Follow up survey

STEADI Follow-Up Survey for CATI

Form Approved

OMB No: 0920-1281

Exp. Date: 01/31/2023

Public Reporting burden of this collection of information is estimated at 15 minutes, 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 (0920-1281).

INTRO_1. Hello, my name is [NAME] and I’m calling from NORC at the University of Chicago. I’m calling on behalf of the Patient Falls Survey. For quality assurance, this call may be recorded or monitored. Is that acceptable to you?

00 Continue without recording

01 Continue with recording

…other standard outcomes

NAME_CHK This survey is for [FILL NAME]. Am I speaking to [him/her]?.

01 YES [continue to intro_2]

02 NO [continue to SCREEN_EXIT]

AVAIL Is [she/he] available?

01 YES, comes to the phone [continue to intro_2]

02 NO [continue to SCREEN_EXIT]

SCREEN_EXIT

This survey can only be completed by [FILL NAME]. We will try back another time. Thank you. [EXIT SURVEY]

INTRO_2. Welcome to the Patient Falls Survey. We appreciate your continued help with this important study. Your participation is voluntary. You can refuse to answer a question or stop the interview at any time, and all information you provide is confidential, and will only be used for the purposes of this study.

01 Continue

02 Set callback

99 Refused to participate

Q1. In general, would you say that your health is excellent, very good, good, fair, or poor?

1 Excellent	2 Very Good	3 Good	4 Fair	5 Poor	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q2_INTRO. For purposes of this survey, you will be asked a series of questions about your 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.

If you have your falls tracking log available, please use it to help you answer the remaining questions.

Q2. Since the last time you took this survey, have you fallen?

1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
□	□	□	□

If yes go to Q3. If No, DK, REF, go to Q10.

Q3. How many times did you fall since the last time you took this survey?

_______ Number of falls

If 0 go to Q10. Else go to Q4.

Thinking of the most recent fall:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q4. Did the fall cause an injury? By injury, we mean the fall caused you to limit your regular activities for at least a day or go seek a health care professional.	□	□	□	□
Q5. Did you get medical attention?	□ go to Q5a	□ If Q3=1, go to Q10. Else go to Q6.	□ If Q3=1, go to Q10. Else go to Q6.	□ If Q3=1, go to Q10. Else go to Q6.
Q5a. Was the medical attention you received provided by an Emory provider?	□	□	□	□

Q5b. What kind of medical attention did you receive? [multiple selection]

1 Emergency Medical Services (EMT, Ambulance)	2 Emergency Room Visit	3 Urgent Care Visit	4 Doctor’s Office Visit In-person	5 Doctor’s Visit over Telemedicine	6 Admitted to Hospital	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□	□

If Q3=1, go to Q10_INTRO. Else go to Q6.

Thinking of the second most recent fall:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q6. Did the fall cause an injury? By injury, we mean the fall caused you to limit your regular activities for at least a day or go seek a health care professional.	□	□	□	□
Q7. Did you get medical attention?	□ go to Q7a	□ If Q3=2, go to Q10. Else go to Q8.	□ If Q3=2, go to Q10. Else go to Q8.
Q7a. Was the medical attention you received provided by an Emory provider?	□	□	□	□

Q7b. What kind of medical attention did you receive? [multiple selection]

1 Emergency Medical Services (EMT, Ambulance)	2 Emergency Room Visit	3 Urgent Care Visit	4 Doctor’s Office Visit In-person	5 Doctor’s Visit over Telemedicine	6 Admitted to Hospital	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□	□

If Q3=2, go to Q10_INTRO. Else go to Q8.

