15th NSOAAP Survey

Appendix J

15th ACL/AoA National Survey of
Older Americans Act Participants
3/17/2021

CONTENTS

Section Name

PROGRAMMING CONVENTIONS

Page

i

INTRODUCTION AND PARTICIPANT VERIFICATION

iii

INDIVIDUAL SERVICE MODULES:
CASE MANAGEMENT
CONGREGATE MEALS
HOME-DELIVERED MEALS
HOMEMAKER
TRANSPORTATION
FAMILY CAREGIVER

1
6
12
21
26
34

ADDITIONAL SERVICE LIST MODULE

69

USDA MODULE

75

FALLS MODULE

76

LIFE CHANGES MODULE

78

SOCIAL INTEGRATION MODULE

79

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE

80

DEMOGRAPHIC INTAKE MODULE

97

CLOSING

105

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. The OMB control number for this
information collection is 0985-0023. Public reporting burden for this information collection is estimated to
average 30 minutes per response; response times may range from 25 minutes to 45 minutes. Send
comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to the Administration for Community Living, Washington, DC 20201
Attn: Dr. Susan Jenkins, (888) 204-0271.

PROGRAMMING CONVENTIONS

The SAMP segment will contain a variable, TALKWHO, which will indicate which type of interview is being
administered as well as the current respondent for that interview. The interview type will never change,
but the type of respondent can change.
The values for SAMP.TALKWHO are as follows:
CG1 - Caregiver answering themselves
CG2 - Proxy answering for caregiver
CG3 - Translator/interpreter answering for caregiver
PG1 - Case Management being answered by participant
PG2 - Proxy answering for participant
PG3 - Translator/interpreter answering for participant
PC1 - Congregate Meals being answered by participant
PC2 - Proxy answering for participant
PC3 - Translator/interpreter answering for participant
PM1 – Home-Delivered Meals being answered by participant
PM2 - Proxy answering for participant
PM3 - Translator/interpreter answering for participant
PH1 - Homemaker being answered by participant
PH2 - Proxy answering for participant
PH3 - Translator/interpreter answering for participant
PT1 - Transportation being answered by participant
PT2 - Proxy answering for participant
PT3 - Translator/interpreter answering for participant

FENCEPOST: If interview was not completed in the first call, FENCEPOST designates where the
interview can resume during subsequent calls.

Page i

GLOBAL DISPLAY IN THE FOOTER OF EACH SCREEN IN CONTACTS AND INTERVIEW:
“{DISPLAY D1} {DISPLAY D2} {DISPLAY D3}”
Display #
D1

D2

D3

Criteria
IF THIS IS A PROXY INTERVIEW
(SAMP.TALKWHO = CG2, PM2, PH2, PC2, PG2,
PT2)
ELSE IF THIS IS AN INTERPRETER INTERVIEW
(SAMP.TALKWHO = CG3, PM3, PH3, PC3, PG3,
PT3)
ELSE IF THIS IS A SUBJECT INTERVIEW
(SAMP.TALKWHO = CG1, PM1, PH1, PC1, PG1,
PT1)
IF THIS IS A CAREGIVER INTERVIEW
(SAMP.TALKWHO = CG1, CG2, OR CG3)
ELSE IF THIS IS A PARTICIPANT INTERVIEW
(SAMP.TALKWHO = PM1, PM2, PM3, PT1, PT2,
PT3, PH1, PH2, PH3, PC1, PC2, PC3, PG1, PG2,
PG3)
ALL

Display Text
“PROXY FOR”

“INTERPRETER FOR”

BLANK

“CAREGIVER:”
“PARTICIPANT:”

“{BASM.BASMFNAM BASMLNAM}”

PROGRAMMER NOTE: THERE ARE SEVERAL VARIABLES REFERENCED THROUGHOUT THESE
SPECIFICATIONS THAT NEED TO BE PRE-LOADED FROM THE SAMPLE FILE. THESE INCLUDE:

NAME OF INTERVIEWEE –– one of 4 types of persons:
Participant
Caregiver
Interpreter/translator
Proxy

TYPE OF SERVICE:
Case Management
Congregate meals
Home-delivered meals
Homemaker
Transportation
Family Caregiver

AGENCY NAME

SERVICE PROVIDER

Page ii

INTRODUCTION AND PARTICIPANT VERIFICATION

HELLO. Hello. May I speak with {Name of Participant (PARTICIPANT)/Name of Caregiver
(CAREGIVER)/NAME OF INTERPRETER (INTERPRETER)/NAME OF PROXY (PROXY)}?
PARTICIPANT IS AVAILABLE ...............................................
CAREGIVER IS AVAILABLE .................................................
INTERPRETER IS AVAILABLE .............................................
PROXY IS AVAILABLE ..........................................................
NOT AVAILABLE ...................................................................

I1.

NO ..........................................................................................
RF ...........................................................................................
DK...........................................................................................

1 [GO TO APPOINTMENT
SCREEN]
2 [Thank you. I will call back
later.]
-7 [Thank you.]
-8 [Thank you. I will call back
later.]

Can you provide me with the correct telephone number for {NAME OF PARTICIPANT/NAME
OF CAREGIVER/NAME OF INTERPRETER/TRANSLATOR/NAME OF PROXY}}?
YES ........................................................................................
NO ..........................................................................................

I4.

1
2 [GO TO I3]

Can you provide me a better time to contact {Name of Participant/Name of Caregiver/NAME
OF INTERPRETER/TRANSLATOR/NAME OF PROXY}?
YES ........................................................................................

I3.

[GO TO S/P]
[GO TO S/P]
[GO TO S/P]
[GO TO S/P]
[GO TO I1]

Is this the correct telephone number to contact {Name of Participant/Name of
Caregiver/NAME OF INTERPRETER/TRANSLATOR/NAME OF PROXY}}?
YES ........................................................................................
NO ..........................................................................................

I2.

1
2
3
4
5

1
2 [Thank you for your time.
CODE PROBLEM]

What is the telephone number for {{NAME OF PARTICIPANT/NAME OF CAREGIVER/
INTERPRETER/TRANSLATOR/PROXY}}? RECORD RESPONSE
(|___|___|___|)
(AREA CODE)

|___|___|___| - |___|___|___|___|
(TELEPHONE NUMBER)

Thank you for the information.
S/P.

PARTICIPANT OR CAREGIVER ON THE PHONE ..............
INTERPRETER/TRANSLATOR ON THE PHONE ................
PROXY ON THE PHONE ......................................................

1
2
3

Page iii

PARTICIPANT VERIFICATION

PROGRAMMER NOTE:
IF S/P = 1 PARTICIPANT ON THE PHONE:
IF TYPE OF SERVICE = CASE MANAGEMENT, GO TO CSINTRO1.
IF TYPE OF SERVICE = CONGREGATE MEALS, GO TO CMINTRO.
IF TYPE OF SERVICE = HOME DELIVERED MEALS, GO TO NRINTRO.
IF TYPE OF SERVICE = HOMEMAKER, GO TO HCMINTRO.
IF TYPE OF SERVICE = TRANSPORTATION, GO TO TRINTRO.
IF S/P = 2 CAREGIVER ON THE PHONE:
IF TYPE OF SERVICE = FAMILY CAREGIVER, GO TO CGINTRO.
IF S/P = 3 INTERPRETER/TRANSLATOR ON THE PHONE:
IF TYPE OF SERVICE = CAREGIVER, GO TO CGINTRIOINT.
IF TYPE OF SERVICE = CASE MANAGEMENT, GO TO CSINTROINT.
IF TYPE OF SERVICE = CONGREGATE MEALS, GO TO CMINTROINT
IF TYPE OF SERVICE = HOME DELIVERED MEALS, GO TO NRINTROINT.
IF TYPE OF SERVICE = HOMEMAKER, GO TO HCMINTROINT.
IF TYPE OF SERVICE =TRANSPORTATION, GO TO TRINTROINT.
IF S/P = 4 PROXY ON THE PHONE:
IF TYPE OF SERVICE = CAREGIVER, GO TO CGINTROPRX.
IF TYPE OF SERVICE = CASE MANAGEMENT, GO TO CSINTROPROX.
IF TYPE OF SERVICE = CONGREGATE MEALS, GO TO CMINTROPROX.
IF TYPE OF SERVICE = HOMEMAKER, GO TO HCMINTROPROX.
IF TYPE OF SERVICE = HOME DELIVERED MEALS, GO TO NRINTROPRX.
IF TYPE OF SERVICE = TRANSPORTATION, GO TO TRINTROPRX.

IF CARE RECIPIENT NAME IS UNKNOWN, FOR THE FAMILY CAREGIVER SURVEY, USE “THE
PERSON YOU CARE FOR.”
FOR ALL OTHER SURVEYS, GENDER WILL BE MALE, I.E., “HE” OR “HIS.”

Page iv

SURVEY MODULES

Page i

CASE MANAGEMENT SERVICE

CSINTRO [PARTICPANT]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S.
Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find
out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}.
We show you received case management services from {PROVIDER NAME/AGENCY NAME}. I would
like to speak with you about those services.
This survey will take about 30 minutes to complete. Your participation is voluntary and very important to
the success of this study. The reports prepared for this study will summarize findings across the sample
and will not associate responses with a specific individual. We will not provide information that identifies
individuals to anyone outside the study team, except as required by law. Your eligibility for services will
not be affected by your decision to participate or by any of answers you give. You may skip any question
that you do not want to answer, or stop the interview at any time, but we would really appreciate your
answering all the questions you can.
GO TO CSSERVERF.
IF NEEDED: {Your/His/Her} case manager is the person who sets up in-home services, such as
homemaker or personal care services for {you/him/her}. The case manager also calls to check on how
{you are/NAME OF PARTICIPANT is} doing, or how {you like/s/he likes} {your/his/her} services.
CSINTROINT [INTERPRETER]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the
U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to
find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY
NAME}. We show you received case management services from (PROVIDER NAME/AGENCY NAME). I
would like to speak with you about those services.
This survey will take about 30 minutes to complete. Your participation is voluntary and very important to
the success of this study. Responses to this data collection will be used only for purposes of this
research. The reports prepared for this study will summarize findings across the sample and will not
associate responses with a specific individual. We will not provide information that identifies individuals to
anyone outside the study team, except as required by law. Your eligibility for services will not be affected
by your decision to participate or by any answers you give.
We would like the client to answer the questions as independently as possible. We want to be sure that,
wherever possible, we are getting (NAME OF PARTICIPANT)’S actual opinions and responses.
IF NEEDED: We were given your name as the interpreter for (NAME OF PARTICIPANT).
[IF NEEDED: {Your/His/Her} case manager is the person who sets up in-home services, such as
homemaker or personal care services for {you/him/her}. The case manager also calls to check on how
{you are/NAME OF PARTICIPANT is} doing, or how {you like/s/he likes} {your/his/her} services.]
PROGRAMMER NOTE: IF INTERPRETER WIL NOT DO INTERVIEW, GO TO CSALTCON.
OTHERWISE, GO TO CSSERVERF.
CSINTROPRX [PROXY]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S.
Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find
out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}.
We show (NAME OF PARTICIPANT) received case management services from {PROVIDER
NAME/AGENCY NAME}. I would like to speak with you about those services.

CASE MANAGEMENT

Page 1

This survey will take about 30 minutes to complete. (NAME OF PARTICIPANT’s) participation is voluntary
and very important to the success of this study. Responses to this data collection will be used only for
purposes of this research. The reports prepared for this study will summarize findings across the sample
and will not associate responses with a specific individual. We will not provide information that identifies
individuals to anyone outside the study team, except as required by law. {His/her} eligibility for services
will not be affected by (his/her) decision to participate or by any answers (s/(he)) gives.
For the remainder of the survey I would like you to answer as though you were [Name of Participant]. All
of the following question[s] pertain to {him/her} Please provide your best estimate as to his/her own
response or opinion.
IF NEEDED: We were given your name as the proxy for (NAME OF PARTICIPANT).
[IF NEEDED: {Your/His/Her} case manager is the person who sets up in-home services, such as
homemaker or personal care services for {you/him/her}. The case manager also calls to check on how
{you are/NAME OF PARTICIPANT is} doing, or how {you like/s/he likes} {your/his/her} services.]
PROGRAMMER NOTE: IF PROXY WILL NOT DO INTERVIEW, CONTINUE WITH CSALTCON.
OTHERWISE GO TO CSSERVERF.

CSALTCON.

