[SP]

Q1.

How many falls have you had between [DROPDOWN LIST MONTH] [DROPDOWN LIST DATE] and [DROPDOWN LIST MONTH] [DROPDOWN LIST DATE]?

RESPONSE OPTIONS:

1. No falls

2. One fall

3. Two falls

4. 3 or more falls

IF Q1=1,77,98,99 GO TO QFINAL1.

Domain	Instrument/Source	Question as written in instrument
Falls history	Designed for survey	What is the date of your most recent fall in the past 12 months?

[SHOW IF Q1=2,3,4]

[GRID; SP]

Q1A.

Please tell us the date [INSERT IF Q1=2: of your fall] [INSERT IF Q1=3,4: for each of your falls].

RESPONSE OPTIONS:

1. [SHOW IF Q1=2] First fall [DROPDOWN LIST DATE]

2. [SHOW IF Q1=3] Second fall [DROPDOWN LIST DATE]

3. [SHOW IF Q1=4] Third fall [DROPDOWN LIST DATE]

4. [SHOW IF Q1=4] Fourth fall [DROPDOWN LIST DATE]

5. [SHOW IF Q1=4] Fifth fall [DROPDOWN LIST DATE]

6. [SHOW IF Q1=4] Sixth fall [DROPDOWN LIST DATE]

7. [SHOW IF Q1=4] Seventh fall [DROPDOWN LIST DATE]

8. [SHOW IF Q1=4] Eighth fall [DROPDOWN LIST DATE]

9. [SHOW IF Q1=4] Ninth fall [DROPDOWN LIST DATE]

10. [SHOW IF Q1=4] Tenth fall [DROPDOWN LIST DATE]

EACH ITEM AT Q1A WILL RECEIVE Q2 THROUGH Q7 AND THE DATE ENTERED AT Q1A WILL PIPE INTO THAT QUESTION TEXT.

[SHOW IF Q1=2,3,4]

DISPLAY – FALL2

Now let’s discuss the circumstances of your fall(s).

[SPACE]

[SHOW IF Q1=3,4] I will repeat these questions for each fall you experienced within the time period specified.

[SHOW IF Q1=2,3,4]

LOOP FOR EACH ITEM WITH AN DATE ENTERED AT Q1A

[IF FIRST ADMINISTRATION OF Q2-Q7 FOR Q1A=1] Let’s start with your first fall listed, which occurred on [INSERT DATE RESPONSE FROM Q1A=1].

[IF SECOND OR MORE ADMINISTRATION OF Q2-Q7 FOR Q1A>1] Now, let’s discuss your next fall that occurred on [INSERT DATE RESPONSE FROM ASSOCAITED ITEM AT Q1A>1].

Domain	Instrument/Source	Question as written in instrument
Falls screener – falls history (circumstances)	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Describe the circumstances of the most recent fall in the past 12 months. Time of fall: AM / PM

[SHOW IF Q1=2,3,4]

[SP]

Q4.

What was the time of day of your fall on [DATE HERE]?

RESPONSE OPTIONS:

1. Morning

2. Afternoon

3. Evening

4. Overnight

Domain	Instrument/Source	Question as written in instrument
Falls screener – falls history (circumstances)	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Location of fall: inside home / outside home / community

[SHOW IF Q1=2,3,4]

[SP]

Q5.

What was the location of your fall on [DATE HERE]?

RESPONSE OPTIONS:

1. Inside of home, please specify: [TEXTBOX]

2. Outside of home, please specify: [TEXTBOX]

3. In community, please specify: [TEXTBOX]

Domain	Instrument/Source	Question as written in instrument
Falls screener – falls history (circumstances)	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Cause of fall: trip / slip / loss of balance / knees gave way / fainted / feeling dizzy or giddy / alcohol or meds / fell out of bed / unknown

[SHOW IF Q1=2,3,4]

[MP]

Q7.

What was the cause of your fall on [DATE HERE]?

RESPONSE OPTIONS:

1. Trip

2. Slip

3. Loss of balance

4. Knees gave way

5. Fainted

6. Feeling dizzy

7. Feeling giddy

8. Alcohol

9. Medications

10. Fell out of bed

11. Pets

12. Stairs

13. Other, please specify: [TEXTBOX]

77. Unknown

Domain	Instrument/Source	Question as written in instrument
Falls screener – falls history	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Was an injury sustained in any of the fall/s in the past 12 months? (rate most severe injury due to a fall in the past 12 months) • No • Minor injury, did not require medical attention • Minor injury, did require medical attention • Severe injury (fracture, etc.)

[SHOW IF Q1=2,3,4]

[SP]

Q2.

Were you hurt or injured in the fall you experienced on [DATE HERE]?

RESPONSE OPTIONS:

1. Yes, please describe any injuries resulting from the fall: [TEXTBOX]

2. No

Domain	Instrument/Source	Question as written in instrument
Falls screener – falls history	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Was an injury sustained in any of the fall/s in the past 12 months? (rate most severe injury due to a fall in the past 12 months) • No • Minor injury, did not require medical attention • Minor injury, did require medical attention • Severe injury (fracture, etc.)

[SHOW IF Q1=2,3,4]

[MP]

Q3.

Did you receive medical care as a result of the fall you experienced on [DATE HERE]?

RESPONSE OPTIONS:

1. Yes

2. No

IF Q3 = 1, THEN ASK Q3A, ELSE GO TO QFINAL1

Q3A.

What kind of care did you receive? (Choose all that apply)

1. Doctor’s visit

2. Emergency Room (ER) visit

3. Hospitalization

SCRIPTING NOTES: PUT QFINAL1, QFINAL2, QFINAL3 in the same screen.

[SINGLE CHOICE]

QFINAL1. Thank you for your time today. Please be sure to use your Health and Stability Survey calendar and log to help you keep track of any falls you experience and respond to the next monthly survey.

To help us improve the experience of AmeriSpeak members like yourself, please give us feedback on this survey.

Please rate this survey overall from 1 to 7 where 1 is Poor and 7 is Excellent.

Poor						Excellent
1	2	3	4	5	6	7

[TEXT BOX] [Needs “no” option]

QFINAL3. Do you have any general comments or feedback on this survey you would like to share? If you would like a response from us, please email [email protected] or call (888) 326-9424.

RE-COMPUTE QUAL=1 “COMPLETE”

SET CO_DATE, CO_TIME, CO_TIMER VALUES HERE

DISPLAY - END

Thank you for completing your monthly update survey for ______________.

Those are all the questions we have. You have earned a reward of [INCENTWCOMMA] AmeriPoints for completing the survey. If you have any questions at all for us, you can email us at [email protected] or call us toll-free at 888-326-9424. Let me repeat that again: email us at [email protected] or call us at 888-326-9424. Thank you for participating in our new AmeriSpeak survey! 

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