Thinking of the third most recent fall:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q8. Did the fall cause an injury? By injury, we mean the fall caused you to limit your regular activities for at least a day or go seek a health care professional.	□	□	□	□
Q9. Did you get medical attention?	□ go to Q9a	□ go to Q10	□ go to Q10	□ go to Q10
Q9a. Was the medical attention you received provided by an Emory provider?	□	□	□	□

Q9b. What kind of medical attention did you receive? [multiple selection]

1 Emergency Medical Services (EMT, Ambulance)	2 Emergency Room Visit	3 Urgent Care Visit	4 Doctor’s Office Visit In-person	5 Doctor’s Visit over Telemedicine	6 Admitted to Hospital	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□	□

Q10_INTRO. IF SURV_NUM=1 DISPLAY: Recently you visited your Emory provider and participated in a falls risk screening. Our records indicate that visit took place on XX/XX/XXXX [FILL FROM SAMPLE FILE=VISIT_DATE]. Since that visit, has a health care professional done any of the following: ELSE DISPLAY: Since the last time you took this survey, has a health care professional done any of the following:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q10. Referred you to physical therapy?	□	□	□	□
Q11. Since that visit has a health care professional referred you to occupational therapy?	□	□	□	□
Q12. Since that visit has a health care professional referred you to an exercise program (such as Tai Chi or yoga)?	□	□	□	□
Q13. Since that visit has a health care professional referred you to an eye doctor?	□	□	□	□
Q14. Since that visit have they referred you to a foot doctor?	□	□	□	□
Q15. Since that visit have they recommended a change to one or more of your medications?	□	□	□	□
Q16. Since that visit have they recommended you use a cane or walker?	□	□	□	□
Q17_INTRO. IF SURV_NUM=1 DISPLAY: Thinking about the time since that Emory visit, ELSE DISPLAY: Since the last time you took this survey,	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q17. Have you gone to physical therapy?	□ ask Q17a	□ go to Q18	□ go to Q18	□ go to Q18

Q17a. Did you receive physical therapy:

□ Over telemedicine

□ In-person

□ Both in person and telemedicine

Q18. Have you gone to occupational therapy?

□ ask Q18a

□ go to Q19

□ go to Q19

□ go to Q19

Q18a. Did you receive occupational therapy:

□ Over telemedicine

□ In-person

□ Both in person and telemedicine

Q19. Have you visited an eye doctor?

□ ask Q19a

□ go to Q20

□ go to Q20

□ go to Q20

Q19a. Did you visit an eye doctor:

□ Over telemedicine

□ In-person

□ Both in person and telemedicine

Q20. Have you visited a foot doctor?

□ ask Q20a

□ go to Q21

□ go to Q21

□ go to Q21

Q20a. Did you visit a foot doctor:

□ Over telemedicine

□ In-person

□ Both in person and telemedicine

Q21. Have you stopped, switched, or reduced one or more of your medications?	□	□	□	□
Q22. Have you used a cane or walker?	□	□	□	□
Q23. Have you reviewed brochures or other materials on how to prevent falls?	□	□	□	□

	1 Tai Chi	2 Matter of Balance	3 Other Exercise	77 Don’t know	99 Prefer not to Answer
Q24. [multiple selection] IF SURV_NUM=1 DISPLAY: Since the Emory visit, have you participated in Tai Chi, Matter of Balance, or some other exercise either in person or online? ELSE DISPLAY: Since the last time you took this survey, have you participated in Tai Chi, Matter of Balance, or some other exercise?	□ ask Q24a	□ ask Q24b	□ go to Q25	□ go to Q25	□ go to Q25

Q24a Did participate in Tai Chi:

□ Online

□ In-person

□ Both in person and online

Q24b Did you participate in Matter of Balance:

□ Online

□ In-person

□ Both in person and online

Q25_INTRO. IF SURV_NUM=1 DISPLAY: Since the Emory visit, have you made any of the following changes to your home to prevent falls? ELSE DISPLAY: Since the last time you took this survey, have you made any of the following changes to your home to prevent falls?	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q25. Installed handrails?	□	□	□	□
Q26. Have you replaced stairs with ramps?	□	□	□	□
Q27. Have you removed clutter?	□	□	□	□
Q28. Have you removed mats or rugs	□	□	□	□
Q29. Have you removed loose cords?	□	□	□	□
Q30. Have you improved lighting?	□	□	□	□
Q31. Have you repaired unsafe or unsteady furniture?	□	□	□	□
Q32. Have you moved furniture?	□	□	□	□
Q33. Have you moved to a safer home?	□	□	□	□