May I have the name and telephone number of someone else to contact?
_________________
FIRST NAME

____________________
LAST NAME

(|___|___|___|)
(AREA CODE)

|___|___|___| - |___|___|___|___|
(TELEPHONE NUMBER)

REFERRED BACK TO PARTICIPANT ..................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1 [GO TO CSINTRO]
-7 [Thank you for your time]
-8 [Thank you for your time]

Thank you for the information. END INTERVIEW.

CSSERVERF. IF NEEDED: We show {you/s/he} may have received [TYPE OF SERVICE] services from
[PROVIDER NAME/ AGENCY NAME]. Is that correct?
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1 [GO TO CSINTRO1]
2
-7
[GO TO CSMGRVER]
-8

PROGRAMMER NOTE: IF NO NAME OF CASE MANAGER NAME ON FILE, GO TO “IF NO.”

CSMGRVER. We show {your/his/her} case manager’s name is {NAME OF CASE MANAGER}. Is that
correct?
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CASE MANAGEMENT

1
2
-7
-8

[Thank you for your time]

Page 2

PROGRAMMER NOTE: IF PARTICIPANT OR INTERPRETER/TRANSLATOR, DISPLAY SECOND
PERSON PRONOUN (E.G., “DO YOU” OR “HAVE YOU”) IN QUESTIONS. IF PROXY, DISPLAY THIRD
PERSON PRONOUN (E.G., “DOES S/HE” OR “HAS S/HE”) WHERE INDICATED.

CSINTRO1. Now we are going to talk about the case management service {you receive/NAME OF
PARTICIPANT receives} from {NAME OF PROVIDER}.
When was the last time {you/s/he} received the case management service? Was it…
(CSDAYS)
Today or yesterday, ...............................................................
More than 1 day to 1 week ago, .............................................
More than 1 week to 1 month ago, or ....................................
More than 1 month ago? .......................................................
ONLY GOT IT ONE TIME [INTERVIEWER NOTE:
INCLUDES R WHO SAYS THEY GOT HELP FOR A
SHORT TIME, E.G. AFTER A HOSPITAL STAY] ................
OVER 1 YEAR AGO……………. ...........................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

THANK3.

1
2
3
4

5
6 [GO TO THANK3]
-7
-8

Thank you, but the focus of this survey is on people who have used the service within the past
year.

FENCEPOST
CSINTRO2. Now I am going to read a few statements about {your/NAME OF PARTICIPANT’s} case
manager and the case management services {you are/s/he is} currently receiving. {Your/His/Her} case
manager is the person who sets up in-home services, such as homemaker or personal care services for
{you/him/her}. The case manager also calls to check on how {you are/NAME OF PARTICIPANT is} doing,
or how {you like/s/he likes} {your/his/her} services. I will read one statement at a time, and then I will read
the answer choices.
Yes
1

No
2

RF
-7

DK
-8

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

CS1.

{Do you know/Does s/he know} how to contact {your/his/her} case
manager when {you need/s/he needs} to? Would {you/s/he} say…
(CSCONT)

CS2.

{Does your/his/her} case manager return {your/his/her} phone calls in a
timely manner? Would {you/s/he} say… (CSFONEC)

CS3.

{Does your/His/Her} case manager explain {your/his/her} services in a
way that {you/s/he} can understand? (CSEXPLN)

CS4.

{Do you/NAME OF PARTICIPANT} and {your/his/her} case manager
work together to decide what services {you need/NAME OF
PARTICIPANT needs}? (CSNEEDS)

CS5.

{Does your/NAME OF PARTICIPANT’s} case manager treat
{you/him/her} with respect? (CSRESPT)

1

2

-7

-8

CS6.

{Does your/his/her} case manager involve {you/him/her} in discussing
and planning for {your/his/her} services? (CSINVOLV)

1

2

-7

-8

CASE MANAGEMENT

Page 3

Yes

No

RF

DK

1

2

-7

-8

CS7.

{Does your/his/her} case manager do a good job setting up care for
{you/him/her}? (CSCARE)

CS8.

{Does your/his/her} case manager help {you/him/her} get services that
{you/s/he} did not have before? (CSGTMOR)

1

2

-7

-8

CS9.

Has {your/his/her} situation improved because of the services
{your/his/her} case manager arranges? (CSBETTR)

1

2

-7

-8

CSINTRO3. Now I would like to ask you a few additional questions about the services {you/s/he} received
through the case management program.
CS10.

How long {have you/has NAME OF PARTICIPANT} been receiving the case management
services? Would {you/he/she} say…
(CSHOWLG)
6 months or less, ....................................................................
More than 6 months, but less than 1 year, .............................
At least 1 year, but less than 2 years, ....................................
2 to 5 years, or .......................................................................
More than 5 years? ................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CS11.

1
2
3
4
5
-7
-8

Did {your/his/her} case manager develop a care plan for the service {you need/s/he needs}?
[IF NEEDED: A care plan is a document that contains information about who saw
{you/him/her}, {your/his/her} needs, what kinds of services {you receive/s/he receives} and
how {you are/s/he is} doing once {you receive/s/he receives} the services.]
(CSSVCPLN)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
CS11a.

1
2 [GO TO CS12]
-7 [GO TO CS12]
-8 [GO TO CS12]

Did {you/NAME OF PARTICIPANT} get a copy of the plan?

(CCOPY)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CS12.

1
2
-7
-8

{Are you/Is s/he} able to select the services {you receive/s/he receives}?
(CSELSVC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CASE MANAGEMENT

1
2
-7
-8

Page 4

CS13.

{Are you/Is s/he} able to select {your/his/her} service provider?
(CSSELPRV)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CS14.

1
2
-7
-8

How would {you/s/he} rate the overall quality of the case management services {you have/s/he
has} received? Would {you/s/he} say …
(CSRATE)
Excellent, ................................................................................
Very good, ..............................................................................
Good, ......................................................................................
Fair, or ....................................................................................
Poor? ......................................................................................
Refused ..................................................................................
Don’t Know .............................................................................

1
2
3
4
5
-7
-8

CSINTRO4. Now I am going to read some statements about the services {you receive/s/he receives}.

CS15.

CS16.

Yes

No

RF

DK

Do the services {you receive/s/he receives} help {you/NAME OF
PARTICIPANT} to continue to live independently? ...............................
(CSSTAYHM)

1

2

-7

-8

As a result of receiving the case management services, {do you/does
s/he} have a better idea of where to get information about other
services? ...............................................................................................
(CSKNOW)

1

2

-7

-8

FENCEPOST

GO TO THE FOLLOWING MODULES AND COMPLETE THE QUESTIONS IN THIS SEQUENCE:
ADDITIONAL SERVICE LIST MODULE; USDA; FALLS; LIFE CHANGES; SOCIAL INTEGRATION;
PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE;
DEMOGRAPHIC INTAKE MODULE.

CASE MANAGEMENT

Page 5

CONGREGATE MEALS

CMINTRO [PARTICPANT]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S.
Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find
out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}.
We show you have attended the meals program provided by {PROVIDER NAME/AGENCY’S NAME}.
We would like to know if these services have been helpful.
This survey will take about 30 minutes to complete. Your participation is voluntary and very important to
the success of this study. Responses to this data collection will be used only for purposes of this
research. The reports prepared for this study will summarize findings across the sample and will not
associate responses with a specific individual. We will not provide information that identifies individuals to
anyone outside the study team, except as required by law. Your eligibility for services will not be affected
by your decision to participate or by any answers you give. You may skip any question that you do not
want to answer, or stop the interview at any time, but we would really appreciate your answering all the
questions you can.
[IF NEEDED: Meals provided at senior centers or other group settings are called congregate meals or
senior lunch programs.]
GO TO CMSERVERF.
CMINTROINT [INTERPRETER]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the
U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to
find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY
NAME}. We show {NAME OF PARTICIPANT} has attended the meals program provided by {PROVIDER
NAME/AGENCY’S NAME}. We would like to know if these services have been helpful.
We would like the client to answer the questions as independently as possible. We want to be sure that,
wherever possible, we are getting {NAME OF PARTICIPANT}’s actual opinions and responses.
This survey will take about 30 minutes to complete. {His/Her} participation is voluntary and very important
to the success of this study. Responses to this data collection will be used only for purposes of this
research. The reports prepared for this study will summarize information provided by participants and will
not associate responses with a specific individual. We will not provide information that identifies
individuals to anyone outside the study team, except as required by law. {His /Her} eligibility for services
will not be affected by {his /her} decision to participate or by any answers {s/he} gives. You may skip any
question that you do not want to answer, or stop the interview at any time, but we would really appreciate
your answering all the questions you can.
IF NEEDED: We were given your name as the interpreter for {NAME OF PARTICIPANT}.
[IF NEEDED: Meals provided at senior centers or other group settings are called congregate meals or
senior lunch programs.]
PROGRAMMER NOTE: IF INTERPRETER WILL NOT DO INTERVIEW, GO TO CMALTCON.
OTHERWISE GO TO CMSERVERF.
CMINTROPRX [PROXY]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S.
Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find
out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}.
We show {NAME OF PARTICIPANT} has the meals program provided by {PROVIDER
NAME/AGENCY’S NAME}. We would like to know if these services have been helpful.
For the remainder of the survey I would like you to answer as though you were {NAME OF
PARTICIPANT}. All of the following questions pertain to {him/her}. Please provide your best estimate as
to {his/her} own response or opinion.
This survey will take about 30 minutes to complete. Your participation is voluntary and very important to
the success of this study. Responses to this data collection will be used only for purposes of this
research. We will not provide information that identifies individuals to anyone outside the study team,

CONGREGATE MEALS

Page 6

except as required by law. {His /Her} eligibility for services will not be affected by {his /her} decision to
participate or by any answers {s/he} gives. You may skip any question that you do not want to answer, or
stop the interview at any time, but we would really appreciate your answering all the questions you can.
IF NEEDED: We were given your name as the proxy for {NAME OF PARTICIPANT}.
[IF NEEDED: A lunch program, or congregate meal is a meal which is provided in a group setting, such
as at a senior center.]
PROGRAMMER NOTE: IF PROXY WILL NOT DO INTERVIEW, CONTINUE WITH CMALTCON.
OTHERWISE GO TO CMSERVERF.
CMALTCON. May I have the name and telephone number of someone else to contact?
_________________
FIRST NAME

____________________
LAST NAME

(|___|___|___|)
(AREA CODE)

|___|___|___| - |___|___|___|___|
(TELEPHONE NUMBER)

REFERRED BACK TO PARTICIPANT ..................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1 [GO TO CMINTRO]
-7 [Thank you for your time]
-8 [Thank you for your time]

Thank you for the information. END INTERVIEW.

CMSERVERF. IF NEEDED: We show {you/s/he} may have received {TYPE OF SERVICE} services from
{PROVIDER NAME/ AGENCY NAME}. Is that correct?
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2 [Thank you for your time]
-7 [Thank you for your time]
-8 [Thank you for your time]

PROGRAMMER NOTE: IF PARTICIPANT OR INTERPRETER/TRANSLATOR, DISPLAY SECOND
PERSON PRONOUN (E.G., “DO YOU” OR “HAVE YOU”) IN QUESTIONS. IF PROXY, DISPLAY
THIRD PERSON PRONOUN (E.G., “DOES S/HE” OR “HAS S/HE”) WHERE INDICATED.

CNRINTRO1. Now we are going to talk about the meals program {you attend/NAME OF PARTICIPANT
attends} {at NAME OF PROVIDER} through {AGENCY NAME}.
CNR1.

When was the last time {you/s/he} received a meal from the meals program? Was it...
(CMDAYS)
Today or yesterday, ...............................................................
More than 1 day to 1 week ago, .............................................
More than 1 week to 1 month ago, or ....................................
More than 1 month ago? .......................................................
I ONLY ATE THERE ONCE ...................................................
OVER 1 YEAR AGO ..............................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CONGREGATE MEALS

1
2
3
4
5
6
-7
-8

[GO TO THANK3]
[GO TO THANK3]
[GO TO THANK3]
[GO TO THANK3]

Page 7

THANK3.

Thank you, but the focus of this survey is on people who have used the service within the
past year.

CNR2.

How long {have you/has NAME OF PARTICIPANT} been participating in the meals
program? Would {you/NAME OF PARTICIPANT} say…
(CMRECEV)
6 months or less, ....................................................................
More than 6 months, but less than 1 year, .............................
At least 1 year, but less than 2 years, ....................................
2 to 5 years, or .......................................................................
More than 5 years? ................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
-7
-8

PROGRAMMER NOTE: HARD RANGE FOR CNR3=0 TO 7.

CNR3.

