Att B-10. Monthly Update Survey 09 26 17

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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!