0920-1208 Home Health Visit Data Collection Forms

Attachment 1i

National Health Interview Survey (NHIS) Follow-up Health Study

Home Health Visit Data Collection Forms

Form Approved

OMB No. 0920-1208

Notice – CDC estimates the average public reporting burden for this collection of information as 60 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0950).

Assurance of Confidentiality – We take your privacy very seriously.  All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes.  NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m) and the Confidential Information Protection and Statistical Efficiency Act (Title III of the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L. No. 115-435, 132 Stat. 5529 § 302)).  In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

Expires: 8/31/2023

National Health Interview Survey (NHIS) Follow-up Health Study

Home Health Visit Data Collection Forms

• Urine collection*

• Anthropometry - Body Measures

• Blood Pressure Measurement

• Venipuncture

• Experience Assessment Interview

*No data collection form for urine collection

Home Health Visit Data Collection Forms

ANTHROPOMETRY - Body Measures

Exclusion Criteria:

• Pregnant participants, identified via the question below, will be excluded from weight and waist measurement, because BMI and BMI/waist circumference statements are not accurate for pregnant women. If a pregnant participant requests to have her weight or waist measured, it will be measured but not stored.

• Participants in wheelchair or unable to stand unassisted will be excluded from height, weight, and waist measurement

• Participants whose weight exceeds the capacity of the scale will be excluded from the weight measurement

• Participants whose waist circumference exceeds the length of the tape measure will be excluded from the weight measurement

• Participants with both arms amputated or the presence of one of the following on each arm will be excluded from the mid-upper arm circumference measure: rashes, gauze dressings, casts, edema (swelling), paralysis, tubes, open sores or wounds, withered arms, arteriovenous shunts (a plastic tube inserted in an artery or vein), or fistula.

Anthropometry Measurements/Questions Units and Answer Options

Are you currently pregnant? Yes/No/Don’t know/Refused

Height Feet and Inches

Shoes worn during height measurement Yes/No

Weight Pounds

Shoes worn during weight measurement Yes/No

Heavy outer clothes worn during weight measurement Yes/No

Heavy items in pockets during weight measurement Yes/No

Any visible amputations Yes/No

Waist Circumference Inches

Heavy outer clothes worn during weight measurement Yes/No

Home Health Visit Data Collection Forms

Blood pressure measurement

Exclusion Criteria:

• Participants with both arms amputated or the presence of one of the following on each arm will be excluded from blood pressure measurement: rashes, gauze dressings, casts, edema (swelling), paralysis, tubes, open sores or wounds, withered arms, arteriovenous shunts (a plastic tube inserted in an artery or vein), or fistula.

• Participants around whose arm the largest cuff size does not fit will be excluded from blood pressure measurement

Blood Pressure Measurements/Questions Units and Answer Options

Arm selected Right/left/Could not obtain

Cuff size selected Child/Adult/Large Arm/Thigh

Heart Rate/Pulse Beats per minute

Maximum Inflation Level mm Hg

Systolic Blood Pressure (Readings 1,2,3) mm Hg

Diastolic Blood Pressure (Readings 1,2,3) mm Hg

Average Blood Pressure mm Hg

Home Health Visit Data Collection Forms

venipuncture

Exclusion Criteria

• Participants with hemophilia or who are receiving cancer chemotherapy, as identified by the questions below, will be excluded from venipuncture

• Participants whose antecubital areas on both arms are callused or have open sore, wound, gauze dressing, rash, or burn scars will be excluded from venipuncture

• Participants wearing casts, shunts (a semi-permanent draining tube), or splints on both arms will be excluded from venipuncture

• Participants with both arms swollen, withered, or paralyzed will be excluded from venipuncture

• Participants who have intravenous catheters (IV) or other medical devices attached to both arms or both hands will be excluded from venipuncture

Pre venipuncture questions

Q1. Do you have hemophilia? SEQ010 (yes, no, refused, don’t know)

Yes (Venipuncture will not be conducted)

No

Refused (Venipuncture will not be conducted)

Don’t know (Venipuncture will not be conducted)

Q2. Have you received cancer chemotherapy in the past four weeks? SEQ020 (yes, no, refused, don’t know)

Yes(Venipuncture will not be conducted)

No

Refused (Venipuncture will not be conducted)

Don’t know (Venipuncture will not be conducted)

Q3. When was the last time you ate or drank anything other than plain water? This includes gum, breath mints, vitamins and non-prescription medicine, but not diet soda or black coffee with artificial sweetener like Sweet’N Low, Nutrasweet, Equal, or Splenda

HH:MM (AM PM ) MMDDYY

Venipuncture Measurements/Questions Units and Answer Options

Venipuncture status Complete\Partially complete\Not done

If venipuncture incomplete or not done, reason (Check all that apply)

Safety exclusion

Participant refusal

No time

Physical limitation

Participant ill/emergency

Equipment failure

Communication problem

Interrupted

Error (technician, software, supply)

No suitable vein

Vein collapsed

Participant not feeling well

Fainting episode

No tubes drawn

Other, specify

Home Health Visit Data Collection Forms

experience assessment interview

We would like to ask you a few questions about your study experience. Your feedback will help us improve studies like this in the future. Please answer honestly. There are no right or wrong answers.

1. How easy or difficult was scheduling your appointment? Very easy, easy, difficult, or very difficult?(Don’t read: Don’t know, refused)

2. (Ask if response to Q1 is easy, difficult, or very difficult): In what ways could the appointment scheduling be improved?

3. How easy or difficult was it to get your questions answered? Very easy, easy, difficult, or very difficult? I didn’t have any questions (Not read to respondent, code only if volunteered). (Don’t read: Don’t know, refused)

4. (Ask if response to Q3 is easy, difficult, or very difficult): In what ways could we better answer your questions?

5. How easy or difficult was it for you to take part in this home visit? Very easy, easy, difficult, or very difficult? (Don’t read: Don’t know, refused)

6. (Ask if response to Q5 is easy, difficult, or very difficult): In what ways could the home visit be made easier and more convenient?

7. How likely or unlikely are you to participate in a study like this in the future? Very likely, likely, unlikely, or very unlikely? (Don’t read: Don’t know, refused)

8. What were your concerns, if any, about participating?

9. Please tell me yes or no, whether you took part in this study for any of the following reasons:

(Read a through f)(Answer options on the screen: Yes, No Don’t read: Don’t know, refused)

1. Free COVID-19 antibody test results

2. Free test results of any other kind

3. The $75 prepaid card

4. Help with COVID-19 and other health efforts in the United States

5. Improve information used by policymakers

6. Some other reason______________________________________________

10. (Ask if response to 9f was yes) What was that reason?

11. (Ask if more than 1 response selected in Q9 a-f) What was your main reason for taking part in this follow-up study? Pick one or specify

1. Free COVID-19 antibody test results

2. Free test results of any other kind

3. The $75 prepaid card

4. Help with COVID-19 and other health efforts in the United States

5. Improve information used by policymakers

6. Other___________________________________________________________