How many days each week {do you/does s/he} receive a meal from the meals program?
(CMDAYSWK)
NUMBER OF DAYS ...............................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

|___|___|
-7
-8

FENCEPOST

CNRINTRO2. The following questions are about {your/NAME OF PARTICIPANT’S} eating habits.
CNR4.

On the days {you/NAME OF PARTICIPANT} received a meal, what portion of all the foods
{you eat/s/he eats} in a day does this meal represent? Would {you/s/he} say…
(CMPORTN)
Less than one-third, ...............................................................
Between one-third and one-half, ............................................
About one-half, or ..................................................................
More than one-half? ...............................................................
OTHER...................................................................................
(Please Specify: _________________________________ )
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CONGREGATE MEALS

1
2
3
4
91
-7
-8

Page 8

Now I am going to ask about the services {you receive/s/he receives}.
CNR19.

How would {you/NAME OF PARTICIPANT} rate the meal program overall? Would
{you/s(he} say…
(CMRATE)
Excellent .................................................................................
Very good ...............................................................................
Good .......................................................................................
Fair .........................................................................................
Poor ........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
-7
-8

FENCEPOST

I’m going to read some statements about the lunch program.
CNR27.

Think about all the foods that {you receive/s/he receives} from the meal program. Now tell
me, how often {are you/is s/he} satisfied with the way the food tastes? Would {you/s/he
say}……
(CMTASTES)
Always, ................................................................................... 1
Usually, .................................................................................. 2
Sometimes ............................................................................. 3
Seldom, or .............................................................................. 4
Never?.................................................................................... 5
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

CNR28.

Think about all the foods that {you receive/s/he receives} from the meal program. Now tell
me, how often {are you/is s/he} satisfied with the variety of the foods? Would {you/s/he
say}……
(CMVR2FD)
Always, ................................................................................... 1
Usually, .................................................................................. 2
Sometimes ............................................................................. 3
Seldom, or .............................................................................. 4
Never?.................................................................................... 5
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

CNR29.

Within the last 12 months, have you {he/she} noticed any changes in the amount or quality of
the food in your meal program?
(CMFQYN)
YES ...................................................................................... .. 1
NO .......................................................................................... 2
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

CONGREGATE MEALS

[GO TO CNR29A]
[GO TO CNR20]
[GO TO CNR20]
[GO TO CNR20]

Page 9

CNR29A.

How has the meal program changed?

[IF NEEDED: Please tell me more about the changes you have noticed.]
[PROBE: Anything else?]
[INTERVIEWER, CODE ALL THAT APPLY]
(CMFQ1-11; CMFQOT)
QUALITY OF FOOD HAS DECLINED ...................................
QUALITY OF FOOD HAS IMPROVED ..................................
AMOUNT/QUANTITY OF FOOD PER MEAL HAS
DECREASED .....................................................................
AMOUNT/QUANTITY OF FOOD PER MEAL HAS
INCREASED.......................................................................
VARIETY IN MEALS HAS DECLINED ..................................
VARIETY IN MEALS HAS IMPROVED .................................
AMOUNT OF FRUITS AND/OR VEGETABLES HAS
DECREASED .....................................................................
AMOUNT OF FRUITS AND/OR VEGETABLES HAS
INCREASED.......................................................................
MORE COLD OR FROZEN MEALS ARE PROVIDED ..........
FEWER COLD OR FROZEN MEALS ARE PROVIDED .......
TYPE OF MEALS HAS CHANGED: MORE FOOD THAT IS
SHELF STABLE IS PROVIDED (FOOD THAT DOES
NOT NEED REGRIGERATION OR FREEZING)...............
FEWER MEALS ARE PROVIDED .........................................
MORE MEALS ARE PROVIDED ...........................................
FEWER CELEBRATION (HOLIDAY OR BIRTHDAY)
MEALS ARE PROVIDED ...................................................
MEAL SERVICE IS PROVIDED LESS OFTEN .....................
MEAL SERVICE IS PROVIDED MORE OFTEN ...................
OTHER ................................................................................
(SPECIFY:_____________________________________)

1
2
3
4
5
6
7
8
9
10

11
12
13
14
15
16
91

[TRAINING/CODING NOTE: “PACKAGING OF MEALS” MAY INCLUDE COMMENTS ABOUT HOW
THE FOOD IS SERVED AND PRESENTED, E.G., PLASTIC MICROWAVABLE TRAYS VS.
ALUMINUM FOIL TRAYS WITH CRIMPED EDGES; REUSABLE OR
ENVIRONMENTALLY-FRIENDLY PACKAGING.]

CNR20.

Would {you/NAME OF PARTICIPANT} recommend this service to a friend?
(CMRECOM)
YES ........................................................................................ 1
NO .......................................................................................... 2
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

CNR21.

{Do you/Does NAME OF PARTICIPANT} eat healthier foods as a result of the meals program?
(CMVARFD)
YES ........................................................................................ 1
NO .......................................................................................... 2
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

CONGREGATE MEALS

Page 10

CNR22.

Does eating meals from the meals program improve {your/NAME OF PARTICIPANT’S}
health?
(CMFLBTR)
YES ........................................................................................ 1
NO .......................................................................................... 2
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

CNR23.

Does the meals program help {you/NAME OF PARTICIPANT} to continue to live
independently?
(CMSTAYHM)
YES ........................................................................................ 1
NO .......................................................................................... 2
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

CNR24.

{Do you/Does NAME OF PARTICIPANT} like the meals that {you get/s/he gets} from the
meals program?
(CMLIKE)
YES ........................................................................................ 1
NO .......................................................................................... 2
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

CNR25.

As a result of receiving meals, {do you/does NAME OF PARTICIPANT} feel better?
(CMFLBR2)
YES ................................................................................... 1
NO ..................................................................................... 2
REFUSED ......................................................................... -7
DON’T KNOW ................................................................... -8

CNR26.

As a result of receiving meals, {do you/does NAME OF PARTICIPANT} see {your/his/her}
friends more often?
(CMFRNDS)
YES ................................................................................... 1
NO ..................................................................................... 2
REFUSED ......................................................................... -7
DON’T KNOW ................................................................... -8

GO TO THE FOLLOWING MODULES AND COMPLETE THE QUESTIONS IN THIS SEQUENCE:
ADDITIONAL SERVICE LIST MODULE; USDA; FALLS; LIFE CHANGES; SOCIAL
INTEGRATION; PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE;

CONGREGATE MEALS

Page 11

DEMOGRAPHIC INTAKE MODULE.

CONGREGATE MEALS

Page 12

HOME-DELIVERED MEALS

NRINTRO [PARTICPANT]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S.
Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find
out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}.
We show you have received Home-Delivered Meals, sometimes called Meals on Wheels, from
{PROVIDER NAME/AGENCY’S NAME}. We would like to know if these services have been helpful.
This survey will take about 30 minutes to complete. Your participation is voluntary and very important to
the success of this study. Responses to this data collection will be used only for purposes of this
research. The reports prepared for this study will summarize information provided by participants and will
not associate responses with a specific individual. We will not provide information that identifies
individuals to anyone outside the study team, except as required by law. Your eligibility for services will
not be affected by your decision to participate or by any answers you give. You may skip any question
that you do not want to answer, or stop the interview at any time, but we would really appreciate your
answering all the questions you can.
[IF NEEDED: Meals on Wheels or Home Delivered Meals are meals that are usually delivered to eat at
home.]
GO TO NRSERVERF.
NRINTROINT [INTERPRETER]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the
U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to
find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY
NAME}. We show {NAME OF PARTICIPANT} has received Home-Delivered Meals, sometimes called
Meals on Wheels, from {PROVIDER NAME/AGENCY’S NAME}. We would like to know if these services
have been helpful.
We would like the client to answer the questions as independently as possible. We want to be sure that,
wherever possible, we are getting {NAME OF PARTICIPANT}’s actual opinions and responses.
This survey will take about 30 minutes to complete. {His/Her} participation is voluntary and very important
to the success of this study. Responses to this data collection will be used only for purposes of this
research. The reports prepared for this study will summarize information provided by participants and will
not associate responses with a specific individual. We will not provide information that identifies
individuals to anyone outside the study team, except as required by law. Your eligibility for services will
not be affected by your decision to participate or by any answers you give. You may skip any question
that you do not want to answer, or stop the interview at any time, but we would really appreciate your
answering all the questions you can.
IF NEEDED: We were given your name as the interpreter for {NAME OF PARTICIPANT}.
[IF NEEDED: Meals on Wheels or Home Delivered Meals are meals that are usually delivered to eat at
home.]
PROGRAMMER NOTE: IF INTERPRETER WILL NOT DO INTERVIEW GO TO NRALTCON.
OTHERWISE GO TO NRSERVERF.
NRINTROPRX [PROXY]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S.
Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find
out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}.
We show {NAME OF PARTICIPANT} has received Home-Delivered Meals, sometimes called Meals on
Wheels, from {PROVIDER NAME/AGENCY’S NAME}. We would like to know if these services have
been helpful.

HOME DELIVERED MEALS

Page 13

For the remainder of the survey I would like you to answer as though you were {NAME OF
PARTICIPANT}. All of the following questions pertain to {him/her}. Please provide your best estimate as
to {his/her} own response or opinion.
This survey will take about 30 minutes to complete. Your participation is voluntary and very important to
the success of this study. Responses to this data collection will be used only for purposes of this
research. The reports prepared for this study will summarize information provided by participants and will
not associate responses with a specific individual. We will not provide information that identifies
individuals to anyone outside the study team, except as required by law. Your eligibility for services will
not be affected by your decision to participate or by any answers you give. You may skip any question
that you do not want to answer, or stop the interview at any time, but we would really appreciate your
answering all the questions you can.
IF NEEDED: We were given your name as the proxy for {NAME OF PARTICIPANT}.
[IF NEEDED: Meals on Wheels or Home Delivered Meals are meals that are usually delivered to eat at
home.]
PROGRAMMER NOTE: IF PROXY WILL NOT DO INTERVIEW, CONTINUE WITH NRALTCON.
OTHERWISE GO TO NRSERVERF.

NRALTCON. May I have the name and telephone number of someone else to contact?
_________________
FIRST NAME

____________________
LAST NAME

(|___|___|___|)
(AREA CODE)

|___|___|___| - |___|___|___|___|
(TELEPHONE NUMBER)

REFERRED BACK TO PARTICIPANT ..................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1 [GO TO NRINTRO]
-7 [Thank you for your time]
-8 [Thank you for your time]

Thank you for the information. END INTERVIEW.

NRSERVERF. IF NEEDED: We show {you/s/he} may have received {TYPE OF SERVICE} services from
{PROVIDER NAME/AGENCY NAME}. Is that correct?
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

[Thank you for your time]

PROGRAMMER NOTE: IF PARTICIPANT OR INTERPRETER/TRANSLATOR, DISPLAY FIRST
PERSON TENSE (E.G., “do you” OR “have you”) IN QUESTIONS. IF PROXY, DISPLAY SECOND
PERSON TENSE (E.G., “does s/he” OR “has s/he”) WHERE INDICATED.

HOME DELIVERED MEALS

Page 14

HNRINTRO1. Now we are going to talk about the home delivered-meals {you receive/NAME OF
PARTICIPANT receives} from {NAME OF PROVIDER}.
HNR1.

When was the last time {you/s/he} received a meal? Was it . . .
(HMDAYS)
Today or yesterday, .......................................................... 1
More than 1 day to 1 week ago, ........................................ 2
More than 1 week to 1 month ago, or ................................ 3
More than 1 month ago?.................................................... 4
ONLY GOT 1 MEAL [INTERVIEWER NOTE: INCLUDES
R WHO SAYS THEY GOT MEALS FOR A SHORT
TIME, E.G. AFTER A HOSPITAL STAY] ..................... 5
OVER 1 YEAR AGO……………. ....................................... 6
REFUSED .......................................................................... -7
DON’T KNOW .................................................................... -8

[GO TO THANK3]
[GO TO THANK3]
[GO TO THANK3]
[GO TO THANK3]

THANK3.

Thank you, but the focus of this survey is on people who have used the service within the
past year.

HNR2.

How long {have you/has NAME OF PARTICIPANT} been receiving home-delivered meals?
Would {you/NAME OF PARTICIPANT} say…
(HMRECEV)
6 months or less, ............................................................... 1
More than 6 months, but less than 1 year, ....................... 2
At least 1 year, but less than 2 years, ............................... 3
2 to 5 years, or .................................................................. 4
More than 5 years? ........................................................... 5
REFUSED ......................................................................... -7
DON’T KNOW ................................................................... -8

HNR2a.

