Proxy Survey (Phone Mode)

77893701 – Telephone

Client	CDC
Project Name	CDC Falls Tools Proxy Survey
Project Number	7984
Survey length (median)	5 minute survey
Population	Adults age 65+
Pretest	N/A
Main	N/A
MODE	Phone and Web
Language	English-only
Incentive	$2
PIMS description	Health and Stability Survey
Eligibility Rate	100%

xxxx

Form Approved

OMB No: 0920-xxxx

Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 5 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).

PHONE SCRIPTS

[CATI - OUTBOUND]

INTRO

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

[IF PROXY RESPONDENT IS AVAILABLE]

[FIRSTNAME] [LASTNAME] gave your contact information so that you could provide some information on how they are doing. They are part of a national survey to understand fall risk for older adults. Be assured 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.

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.

[SP]

Q1.

When was your last contact with [FIRSTNAME] [LASTNAME]?

RESPONSE OPTIONS:

1. Today

2. Yesterday

3. Other, please specify: [TEXTBOX]

[SP]

Q1.

We have been unable to reach [FIRSTNAME] [LASTNAME] for our monthly follow-up interview. It is possible he or she may have decided not to participate, but it is also possible he or she is unable to participate at this time. Do you know why [FIRSTNAME] [LASTNAME] is unable to participate in the Health and Stability Survey at this time?

RESPONSE OPTIONS:

1. Moved

2. Illness

3. Hospitalized for a fall

4. Hospitalized for other reason

5. Died

6. Busy/unavailable

7. Other, please specify: [TEXTBOX]

8. Don’t know

DISPLAY – FALLS

For purposes of this survey, you will be asked a series of questions about [FIRSTNAME] [LASTNAME]’s health with a particular focus on falls. 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 has [FIRSTNAME] [LASTNAME] had between [DROPDOWN LIST MONTH] [DROPDOWN LIST DATE] and [DROPDOWN LIST MONTH] [DROPDOWN LIST DATE]?

RESPONSE OPTIONS:

1. No falls

2. One fall, please specify date if known: [DROPDOWN LIST DATE]

3. Two falls, please specify date for each if known: [DROPDOWN LIST DATE]; [DROPDOWN LIST DATE]

4. 3 or more falls, please specify date for each if known: [DROPDOWN LIST DATE]; [DROPDOWN LIST DATE]; [DROPDOWN LIST DATE]; [DROPDOWN LIST DATE]

77. Don’t know

IF Q1=1,2,77,98,99 GO TO END.

[SHOW IF Q1=2,3,4]

DISPLAY – FALL2

Let’s discuss the circumstances of [FIRSTNAME] [LASTNAME]’s fall(s). [RED TEXT IF MORE THAN ONE FALL ONLY] I will repeat these questions for each fall [FIRSTNAME] [LASTNAME] experienced within the time period specified.

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 their fall on [DATE HERE]?

RESPONSE OPTIONS:

1. Morning

2. Afternoon

3. Evening

4. Overnight

77. Don’t know

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 their 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]

77. Don’t know

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 their 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.

Was [FIRSTNAME] [LASTNAME] hurt or injured in the fall he/she experienced on [DATE HERE]?

RESPONSE OPTIONS:

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

2. No

77. Don’t know

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.

Was [FIRSTNAME] [LASTNAME] in need of medical care as a result of his/her fall on [DATE HERE]?

RESPONSE OPTIONS:

1. No

2. Yes, please chose all that apply:

   1. Doctor’s visit

   2. Emergency Room (ER) visit

   3. Hospitalization

77. Don’t know

Proxy address confirmation

RESADDRESS.

Thank you for answering our questions. Before we complete the interview, we will need to confirm your mailing address.

In order to send you your $2 incentive for completing this survey we will need to confirm your mailing address. Is this the address where you would like to receive your reward?

[PULL DATA FROM THE SAMPLE FILE].

Street Address 1

Street Address 2

City State Zip Code

RESPONSE OPTIONS:

1)    YES

2)    NO

[List address collected from baseline survey with original respondent.]

[SHOW IF RESADDRESS=2,77,98,99]

RESADDRESS2.

Please review the mailing address below and correct it if necessary.

Street Address 1 [TEXTBOX]

Street Address 2 [TEXTBOX]

City [TEXTBOX] State [DROPDOWN WITH 50 STATES LISTED] Zip Code [NUMBOX ACCEPT 5 DIGITS]

[DISPLAY]

END.

Thank you for taking the time to answer these questions today on behalf of [FIRSTNAME] [LASTNAME]. 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 AmeriSpeak survey! 

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