	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q34. Do you take medicine prescribed for you to help you sleep such as zolpidem (Ambien), zaleplon (Sonata), or eszopiclone (Lunesta)?	□	□	□	□
Q35. Do you take over-the-counter medicine to help you sleep such as diphenhydramine (Benedryl, ZZZQuil, Tylenol PM) or doxylamine (Unisom)?	□	□	□	□
Q36a. Do you take opioid medicine prescribed for you to help with pain? These might include tramadol (Ultram), oxycodone (Roxicodone, Percocet, Oxycontin), hydrocodone (Lortab, Vicodin), morphine (MsContin), hydromorphone (Dilaudid), or fentanyl (Duragesic).	□	□	□	□
Q36b. Do you take non-opioid medicine prescribed for you to help with pain, such as ibuprofen (Motrin), naproxen (Naprosyn), or diclofenac (Voltaren)?	□	□	□	□
Q37 Do you take over the counter medicine to help with pain such as ibuprofen (Motrin, Advil), acetaminophen (Tylenol) or naproxen (Aleve)?	□	□	□	□
Q38. Do you take medicine prescribed for you to help your mood or for sadness, such as sertraline (Zoloft), citalopram (Celexa), or duloxetine (Cymbalta)?	□	□	□	□
Q39. Do you take medicine prescribed for you to help with anxiety or nervousness, such as alprazolam (Xanax), lorazepam (Ativan), or diazepam (Valium)?	□	□	□	□
Q40. Do you take medicine prescribed for you to help with mood stability, such as risperidone (Risperdal), aripiprazole (Abilify), or quetiapine (Seroquel)?	□	□	□	□
Q41. Do you take Vitamin D or a multivitamin?	□	□	□	□

Q42. How many prescription medications do you take regularly?

______ number of medications

Q43. In the last three months, on average, how many days per week did you have any alcohol to drink?

0 Zero or Less than One Day per Week	1 Day per Week	2 Days per Week	3 or More Days per Week	77 Don’t know	99 Prefer not to Answer
□	□	□	□	□	□

Q44. Did you use marijuana in the last 30 days?

1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
□	□	□	□

If SURV_NUM=3 THEN GO TO Q45. ELSE GO TO TOKEN. DEFINE SURV_NUM AS 1,2,3, WILL BE IN THE SAMPLE FILE TO DISTINGUISH BETWEEN ROUNDS OF THE QUARTERLY SURVEY

[asked only in the last quarterly survey]

On a scale of 1 to 5, where 1 means “Strongly Disagree” and 5 means “Strongly Agree,” please indicate your agreement with the following statements:	1 Strongly Disagree	2 Disagree	3 Neither Agree nor Disagree	4 Agree	5 Strongly Agree	77 Don’t Know	99 Prefer not to Answer
Q45. Older people fall and there is nothing that can be done about it.	□	□	□	□	□	□	□
Q46. There are things I can do to reduce my risk of falling.	□	□	□	□	□	□	□

TOKEN. Those are all the questions I have. Thank you for taking the time to participate today.

[IF SURV_NUM<3 DISPLAY: You will be contacted again in approximately three months to answer follow-up questions about your experience with falls. Please remember to track your survey participation and falls in your falls tracking log, which was provided in your survey invitation. If you don’t have the falls tracking log, you can use any calendar. Tracking this information will make it easier to answer the questions in the follow-up survey.]

As a token of our appreciation, we will send you postage stamps valued at $3. Please confirm that your mailing address is:

[FILL NAME AND MAILING ADDRESS FROM SAMPLE FILE]

01 My address is correct. Go to thank you screen]

02 My address is NOT correct. [go to Q34ADD]

03 Please do NOT send stamps. [Go to thank you screen]

Q34ADD

Please enter your mailing address.

FIRST AND LAST NAME _____________

STREET ADDRESS __________________________

CITY ____________________

STATE ________________________

ZIP CODE _________________________

[thank you screen]

Thank you for participating! If you have any questions, you can contact the study team at 1-877-898-5903.