Has knowing that you will receive regular visits by the home delivered meals or Meals-onWheels" volunteer/driver made you feel safer at home?
(NEW.SAFER)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

HOME DELIVERED MEALS

Page 15

HNR2b[49b]. Other than the person who delivers the meals how many times a week do {you have/ NAME
OF PARTICIPANT has} personal contact (face-to-face) with a friend, family member, or other
visitor?
(NEW.PERSONALCONTACT)
NONE .................................................................................. 1
ONE TIME ........................................................................... 2
TWO TIMES ........................................................................ 3
THREE TIMES .................................................................... 4
FOUR TIMES ...................................................................... 5
FIVE TIMES ........................................................................ 6
SIX TIMES ........................................................................... 7
EVERYDAY ......................................................................... 8
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

HNRINTRO2.

Now, I am going to ask about the days {you receive/NAME OF PARTICIPANT receive}
home-delivered meals.

PROGRAMMER NOTE: SOFT RANGE FOR HNR3=0 TO 4; HARD RANGE = 0 TO 6
HNR3.

How many meals {do you/does s/he} get on the days that {you receive/s/he
receives} home-delivered meals?

(HMATTENA)
NUMBER OF MEALS|___|___| [INTERVIEWER NOTE:
91]
OTHER ..............................................................................
(Please Specify: _______________________________ )
REFUSED .........................................................................
DON’T KNOW ...................................................................

IF NUMBER VARIES, ENTER
91
-7
-8

HNR3a [A15.1] How long ago did {you/ NAME OF PARTICIPANT} first receive a home-delivered meal?
PROBE: You may answer in days, weeks, months, or years. Your best estimate is fine.
|___| (0-999)
DAYS AGO (RANGE 0-45) .................................................
WEEKS AGO (RANGE 1-30) ..............................................
MONTHS AGO (RANGE 1-13) ...........................................
YEARS AGO (RANGE 1-40) ...............................................
REFUSED ...........................................................................
DON’T KNOW .....................................................................

1
2
3
4
7
8

PROGRAMMER NOTE: HARD RANGE FOR HNR4 = 0 to 7

HOME DELIVERED MEALS

Page 16

HNR4.

How many days each week {do you/does s/he} receive home-delivered meals?
(HMDAYPST)
NUMBER OF DAYS ........................................... |___|___|
REFUSED ......................................................................... -7
DON’T KNOW ................................................................... -8

HARD CHECK: IF DAYS PER WEEK GT 7; I want to be sure I recorded your answer correctly.
HNR5.

Think of a typical day {you eat/NAME OF PARTICIPANT eats} a meal from home-delivered
meals. Of all {you ate/s/he ate} that day, what portion of all the foods {you eat/s/he eats}
does the meal represent? Would {you/s/he} say…
(HMPORTN)
Less than one-third, ..........................................................
Between one-third and one-half, .......................................
About one-half, or..............................................................
More than one-half? ..........................................................
OTHER ..............................................................................
(Please Specify: _______________________________ )
REFUSED .........................................................................
DON’T KNOW ...................................................................

HNR20.

1
2
3
4
91
-7
-8

How would {you/NAME OF PARTICIPANT} rate the home-delivered meals program overall?
Would {you/s(he)} say…
(HMRATE)
Excellent, ........................................................................... 1
Very good, ......................................................................... 2
Good, ................................................................................ 3
Fair, or ............................................................................... 4
Poor? ................................................................................. 5
REFUSED ......................................................................... -7
DON’T KNOW ................................................................... -8

HOME DELIVERED MEALS

Page 17

I’m going to read some statements about the meals program.
HNR21.

Think about all the foods that {you receive/s/he receives} from the home-delivered meals
program. Now tell me, how often {are you/is s/he} satisfied with the way the food tastes?
Would {you/s/he say}……
(HMTASTES)
Always, ................................................................................... 1
Usually, .................................................................................. 2
Sometimes, ............................................................................ 3
Seldom, or .............................................................................. 4
Never?.................................................................................... 5
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

HNR22.

Think about all the foods that {you receive/s/he receives} from the home-delivered meals
program. Now tell me, how often {are you/is s/he} satisfied with the variety of the foods?
Would {you/s/he say}……
(HMVR2FD)
Always, ................................................................................... 1
Usually, .................................................................................. 2
Sometimes, ............................................................................ 3
Seldom, or .............................................................................. 4
Never?.................................................................................... 5
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

HNR22a1.

Within the last 12 months, have {you/NAME OF PARTICIPANT} noticed any changes in the
amount or quality of the food in your home-delivered meals?
(HNRFQYN)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

HOME DELIVERED MEALS

1
2
-7
-8

[GO TO HNR22a2]
[GO TO HNR23]
[GO TO HNR23]
[GO TO HNR23]

Page 18

HNR22a2.

How has (your/s/he} home-delivered meals service changed?

[IF NEEDED: Please tell me more about the changes you have noticed.]
[PROBE: Anything else?]
[INTERVIEWER, CODE ALL THAT APPLY]
(HNRFQ1-11; HNRFQOT)
QUALITY OF FOOD HAS DECLINED ..................................
QUALITY OF THE FOOD HAS IMPROVED..........................
AMOUNT/QUANTITY OF FOOD PER MEAL HAS
DECREASED. ....................................................................
AMOUNT/QUANTITY OF FOOD PER MEAL HAS
INCREASED.......................................................................
VARIETY IN MEALS HAS DECLINED ..................................
VARIETY IN MEALS HAS IMPROVED .................................
AMOUNT OF FRUITS AND/OR VEGETABLES HAS
DECREASED .....................................................................
AMOUNT OF FRUITS AND/OR VEGETABLES HAS
INCREASED.......................................................................
MORE COLD OR FROZEN MEALS ARE PROVIDED ..........
FEWER COLD OR FROZEN MEALS ARE PROVIDED .......
TYPE OF MEALS HAS CHANGED: MORE FOOD THAT IS
SHELF STABLE IS PROVIDED (FOOD THAT DOES
NOT REQUIRE REFRIGERATION OR FREEZING) .........
FEWER MEALS ARE PROVIDED .........................................
MORE MEALS ARE PROVIDED ...........................................
FEWER CELEBRATION (HOLIDAY OR BIRTHDAY)
MEALS ARE PROVIDED ...................................................
MEAL SERVICE IS PROVIDED LESS OFTEN .....................
MEAL SERVICE IS PROVIDED MORE OFTEN ...................
OTHER ...................................................................................
(SPECIFY: _____________________________________ )

1
2
3
4
5
6
7
8
9
10

11
12
13
14
15
16
91

[TRAINING/CODING NOTE: FOR HOME-DELIVERED MEALS, “PACKAGING OF MEALS” MAY
INCLUDE COMMENTS ABOUT HOW THE FOOD IS SERVED AND PRESENTED, E.G.,
PLASTIC MICROWAVEABLE TRAYS VS. ALUMINUM FOIL TRAYS WITH CRIMPED
EDGES; REUSABLE OR ENVIRONMENTALLY-FRIENDLY PACKAGING.]

HNR23.

Do the home-delivered meals arrive when expected?
(HMONTIME)
Always, ................................................................................... 1
Usually, .................................................................................. 2
Sometimes ............................................................................. 3
Seldom, or .............................................................................. 4
Never?.................................................................................... 5
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

HOME DELIVERED MEALS

Page 19

HNR24.

{Do you/Does NAME OF PARTICIPANT} like the meals {you get/s/he gets} from the homedelivered meals program?
(HNRLIKE)
YES ........................................................................................ 1
NO .......................................................................................... 2
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

HNR25.

Would you recommend this service to a friend?
(HNRRECOM)
YES ........................................................................................ 1
NO .......................................................................................... 2
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

HNR26.

Do you eat healthier foods as a result of the meals program?
(HMVARFD)
YES ........................................................................................ 1
NO .......................................................................................... 2
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

HNR27.

Does receiving home-delivered meals improve (your/NAME OF PARTICIPANT’S) health?
(HMFLBTR)
YES ........................................................................................ 1
NO .......................................................................................... 2
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

HNR28.

Do the home-delivered meals help (you/NAME OF PARTICIPANT) to continue to live
independently?
(HMSTAYHM)
YES ........................................................................................ 1
NO .......................................................................................... 2
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

HNR29.

As a result of receiving home-delivered meals, {do you/does NAME OF PARTICIPANT} feel
better?
(HMFLBR2)
YES ...................................................................................

HOME DELIVERED MEALS

1

Page 20

NO ..................................................................................... 2
REFUSED ......................................................................... -7
DON’T KNOW ................................................................... -8

GO TO THE FOLLOWING MODULES AND COMPLETE THE QUESTIONS IN THIS SEQUENCE:
ADDITIONAL SERVICE LIST MODULE; USDA; FALLS; LIFE CHANGES; SOCIAL
INTEGRATION;
PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE;
DEMOGRAPHIC INTAKE MODULE.

HOME DELIVERED MEALS

Page 21

HOMEMAKER SERVICE

HCMINTRO [PARTICIPANT]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the
U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to
find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY
NAME}. We show you received homemaker services from (PROVIDER NAME/AGENCY NAME). I would
like to speak with you about those services.
This survey will take about 30 minutes to complete. Your participation is voluntary and very important to
the success of this study. Responses to this data collection will be used only for purposes of this
research. The reports prepared for this study will summarize information provided by participants and will
not associate responses with a specific individual. We will not provide information that identifies
individuals to anyone outside the study team, except as required by law. {His/her} eligibility for services
will not be affected by (his/her) decision to participate or by any answers (s/(he)) gives. You may skip any
question that you do not want to answer, or stop the interview at any time, but we would really appreciate
your answering all the questions you can.
[IF NEEDED: Homemaker or Housekeeping Services are services that may include help with doing light
housework, laundry, preparing meals or shopping.]
GO TO HCMSERVERF.
HCMINTROINT [INTERPRETER]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of
the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a
survey to find out how we can help meet the needs of people being served by {PROVIDER
NAME/AGENCY NAME}. We show you received homemaker services from (PROVIDER NAME/AGENCY
NAME). I would like to speak with you about those services.
This survey will take about 30 minutes to complete. Your participation is voluntary and very important to
the success of this study. Responses to this data collection will be used only for purposes of this
research. The reports prepared for this study will summarize information provided by participants and will
not associate responses with a specific individual. We will not provide information that identifies
individuals to anyone outside the study team, except as required by law. {His/her} eligibility for services
will not be affected by (his/her) decision to participate or by any answers (s/(he)) gives. You may skip any
question that you do not want to answer, or stop the interview at any time, but we would really appreciate
your answering all the questions you can.
We would like the client to answer the questions as independently as possible. We want to be sure that,
wherever possible, we are getting (NAME OF PARTICIPANT)’S actual opinions and responses.
IF NEEDED: We were given your name as the interpreter for (NAME OF PARTICIPANT).
[IF NEEDED: Homemaker or Housekeeping Services are services that may include help with doing light
housework, laundry, preparing meals or shopping.]
PROGRAMMER NOTE: IF INTERPRETER WILL NOT DO INTERVIEW GO TO HCMALTCON.
OTHERWISE GO TO HCMSERVERF.
HCMINTROPRX [PROXY]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S.
Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find
out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}.
We show (NAME OF PARTICIPANT) received Homemaker Services from {PROVIDER NAME/AGENCY
NAME}. I would like to speak with you about those services.

HOMEMAKER

Page 22

This survey will take about 30 minutes to complete. (NAME OF PARTICIPANT’s) participation is voluntary
and very important to the success of this study. Responses to this data collection will be used only for
purposes of this research. The reports prepared for this study will summarize information provided by
participants and will not associate responses with a specific individual. We will not provide information
that identifies individuals to anyone outside the study team, except as required by law. {His/her} eligibility
for services will not be affected by (his/her) decision to participate or by any answers (s/(he)) gives. You
may skip any question that you do not want to answer, or stop the interview at any time, but we would
really appreciate your answering all the questions you can.
For the remainder of the survey I would like you to answer as though you were [Name of Participant]. All
of the following question[s] pertain to {him/her} Please provide your best estimate as to his/her own
response or opinion.
IF NEEDED: We were given your name as the proxy for (NAME OF PARTICIPANT).
[IF NEEDED: Homemaker or Housekeeping Services are services that may include help with doing light
housework, laundry, preparing meals or shopping.]
PROGRAMMER NOTE: IF PROXY WILL NOT DO INTERVIEW, CONTINUE WITH HCMALTCON.
OTHERWISE GO TO HCMSERVERF.

HCMALTCON. May I have the name and telephone number of someone else to contact?
_________________
FIRST NAME

____________________
LAST NAME

(|___|___|___|)
(AREA CODE)

|___|___|___| - |___|___|___|___|
(TELEPHONE NUMBER)

REFERRED BACK TO PARTICIPANT ..................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1 [GO TO HCMINTRO]
-7 [Thank you for your time]
-8 [Thank you for your time]

Thank you for the information. END INTERVIEW.

HCMSERVERF. IF NEEDED: We show {you/s/he} may have received [TYPE OF SERVICE] services from
[PROVIDER NAME/AGENCY NAME]. Is that correct?
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

[Thank you for your time]
[Thank you for your time]
[Thank you for your time]

PROGRAMMER NOTE: IF PARTICIPANT OR INTERPRETER/TRANSLATOR, DISPLAY SECOND
PERSON PRONOUN (E.G., “DO YOU” OR “HAVE YOU”) IN QUESTIONS. IF PROXY, DISPLAY
THIRD PERSON PRONOUN (E.G., “DOES S/HE” OR “HAS S/HE”) WHERE INDICATED.

HOMEMAKER

Page 23

HCINTRO1. Now we are going to talk about the homemaker or housekeeping service {you receive/NAME
OF PARTICIPANT receives} from {NAME OF PROVIDER}
HC1.

When was the last time {you/s/he} received the homemaker or housekeeping service? Was
it…
(HCDAYS)
Today or yesterday, ...............................................................
More than 1 day to 1 week ago, .............................................
More than 1 week to 1 month ago, or ....................................
More than 1 month ago? .......................................................
ONLY GOT IT ONE TIME [INTERVIEWER NOTE:
INCLUDES R WHO SAYS THEY GOT HELP FOR A
SHORT TIME, E.G. AFTER A HOSPITAL STAY] ............
OVER 1 YEAR AGO……………. ...........................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4

5
6
-7
-8

[GO TO THANK3]
[GO TO THANK3]
[GO TO THANK3]
[GO TO THANK3]

THANK3.

Thank you, but the focus of this survey is on people who have used the service within the past
year.

HC2.

How long {have you/has NAME OF PARTICIPANT} been receiving homemaker services?
Would {you/ NAME OF PARTICIPANT} say…
(HCRECEV)
6 months or less, ....................................................................
More than 6 months, but less than 1 year, .............................
At least 1 year, but less than 2 years, ....................................
2 to 5 years, or .......................................................................
More than 5 years? ................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
-7
-8

PROGRAMMER NOTE: HARD RANGE IN HCMOFT IS 0 to 7.
HC3.

How often does the homemaker help with housework?
(HCMOFT and HCWEEK and HCMONTH)
NUMBER OF TIMES PER WEEK .................................... 1
NUMBER OF TIMES PER MONTH .................................. 2
REFUSED ......................................................................... -7
DON’T KNOW ................................................................... -8

FENCEPOST

HOMEMAKER

Page 24

HC4.

When the homemaker comes, how many hours of help {do you/does s/he} receive?
(SHCHRS)
NUMBER OF HOURS........................................ |___|___|
REFUSED ......................................................................... -7
DON’T KNOW ................................................................... -8

HC5.

Does {your/his/her} homemaker do things the way {you want/s/he wants} them done?
(HCHM07)
YES ................................................................................... 1
NO ..................................................................................... 2
REFUSED ......................................................................... -7
DON’T KNOW ................................................................... -8

HC6.

Does {your/his/her} homemaker do what {you ask/s/he asks} them to?
(SHCHM09)
YES ................................................................................... 1
NO ..................................................................................... 2
REFUSED ......................................................................... -7
DON’T KNOW ................................................................... -8

HC7.

How would {you/NAME OF PARTICIPANT} rate the quality of your homemaker service?
Would (you/Name of Participant) say…
(HCARATE)
Excellent, ................................................................................
Very good, ..............................................................................
Good, ......................................................................................
Fair, or ....................................................................................
Poor? ......................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
-7
-8

FENCEPOST
HCINTRO2. I’m going to read some statements about the homemaker program. Please tell me:

HC8.

HC9.

Would {You/NAME OF PARTICIPANT} recommend the
Homemaker program to a friend? .............................................
(HCRREC)
Do the services {you receive/s/he receives} help {you/NAME
OF PARTICIPANT} to continue to live independently? ............
(HCSTAYHM)

YES

NO

RF

DK

1

2

-7

-8

1

2

-7

-8

FENCEPOST

HOMEMAKER

Page 25

GO TO THE FOLLOWING MODULES AND COMPLETE THE QUESTIONS IN THIS SEQUENCE:
ADDITIONAL SERVICE LIST MODULE;
USDA MODULE;
FALLS;
LIFE CHANGES;
SOCIAL INTEGRATION;
PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE;
DEMOGRAPHIC INTAKE MODULE.

HOMEMAKER

Page 26

TRANSPORTATION SERVICES

TRINTRO [PARTICIPANT]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S.
Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find
out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}.
We show you have received Transportation Services from {PROVIDER NAME/AGENCY’S NAME}. We
would like to know if these services have been helpful.
This survey will take about 30 minutes to complete. Your participation is voluntary and very important to
the success of this study. Responses to this data collection will be used only for purposes of this
research. The reports prepared for this study will summarize information provided by participants and will
not associate responses with a specific individual. We will not provide information that identifies
individuals to anyone outside the study team, except as required by law. Your eligibility for services will
not be affected by your decision to participate or by any answers you give. You may skip any question
that you do not want to answer, or stop the interview at any time, but we would really appreciate your
answering all the questions you can.
[IF NEEDED: Transportation is a bus or other vehicle that picks people up and takes them places such as
to the doctor, the senior center or shopping [IF NEEDED: Includes recreational trips].]
PROGRAMMER NOTE: GO TO TRSERVERF.
TRINTROINT [INTERPRETER]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the
U.S. Department of Health and Human Services’ Administration on Aging. We are conducting a survey to
find out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY
NAME}. We show {NAME OF PARTICIPANT} has received Transportation Services from {PROVIDER
NAME/AGENCY NAME}. We would like to know if these services have been helpful.
We would like the client to answer the questions as independently as possible. We want to be sure that,
wherever possible, we are getting {NAME OF PARTICIPANT’S} actual opinions and responses.
This survey will take about 30 minutes to complete. {NAME OF PARTICIPANT’s} participation is voluntary
and very important to the success of this study. Responses to this data collection will be used only for
purposes of this research. The reports prepared for this study will summarize information provided by
participants and will not associate responses with a specific individual. We will not provide information
that identifies individuals to anyone outside the study team, except as required by law. Your eligibility for
services will not be affected by your decision to participate or by any answers you give. You may skip any
question that you do not want to answer, or stop the interview at any time, but we would really appreciate
your answering all the questions you can.
IF NEEDED: We were given your name as the interpreter for {NAME OF PARTICIPANT)}
[IF NEEDED: Transportation is a bus or other vehicle that picks people up and takes them places such as
to the doctor, the senior center or shopping [IF NEEDED: Includes recreational trips].]
PROGRAMMER NOTE: IF INTERPRETER WILL NOT DO INTERVIEW GO TO TRALTCON.
OTHERWISE GO TO TRSERVERF.
TRINTROPRX [PROXY]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S.
Department of Health and Human Services’ Administration on Aging. We are conducting a survey to find
out how we can help meet the needs of people being served by {PROVIDER NAME/AGENCY NAME}.
We show {NAME OF PARTICIPANT} has received Transportation Services from {PROVIDER
NAME/AGENCY’S NAME}. We would like to know if these services have been helpful.

TRANSPORTATION

Page 27

For the remainder of the survey I would like you to answer as though you were {NAME OF
PARTICIPANT}. All of the following question{s} pertain to {him/her}. Please provide your best estimate as
to {his/her} own response or opinion.
This survey will take about 30 minutes to complete. (NAME OF PARTICIPANT’s) participation is voluntary
and very important to the success of this study. Responses to this data collection will be used only for
purposes of this research. The reports prepared for this study will summarize information provided by
participants and will not associate responses with a specific individual. We will not provide information
that identifies individuals to anyone outside the study team, except as required by law. Your eligibility for
services will not be affected by your decision to participate or by any answers you give. You may skip any
question that you do not want to answer, or stop the interview at any time, but we would really appreciate
your answering all the questions you can.
IF NEEDED: We were given your name as the proxy for (NAME OF PARTICIPANT).
[IF NEEDED: Transportation is a bus or other vehicle that picks people up and takes them places such as
to the doctor, the senior center or shopping.] [IF NEEDED: Includes recreational trips.]
PROGRAMMER NOTE: IF PROXY WILL NOT DO INTERVIEW CONTINUE WITH TRALTCON.
OTHERWISE GO TO TRSERVERF.

TRALTCON. May I have the name and telephone number of someone else to contact?
_________________
FIRST NAME

____________________
LAST NAME

(|___|___|___|)
(AREA CODE)

|___|___|___| - |___|___|___|___|
(TELEPHONE NUMBER)

REFERRED BACK TO PARTICIPANT ..................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1 [GO TO TRINTRO]
-7 [Thank you for your time.]
-8 [Thank you for your time.]

Thank you for the information. END INTERVIEW.

TRSERVERF. IF NEEDED: We show {you/s/he} may have received {TYPE OF SERVICE} services from
{PROVIDER NAME/AGENCY NAME}. Is that correct?
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2 [Thank you for your time.]
-7 [Thank you for your time.]
-8 [Thank you for your time.]

PROGRAMMER NOTE: IF PARTICIPANT OR INTERPRETER/TRANSLATOR, DISPLAY SECOND
PERSON PRONOUN (E.G., “DO YOU” OR “HAVE YOU”) IN QUESTIONS. IF PROXY, DISPLAY
THIRD PERSON PRONOUN (E.G., “DOES S/HE” OR “HAS S/HE”) WHERE INDICATED.

TRANSPORTATION

Page 28

TRINTRO1. First, I am going to ask some questions about the transportation service {you receive/NAME
OF PARTICIPANT receives} from {PROVIDER NAME/AGENCY NAME}.
[NEWTR1/OLD TR2]

When was the last time {you/s/he} used this service? Was it…

(TRDAYS)
Today or yesterday, ...............................................................
More than 1 day to 1 week ago, .............................................
More than 1 week to 1 month ago, or ...................................
More than 1 month ago? ........................................................
ONLY GOT IT ONE TIME [INTERVIEWER NOTE:
INCLUDES R WHO SAYS THEY GOT HELP FOR A
SHORT TIME, E.G. AFTER A HOSPITAL STAY] ............
OVER 1 YEAR AGO……………. ...........................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

THANK3.

1
2
3
4

5
6
-7
-8

[GO TO THANK3
[GO TO THANK3]
[GO TO THANK3
[GO TO THANK3

Thank-you, but the focus of this survey is on people who have used the service within the past
year.

[NEWTR2/OLDTR1]
it…

About how long ago did {you/s/he} start using this transportation service? Was

(HOWLONG)
6 months or less, ....................................................................
More than 6 months, but less than 1 year, .............................
At least 1 year, but less than 2 years, ....................................
2 to 5 years, or .......................................................................
More than 5 years? ................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
-7
-8

FENCEPOST

TR3.

How often {do you/does s/he} use the transportation service?
(TROFTEN)
5 or more times per week, ......................................................
2 to 4 times per week, ............................................................
Once per week, ......................................................................
1 to 3 times per month, or ......................................................
Less than once per month? ....................................................
ONLY USED IT ONCE/FOR A SHORT TIME
[INTERVIEWER NOTE: IF RESPONDENT SAYS THEY
USED IT FOR A SHORT TIME].........................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

TRANSPORTATION

1
2
3
4
5

6 [GO TO THANK3]
-7 [GO TO THANK3
-8 [GO TO THANK3

Page 29

TR4.

About how many local one-way trips a month {do you/does NAME OF PARTICIPANT} make
using this service? For example, if {you go/s/he goes} to the grocery store and then
{come/comes} back using this service, that counts as 2 one-way trips.
(TRMONTH)
NUMBER OF TRIPS ..............................................................

|___|___|___|
SOFT RANGE = 0-30
HARD RANGE = 0-100
LESS THAN ONCE A MONTH .............................................. L
OTHER ................................................................................... 91
(SPECIFY:_______________________________________)
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

PROGRAMMER NOTE: IF TROFTEN=6, AUTOCODE TRPROP THEN GO TO TRRATE.

TR5.

In an average month, would {you/ NAME OF PARTICIPANT} say {you rely/s/he relies} on
this transportation service for:
(TRPROP and TRPROPOS)
Just a few of {your/ his/her} local trips,................................... 1
About 1/4 of all {your/ his/her} local trips, ............................... 2
About 1/2 of all {your/ his/her} local trips, ............................... 3
About 3/4 of all {your/ his/her} local trips, or........................... 4
Nearly all of {your/ his/her} local trips? ................................... 5
OTHER ................................................................................... 91
(SPECIFY:_______________________________________)
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

TR6.

When using {PROVIDER OF SERVICE} where {do you/does NAME OF PARTICIPANT} get
on the vehicle? Would {you/s/he} say . . .
(TRGTSON)
The driver comes to {your/ his/her} door, ...............................
The vehicle stops in front of {your / his/her} home or in
the driveway, ..........................................................................
The vehicle stops down the block, or .....................................
{You have/ NAME OF PARTICIPANT has} to walk several
blocks to get on the vehicle? ..................................................
{YOU GET/NAME OF PARTICIPANT GETS} ON THE
BUS AT THE SENIOR CENTER? .........................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
-7
-8

FENCEPOST

TRANSPORTATION

Page 30

TRINTRO2. For the next few questions, please tell me how frequently these statements apply to {your/
NAME OF PARTICIPANT’s} overall experience with {PROVIDER NAME/AGENCY NAME}.
Please select one of these five responses: always, usually, sometimes, seldom, or never.

Always

Usually

Sometimes

Seldom

Never

(TRFRE05 - TRFRE17)

RF

The drivers pick {you/him/her} up when they are
supposed to. [IF NEEDED: Would {you/NAME
OF PARTICIPANT} say…]

1

2

3

4

5

-7

-8

TR8.

The drivers are polite. [IF NEEDED: Would
{you/NAME OF PARTICIPANT} say…]

1

2

3

4

5

-7

-8

TR9.

The vehicles are easy to get into and out of.
Would {you/NAME OF PARTICIPANT} say…

1

2

3

4

5

-7

-8

TR10. The vehicles are comfortable. Would
{you/NAME OF PARTICIPANT} say…

1

2

3

4

5

-7

-8

TR11. {You arrive/S/He arrives} at {your/his/her}
destination on time. [IF NEEDED: Would
{you/NAME OF PARTICIPANT} say…]

1

2

3

4

5

-7

-8

TR12. {You/NAME OF PARTICIPANT} can get to the
places {you want/ s/he wants} or {need/needs}
to go. [IF NEEDED: Would {you/NAME OF
PARTICIPANT} say…]

1

2

3

4

5

-7

-8

TR13. {You get/S/He gets} rides at the times and on
the days {you need/s/he needs} them. [IF
NEEDED: Would {you/NAME OF
PARTICIPANT} say…]

1

2

3

4

5

-7

-8

TR7.

TR14.

DK

{Do you/Does NAME OF PARTICIPANT} need help getting into and out of {your/his/her}
home?
(NEEDHLP)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
TR14b.

1
2 [GO TO TR15]
-7 [GO TO TR15]
-8 [GO TO TR15]

Does the driver or aide help {you/him/her} get into and out of {your/his/her} home?
(GETHELP)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

TRANSPORTATION

1
2
-7
-8

Page 31

TR15.

{Do you/Does NAME OF PARTICIPANT} need help getting into or out of the van or bus?
(NEEDBHLP)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
TR15b.

1
2 [GO TO TR16]
-7 [GO TO TR16]
-8 [GO TO TR16]

Does the driver or aide help {you/him/her} get into or out of the van or bus?
(GETBHELP)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

TR16.

{Do you/Does NAME OF PARTICIPANT} use {your/his/her} transportation service to get to:
(TRACTA TO TRACTK)
YES

NO

RF

DK

A.

Doctors and health care providers? ......................................

1

2

-7

-8

B.

Shopping? .............................................................................
[INTERVIEWER NOTE: INCLUDES HAIRDRESSER]

1

2

-7

-8

C.

Volunteer activities? ..............................................................

1

2

-7

-8

D.

Senior center? .......................................................................

1

2

-7

-8

E.

Pick up food or to get a meal? ..............................................

1

2

-7

-8

F.

Friends, neighbors, and relatives? ........................................

1

2

-7

-8

G.

Social events and recreation activities?................................

1

2

-7

-8

H.

Clubs and meetings? ............................................................

1

2

-7

-8

I.

Religious services? ...............................................................

1

2

-7

-8

J.

Work?....................................................................................

1

2

-7

-8

K.

Some other place? ...............................................................

1

2

-7

-8

PROGRAMMER NOTE: IF ALL OF TR16 A-J AND 91 ARE 2, -7, AND/OR -8, AUTOCODE TR16K “1.”
IF ANY OF TR16 A-J AND/OR 91 ARE 1, AUTOCODE TR16K “2.”
FENCEPOST

TRANSPORTATION

Page 32

TR17.

Next, how would {you/ NAME OF PARTICIPANT} rate the transportation service that
{you/s/he} received? Would {you/ s/he} say…
(TRRATE)
Excellent .................................................................................
Very good, ..............................................................................
Good, ......................................................................................
Fair, or ....................................................................................
Poor? ......................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
-7
-8

FENCEPOST

TR18.

{Do you/ Does NAME OF PARTICIPANT} get around more than {you/s/he} did before
{you/s/he} had this service? Would {you/s/he} say…
(AROUND)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

TRINTRO3. Please tell me:

(TRR

TR19. Would {You/ NAME OF PARTICIPANT}
recommend this transportation service to a friend? ...........
(TRRECOM)
TR20. Do the services {you receive/s/he receives} help
{you/NAME OF PARTICIPANT} to continue to live
independently? ...................................................................
(TRSTAY)

YES

NO

RF

DK

1

2

-7

-8

1

2

-7

-8

FENCEPOST

TRINTRO4. Now, I would like to ask if {you have/s/he has} a car or personal motor vehicle.
TR21.

Is there a car or personal motor vehicle in working condition in {your/NAME OF
PARTICIPANT’s} household?
(TRISCAR)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

TRANSPORTATION

1
2
-7
-8

[SKIP TR22]
[SKIP TR22]
[SKIP TR22]

Page 33

TR22.

{Do you/Does NAME OF PARTICIPANT} ever drive that car or personal motor vehicle?
(TRDRIVE)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

GO TO THE FOLLOWING MODULES AND COMPLETE THE QUESTIONS IN THIS SEQUENCE:
ADDITIONAL SERVICE LIST MODULE; USDA; FALLS; LIFE CHANGES; SOCIAL
INTEGRATION;
PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE;
DEMOGRAPHIC INTAKE MODULE.

TRANSPORTATION

Page 34

FAMILY CAREGIVER SURVEY

CGINTRO [CAREGIVER/PARTICIPANT]. My name is {INTERVIEWER’S NAME} and I am calling on
behalf of the U.S. Department of Health and Human Services’ Administration on Aging. We are conducting
a survey to find out how we can help meet the needs of caregivers and seniors being served by {PROVIDER
NAME/AGENCY NAME}. We show you have received caregiver support services from {PROVIDER
NAME/AGENCY NAME} to help you take care of {CARE RECIPIENT}. We would like to know if these
caregiver support services have been helpful.
This survey will take about 30 minutes to complete. Your participation is voluntary and very important to the
success of this study. Responses to this data collection will be used only for purposes of this research. The
reports prepared for this study will summarize information provided by participants and will not associate
responses with a specific individual. We will not provide information that identifies individuals to anyone
outside the study team, except as required by law. Your eligibility for services will not be affected by your
decision to participate or by any answers you give. You may skip any question that you do not want to
answer, or stop the interview at any time, but we would really appreciate your answering all the questions
you can.
CGINTROINT [INTERPRETER]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the
U.S. Department of Health and Human Services’. Administration on Aging, We are conducting a survey to
find out how we can help meet the needs of caregivers and seniors being served by {PROVIDER
NAME/AGENCY NAME}. We show {NAME OF CAREGIVER} has received caregiver support services from
{PROVIDER NAME/AGENCY NAME} to help {him/her} take care of {CARE RECIPIENT}. We would like to
know if these caregiver support services have been helpful.
We would like {NAME OF CAREGIVER} to answer the questions as independently as possible. We want
to be sure that, wherever possible, we are getting {NAME OF CAREGIVER}’s actual opinions and
responses.
This survey will take about 30 minutes to complete. {NAME OF CAREGIVER’s} participation is voluntary
and very important to the success of this study. Responses to this data collection will be used only for
purposes of this research. The reports prepared for this study will summarize information provided by
participants and will not associate responses with a specific individual. We will not provide information that
identifies individuals to anyone outside the study team, except as required by law. {His/Her} and {CARE
RECIPIENT}’s eligibility for services will not be affected by {NAME OF CAREGIVER’s} decision to
participate or by any answers {s/he} gives. You may skip any question that you do not want to answer, or
stop the interview at any time, but we would really appreciate your answering all the questions you can.
IF NEEDED: We were given your name as the interpreter for {NAME OF CAREGIVER}.
CGINTROPRX [PROXY]. My name is {INTERVIEWER’S NAME} and I am calling on behalf of the U.S.
Department of Health and Human Services’. Administration on Aging, We are conducting a survey to find
out how we can help meet the needs of caregivers and seniors being served by {PROVIDER
NAME/AGENCY NAME}. We got {NAME OF CAREGIVER} information from {PROVIDER NAME/AGENCY
NAME}.
We want to be sure that, wherever possible, we are getting {NAME OF CAREGIVER}’s actual opinions and
responses. For the remainder of the survey, I would like you to answer as though you were {NAME OF
CAREGIVER}. All of the following questions pertain to {him/her} Please provide your best estimate as to
{his/her} own response or opinion.
This survey will take about 30 minutes to complete. {His/Her} participation is voluntary and very important
to the success of this study. Responses to this data collection will be used only for purposes of this research.
The reports prepared for this study will summarize information provided by participants and will not
associate responses with a specific individual. We will not provide information that identifies individuals to

FAMILY CAREGIVER

Page 35

anyone outside the study team, except as required by law. {His/Her} and {CARE RECIPIENT}’s eligibility
for services will not be affected by {NAME OF CAREGIVER’s} decision to participate or by any answers
{s/he} gives. You may skip any question that you do not want to answer, or stop the interview at any time,
but we would really appreciate your answering all the questions you can.
IF NEEDED: We were given your name as the proxy for {NAME OF CAREGIVER}.
SKIP TO CGB IF NO CARE RECIPIENT NAME

CGA.

{You are/NAME OF CAREGIVER is} listed as someone who currently provides care for
{CARE RECIPIENT}. {Are you/Is s/he} still the caregiver for {CARE RECIPIENT}?
(CGSTLCR)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

IF NO, RECORD ANY COMMENTS RESPONDENT MADE ABOUT FORMER CARE
RECIPIENT (E.G., RESPONDENT IN NURSING HOME, DECEASED, ETC):
_____________________________________________________________________________
_____________________________________________________________________________

PROGRAMMER NOTE: IF CGA IS NO, RF, OR DK, GO TO CLOSING AND END INTERVIEW AFTER
INTERVIEWER ENTERS ANY COMMENTS.

CGB.

Is {CARE RECIPIENT} 60 years of age or older?
(CGAGE60)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

PROGRAMMER NOTE: IF CGB IS NO, RF, OR DK, GO TO CLOSING AND END INTERVIEW.

PROGRAMMER NOTE: IF INTERPRETER WILL NOT DO INTERVIEW, GO TO CGALTCON.
OTHERWISE, GO TO CGINTRO1.

PROGRAMMER NOTE: IF PROXY WILL NOT DO INTERVIEW, CONTINUE WITH CGALTCON.
OTHERWISE CONTINUE WITH CGINTRO1.

FAMILY CAREGIVER

Page 36

CGALTCON.

May I have the name and telephone number of someone else to contact?
_________________
FIRST NAME

____________________
LAST NAME

(|___|___|___|)
(AREA CODE)

|___|___|___| - |___|___|___|___|
(TELEPHONE NUMBER)

REFERRED BACK TO CAREGIVER ....................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1 [GO TO CGINTRO]
-7 [GO TO THANK YOU]
-8 [GO TO THANK YOU]

THANK-YOU. Thank you for the information. END INTERVIEW.

CGINTRO1.

This survey typically takes 30 minutes. {You/NAME OF CAREGIVER} may be more
comfortable answering these questions if {you are/s/he is} not in the presence of the person
{you are/s/he is} caring for. Is this a good time for {you/him/her}?
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2 [GO TO APPOINTMENT]
-7
-8

FENCEPOST
CGINTRO2. Now, let’s begin the caregiver survey. {Your/NAME OF CAREGIVER’s} participation is
voluntary and very important to the success of this study.

PROGRAMMER NOTE: IF CAREGIVER IS FEMALE, USE FIRST DISPLAY IN SECOND SENTENCE
OF CG1 (E.G.: WIFE OR DAUGHTER). IF CAREGIVER IS MALE, USE SECOND DISPLAY (E.G.
HUSBAND OR SON). IF CARE RECIPIENT’S NAME IS NOT ON FILE, REFER TO THE CARE
RECIPIENT AS “THE PERSON YOU CARE FOR” IN THE FIRST DISPLAY AND “THEIR” IN THE
SECOND DISPLAY.

FAMILY CAREGIVER

Page 37

CG1.

What is {your/his/her} relationship to {CARE RECIPIENT/the person you care for}? Are you
{Is he/she} his/her…
[INTERVIEWER NOTE: READ CATEGORIES IF NEEDED]
(CGREL)
HUSBAND, ............................................................................. 1
WIFE,...................................................................................... 2
SON, ....................................................................................... 3
SON-IN-LAW, ......................................................................... 4
DAUGHTER, .......................................................................... 5
DAUGHTER-IN-LAW, ............................................................ 6
FATHER, ................................................................................ 7
MOTHER, ............................................................................... 8
BROTHER, ............................................................................. 9
SISTER, ................................................................................. 10
GRANDDAUGHTER, ............................................................. 11
GRANDSON, ......................................................................... 12
NIECE, ................................................................................... 13
NEPHEW, .............................................................................. 14
A FRIEND OR NEIGHBOR OR ANOTHER PERSON, OR ... 15
OTHER RELATIVE ................................................................ 91
(SPECIFY: _______________________________________)
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

FENCEPOST
PROGRAMMER NOTE: IF CARE RECIPIENT’S NAME IS NOT ON FILE FROM AREA AGENCY, ASK
CGC. ELSE, GO TO CG2.

CGC.

[ASK OF ALL] What is {CARE RECIPIENT’s} sex?
(RGENDER)
MALE ......................................................................................
FEMALE .................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

IF RELATIONSHIP IN CG1 = NIECE OR NEPHEW, INSERT “{YOUR/HIS/HER} RELATIVE” IN PLACE
OF CARE RECIPIENT NAME IN THE REST OF THE INTERVIEW AND SKIP TO CG2
IF RELATIONSHIP IN CG1 = OTHER RELATIVE, INSERT “{YOUR/HIS/HER} {CGRELOS}” IN PLACE
OF CARE RECIPIENT NAME IN THE REST OF THE INTERVIEW AND SKIP TO CG2
IF RELATIONSHIP IN CG1 = FRIEND, DK, OR RF, CONTINUE TO SHOW “THE PERSON YOU CARE
FOR” IN PLACE OF CARE RECIPIENT NAME IN THE REST OF THE INTERVIEW AND SKIP TO CG2

FAMILY CAREGIVER

Page 38

I’m going to read several activities that some people need help with. {Do you/Does NAME
OF CAREGIVER} help {CARE RECIPIENT} with …

G2.

(CGACTI01 TO CGACTI06)

1.
2.
3.
4.
5.
6.

Activities like dressing, eating, bathing, or getting to the bathroom?
Medical needs such as taking medicine or changing bandages? .....
Keeping track of bills, checks, or other financial matters? ................
Preparing meals, doing laundry, or cleaning the house? ..................
Local trips, such as going shopping or to the doctor’s office?...........
Arranging for care or services provided by others? ..........................

YES
1
1
1
1
1
1

NO
2
2
2
2
2
2

RF
-7
-7
-7
-7
-7
-7

DK
-8
-8
-8
-8
-8
-8

IF CG2 1 THROUGH 6 ARE ALL NO (2), RF (-7) OR DK (-8), GO TO CG2B. ELSE, GO TO CGINTRO3.
AS LONG AS SOMETHING IS ENTERED IN OPEN-ENDED RESPONSE (CG2B), CONTINUE
INTERVIEW. IF CG2B IS NONE (1), RF OR DK, GO TO CLOSE2.
FENCEPOST

ACCEPT UP TO 6 LINES OF 60 CHARACTERS EACH IN CG2B.
AS LONG AS SOMETHING IS ENTERED IN OPEN-ENDED RESPONSE (CG2B), CONTINUE
INTERVIEW. IF CG2B IS NONE (1), RF OR DK, GO TO CLOSING.
CG2B.

What kind of care {do you/ does NAME OF CAREGIVER} provide for {CARE
RECIPIENT}?
(COMM.COMMTEXT)
NONE ........................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1 [GO TO CLOSING]
-7 [GO TO CLOSING]
-8 [GO TO CLOSING]

OPEN-ENDED RESPONSES:
A. ___________________________________________________________________________
B. ___________________________________________________________________________
C. ___________________________________________________________________________
D. ___________________________________________________________________________
E. ___________________________________________________________________________
F. ___________________________________________________________________________

FENCEPOST

FAMILY CAREGIVER

Page 39

The first few questions are about your caregiving experiences.
CG3.

What prompted you to contact [AGENCY NAME]?
(CGAGNAME)
MEDICAL OR HEALTH ISSUE OR HOSPITALIZATION ... 1
SPOUSE, SON/DAUGHTER, SIBLING, FRIEND
NO LONGER ABLE TO HELP .......................................... 2
PAID CAREGIVER QUIT .................................................... 3
RECENTLY MOVED TO THE AREA .................................. 4
NEED TRANSPORTATION ................................................ 5
JUST WANTED INFORMATION ........................................ 6
WAITING LIST .................................................................... 7
INFORMATION AND ASSISTANCE (I&A) ......................... 8
DON’T REMEMBER ............................................................ 9
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG4.

Please think about all of the health care professionals or service providers who give care or
treatment to [CARE RECIPIENT’S NAME]. How easy or difficult is it for {you/him/her} to
coordinate care between those providers?
(CGCOORD)
Very easy ............................................................................ 1
Somewhat easy ................................................................... 2
Somewhat difficult ............................................................... 3
Very difficult ......................................................................... 4
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
NOT APPLICABLE .............................................................. -9

CG5.

If [CARE RECIPIENT’S NAME] needed a greater amount of care would you be able to
increase your caregiving responsibilities?
(CGMORE)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FAMILY CAREGIVER

Page 40

CG6.

How long have you been receiving caregiver support services?
(CGHOWLNG)
6 months or less, ................................................................. 1
More than 6 months, but less than 1 year, .......................... 2
At least 1 year, but less than 2 years, ................................. 3
2 to 5 years, ......................................................................... 4
5 to 10 years, ....................................................................... 5
11 to 20 years, or ................................................................ 6
More than 20 years? ........................................................... 7
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG7.

Do you know where to go to ask for respite care, which allows you a brief period of rest or
relief while temporary care is provided to [CARE RECIPIENT’S NAME] either in your home or
his/her home or someplace else?
(KNOWRSPT)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG8.

Have you attended caregiver education or training such as classroom or on-line courses?
(ATTNDTRN)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

GO TO CG9
GO TO CG8a
GO TO CG9
GO TO CG9

FENCEPOST
CG8a.

IF NO, do you have a need for caregiver education or training, such as classroom or
on-line courses?
(NEEDEDU)
YES ......................................................................... 1
NO .......................................................................... 2
REFUSED............................................................... -7
DON’T KNOW......................................................... -8

FAMILY CAREGIVER

Page 41

CG9.

Have you attended counseling to assist with your specific caregiving situation?
(ATTNDCON)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
CG9a.

GO TO CG10
GO TO CG9a
GO TO CG10
GO TO CG10

IF NO, do you have a need for counseling to assist with his/her specific caregiving
situation?
(NEEDCON)
YES ......................................................................... 1
NO .......................................................................... 2
REFUSED............................................................... -7
DON’T KNOW......................................................... -8

CG10.

Have you attended caregiver support groups?
(ATTNDSUP)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
CG10a.

GO TO CG11
GO TO CG10a
GO TO CG11
GO TO CG11

IF NO, do you have a need for attending caregiver support groups?
(NEEDSUP)
YES ......................................................................... 1
NO .......................................................................... 2
REFUSED............................................................... -7
DON’T KNOW......................................................... -8

CG11.

In the last year, have you found financial help for {CARE RECIPIENT} including helping
him/her apply for Medicaid?
(HELPFIN)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FAMILY CAREGIVER

Page 42

CG12.

Have the Family Caregiver services provided Supplemental Services such as:
(CGSUPA – CGSUPD , SUPPSVE, CGUSPF-CGSUPG)
YES

NO

RF

DK

a. Home modifications, such as a ramp or grab bar? ............................

1

2

-7

-8

b. Liquid nutritional supplements, such as Ensure, Boost, or
Glucerna? ..........................................................................................

1

2

-7

-8

c.

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

Money or a stipend? ..........................................................................

1

2

-7

-8

g. Anything else? ..................................................................................
(SPECIFY:____________________________________________)

1

2

-7

-8

Walkers, canes crutches, Hoyer Lift, microwaves? ...........................

d. Emergency response system, CPAP or apnea machines, hospital
bed, or a device to monitor wandering? ............................................
e. Consumable supplies such as wound care, catheter, or
incontinence supplies? [IF NEEDED: CONSUMABLE SUPPLIES
ARE THINGS THAT YOU USE ONCE AND THROW AWAY]
f.

FENCEPOST

CG13.

As a result of the caregiver services {you have/NAME OF CAREGIVER has} received, {do
you/does s/he}…
(CGAFECA-CGAFECE)
YES

NO

RF

DK

a. Have more time for personal activities? ............................................

1

2

-7

-8

b. Feel less stress? ................................................................................

1

2

-7

-8

c.

Find it easier to care for {CARE RECIPIENT}? .................................

1

2

-7

-8

d. Have a clearer understanding of how to get the services {you/
NAME OF CAREGIVER} and {CARE RECIPIENT} need? ...............

1

2

-7

-8

e. Know more about {CARE RECIPIENT’s} condition or illness? .........

1

2

-7

-8

CG14.

Have these caregiver services helped you to be a better caregiver?
(CGHELP)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

FENCEPOST

FAMILY CAREGIVER

Page 43

CG15.

Have these caregiver services enabled {you/NAME OF CAREGIVER} to provide care for
{CARE RECIPIENT} for a longer time than would have been possible without these
services?
(CGCARLG)
YES, .......................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CG16.

1
2
-7
-8

Overall, how would {you/ NAME OF CAREGIVER} rate the caregiver support services {you
have/s/he has} received? Would {you/ NAME OF CAREGIVER} say…
(CGRATE)
Excellent, ................................................................................
Very good, ..............................................................................
Good, ......................................................................................
Fair, or ....................................................................................
Poor? ......................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
-7
-8

FENCEPOST

CG17.

Has it been difficult for {you/ NAME OF CAREGIVER} to get services from agencies for
{CARE RECIPIENT}?
(CGDIFF)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

FAMILY CAREGIVER

1
2
-7
-8

Page 44

CGINTRO4. Now, I would like to ask you a few questions about {your/NAME OF CAREGIVER’s}
employment.
CG18.

Are you currently employed?
(CAREMP)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
CG18a.

GO TO CG18a
GO TO CG19
GO TO CG19
GO TO CG19

Has providing care for {CARE RECIPIENT} interfered with {your/NAME OF
CAREGIVER’s} job?
(CGINTER)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

CG19.

1
2 [GO TO CGINTRO5]
-7 [GO TO CGINTRO5]
-8 [GO TO CGINTRO5]

Because of providing care for [NAME OF CARE RECIPIENT] care for, did you...
(CRPROBA-CRPROBI)
YES

NO

RF

DK

a. Take a less demanding job? ........................................

1

2

-7

-8

b. Change from full-time to part-time work/reduced your
official working hours? ..................................................

1

2

-7

-8

c.

Lose some of your employment fringe benefits? .........

1

2

-7

-8

d. Have time conflicts between working and caregiving? .

1

2

-7

-8

e. Use your vacation time to provide care? ......................

1

2

-7

-8

f.

Take a leave of absence to provide care? ...................

1

2

-7

-8

g. Lose a promotion? ........................................................

1

2

-7

-8

h. Work less than your normal number of hours last
month? ..........................................................................

1

2

-7

-8

i.

1

2

-7

-8

Other? ...........................................................................
(SPECIFY:_________________________________)

FAMILY CAREGIVER

Page 45

CG19a.

(IF YES, TO ANY OF THE ABOVE) Did the caregiver support services helped you
deal with these work difficulties?
(CAREHLP)
YES ......................................................................... 1
NO .......................................................................... 2
REFUSED............................................................... -7
DON’T KNOW......................................................... -8

IF NO TO ALL CG19 a to g GO TO CG21.

CG20.

As a result of caregiving-related changes in your employment or expenses, have you had to...
(CGFINCLA-CGFINCLJ)
YES

NO

RF

DK

a. Dip into your savings? ....................................................

1

2

-7

-8

b. Take out a loan or increase your level of credit card
debt? ..............................................................................

1

2

-7

-8

Cut back on your own spending for vacations or
travel?.............................................................................

1

2

-7

-8

d. Cut back on your own spending for hobbies, going out
to eat, movies, or other leisure activities? ......................

1

2

-7

-8

e. Cut down on your own spending for groceries? ............

1

2

-7

-8

Cut back on your own spending on health care or
dental care? ...................................................................

1

2

-7

-8

g. Cut back on your own spending for basic home
maintenance? .................................................................

1

2

-7

-8

h. Cut back on your own spending for necessities you
have not already mentioned, such as clothing,
transportation, or home utilities (home utilities include
things such as electricity, water, and phone) .................

1

2

-7

-8

i.

Quit your job ...................................................................

1

2

-7

-8

j.

Other? ............................................................................
(SPECIFY: __________________________________ )

1

2

-7

-8

c.

f.

FAMILY CAREGIVER

Page 46

CGINTRO5. The following questions are about {your/his/her} situation as a caregiver.
CG21.

I gain “no,” “some,” or “a lot” of satisfaction from performing my care tasks. Please select the
response that that best fits your situation. Would you say...
(CGSATISA-CGSATISC)

CG22.

YES

NO

RF

DK

a. No satisfaction ................................................................

1

2

-7

-8

b. Some satisfaction, or ......................................................

1

2

-7

-8

c.

1

2

-7

-8

YES

NO

RF

DK

a. Medications or medical care? .......................................

1

2

-7

-8

b. Insurance premiums or copayments? ..........................

1

2

-7

-8

Mobility devices, such as walkers, canes, or
wheelchairs? .................................................................

1

2

-7

-8

d. Features that have made [CARE RECIPIENT’S
NAME] home safer, such as a railing or ramp, grab
bars in the bathroom, a seat for the shower or tub or
an emergency response system? ................................

1

2

-7

-8

e. Any other assistive devices that make it easier or
safer to do activities or do them on his/her own? .........

1

2

-7

-8

f.

1

2

-7

-8

A lot of satisfaction .........................................................

In the last year have you paid for [CARE RECIPIENT’S NAME]...
(CGPAIDA-CGPAIDF)

c.

Other? ...........................................................................
(SPECIFY:_________________________________)

Now, I am going to ask you about how you feel these days.
CG23.

How much of the time during the past four weeks have you...
(CGFEELA-CGFEELC)
All of
the Time

Most of
the Time

Some of
the Time

A little of
the Time

None of
the Time

RF

DK

a. Felt calm and peaceful? ..

1

2

3

4

5

-7

-8

b. Have a lot of energy?.......

1

2

3

4

5

-7

-8

1

2

3

4

5

-7

-8

c.

Felt downhearted and
depressed? ......................

FAMILY CAREGIVER

Page 47

Now, I am going to ask you about how caregiving fits in with your other activities. Please select the situation
that best fits your answer.
CG24.

Regarding your present social activities, do you feel that you are doing...
(CGACT)
About enough ...................................................................... 1
Too much ............................................................................ 2
Would like to be doing more ................................................ 3
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG25.

Have your social opportunities increased since you became involved with [PROVIDER
AGENCY NAME] services?
(CGOPPINC)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG26.

How often does caregiving prevent you from having enough time for yourself?
(CGTIME)
Always ................................................................................. 1
Usually ................................................................................. 2
Sometimes .......................................................................... 3
Rarely .................................................................................. 4
Never ................................................................................... 5
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG27.

How often does caregiving prevent you from having enough time for your family?
(CGFAMILY)
Always ................................................................................. 1
Usually ................................................................................. 2
Sometimes .......................................................................... 3
Rarely .................................................................................. 4
Never ................................................................................... 5
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FAMILY CAREGIVER

Page 48

CG28.

How often does caregiving conflict with your social life?
(CGSOCIAL)
Always ................................................................................. 1
Usually ................................................................................. 2
Sometimes .......................................................................... 3
Rarely .................................................................................. 4
Never ................................................................................... 5
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG29.

How often does being a caregiver for the person you care for give you the joy of spending
time with someone you care about?
(CGJOY)
Always ................................................................................. 1
Usually ................................................................................. 2
Sometimes .......................................................................... 3
Rarely .................................................................................. 4
Never ................................................................................... 5
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG30.

How often does being a caregiver provide you with a sense of accomplishment?
(CGACOMP)
Always ................................................................................. 1
Usually ................................................................................. 2
Sometimes .......................................................................... 3
Rarely .................................................................................. 4
Never ................................................................................... 5
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG31.

How often does providing care for the person you care for give you the satisfaction of knowing
that they are receiving the care and attention they need?
(CGATTION)
Always ................................................................................. 1
Usually ................................................................................. 2
Sometimes .......................................................................... 3
Rarely .................................................................................. 4
Never ................................................................................... 5
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FAMILY CAREGIVER

Page 49

CG32.

How often do you feel that the person you care for appreciates the care that you are providing
to [CARE RECIPIENT’S NAME]?
(CRAPREC)
Always ................................................................................. 1
Usually ................................................................................. 2
Sometimes .......................................................................... 3
Rarely .................................................................................. 4
Never ................................................................................... 5
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG33.

As a caregiver, how often do you feel you are fulfilling your duty by caring for the [CARE
RECIPIENTS NAME]?
(CGDUTY)
Always ................................................................................. 1
Usually ................................................................................. 2
Sometimes .......................................................................... 3
Rarely .................................................................................. 4
Never ................................................................................... 5
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

For the next set of questions, I will ask you how true the statement is for you.
CG34.

You can always manage to solve difficult problems if you try hard enough. Would you say...
(CGSOLV)
Not at all true ....................................................................... 1
Hardly true ........................................................................... 2
Moderately true ................................................................... 3
Exactly true .......................................................................... 4
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG35.

It is easy for you to stick to your aims and accomplish your goals. Would you...
(CGAIMS)
Not at all true ....................................................................... 1
Hardly true ........................................................................... 2
Moderately true ................................................................... 3
Exactly true .......................................................................... 4
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FAMILY CAREGIVER

Page 50

CG36.

You are confident that you could deal efficiently with unexpected events. Would you say...
(CGEFF)
Not at all true ....................................................................... 1
Hardly true ........................................................................... 2
Moderately true ................................................................... 3
Exactly true .......................................................................... 4
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG37.

Thanks to your resourcefulness, you know how to handle unforeseen situations. Would you
say...
(CGRESORC)
Not at all true ....................................................................... 1
Hardly true ........................................................................... 2
Moderately true ................................................................... 3
Exactly true .......................................................................... 4
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG38.

You can solve most problems if you invest the necessary effort. Would you say...
(CGSOLVE)
Not at all true ....................................................................... 1
Hardly true ........................................................................... 2
Moderately true ................................................................... 3
Exactly true .......................................................................... 4
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG39.

You can remain calm when facing difficulties because you can rely on your coping abilities.
Would you say...
(CGRELY)
Not at all true ....................................................................... 1
Hardly true ........................................................................... 2
Moderately true ................................................................... 3
Exactly true .......................................................................... 4
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FAMILY CAREGIVER

Page 51

CG40.

When you are confronted with a problem you can usually find several solutions. Would you
say...
(CGCONFRNT)
Not at all true ....................................................................... 1
Hardly true ........................................................................... 2
Moderately true ................................................................... 3
Exactly true .......................................................................... 4
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG41.

If someone opposes you, you can find the means and ways to get what you want. Would you
say...
(CGWANT)
Not at all true ....................................................................... 1
Hardly true ........................................................................... 2
Moderately true ................................................................... 3
Exactly true .......................................................................... 4
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG42.

If you are in trouble, you can usually think of a solution. Would you say...
(CGTRBL)
Not at all true ....................................................................... 1
Hardly true ........................................................................... 2
Moderately true ................................................................... 3
Exactly true .......................................................................... 4
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG43.

You can usually handle whatever comes your way. Would you say...
(CGHANDL)
Not at all true ....................................................................... 1
Hardly true ........................................................................... 2
Moderately true ................................................................... 3
Exactly true .......................................................................... 4
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FAMILY CAREGIVER

Page 52

CGINTRO6. The next set of questions are about {your/NAME OF CAREGIVER’s} health.
CG44.

Compared to one year ago, how would {you/ NAME OF CAREGIVER} rate your health in
general now? Would {you/s/he} say:
(CGHEALTH)
Much better, ...........................................................................
Somewhat better, ...................................................................
About the same, .....................................................................
Somewhat worse ....................................................................
Much worse ............................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CG45.

1
2
3
4
5
-7
-8

In the past month, have you been bothered by pain?
(CGPAIN)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
CG45a.

GO TO CG45a
GO TO CG46
GO TO CG46
GO TO CG46

IF YES, in the last month how often has pain limited your activities?

(CGLIMIT)
Every day ................................................................ 1
Most days ............................................................... 2
Some days .............................................................. 3
Rarely ..................................................................... 4
Never ...................................................................... 5
REFUSED............................................................... -7
DON’T KNOW......................................................... -8

CG46.

In the past 12 months, have you been to see a doctor? Do not include going to the hospital
emergency department.
(CGDOCTOR)

INTERVIEWER NOTE:
DOCTOR INCLUDES PHYSICIANS ASSISTANT OR NURSE PRACTITIONER
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FAMILY CAREGIVER

Page 53

CG47.

In the past 12 months, have you been to an urgent care center? Do not include going to the
hospital or to the hospital emergency department.
(CGURGNT)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG48.

In the past 12, months, have you been to a hospital emergency department?
(CGER)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
CG48a.

GO TO CG48a
GO TO CG49
GO TO CG49
GO TO CG49

In the past 12 months, how many times did you go to a hospital emergency
department?
(CGERNUMB)
|___|___|___| TIMES
REFUSED............................................................... -7
DON’T KNOW......................................................... -8

CG49.

In the past 12 months did you have to stay overnight in a hospital?
(CGHOSP)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
CG49a.

GO TO CG49a
GO TO CG50
GO TO CG50
GO TO CG50

If YES, in the past 12 months, how many times were you hospitalized for one night
or longer?
(CGHOSPN)
|___|___|___| TIMES
REFUSED............................................................... -7
DON’T KNOW......................................................... -8

FAMILY CAREGIVER

Page 54

CG49b.

If YES, how many total nights did you spend in the hospital?
(CGHOSPNN)
|___|___|___| NIGHTS
REFUSED............................................................... -7
DON’T KNOW......................................................... -8

CG50.

In the past 12 months, did you have to stay overnight in a nursing home or rehabilitation
center?
(CGREHAB)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
CG50a.

GO TO CG50a
GO TO CG51
GO TO CG51
GO TO CG51

IF YES, in the past 12 months, how many times have you stayed in a nursing home
or live in a rehabilitation center?
(CGREHABN)
|___|___|___| TIMES
REFUSED............................................................... -7
DON’T KNOW......................................................... -8

CG51.

Thinking about all the family members or friends who provide help, care, or supervision for
[NAME OF CARE RECIPIENT], what proportion of the care do you provide during a typical
week? Would you say...
(CGPORT)
Less than one-quarter ......................................................... 1
About one-quarter ............................................................... 2
About one-half ..................................................................... 3
About three-quarters ........................................................... 4
All or almost all of the care .................................................. 5
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FAMILY CAREGIVER

Page 55

The next questions ask about any thoughts you have had about alternative types of care.
CG52.

In the past six months, have you ever considered a nursing home, boarding home, or assisted
living for [NAME OF CARE RECIPIENT]?
(CGNH)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG53.

In the past six months, have you felt that [NAME OF CARE RECIPIENT] would be better off
in a nursing home, boarding home, or assisted living facility?
(CGNHBTR)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG54.

In the past six months, have you discussed the possibility of a nursing home, boarding home,
or assisted living with family members or others excluding [NAME OF CARE RECIPIENT]?
(NHCRDIS)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
CG54a.

GO TO CG54a
GO TO CG55
GO TO CG55
GO TO CG55

If YES, in the past six months have you discussed that possibility with the [NAME
OF CARE RECIPIENT]?
(NHDISCR)
YES ......................................................................... 1
NO .......................................................................... 2
REFUSED............................................................... -7
DON’T KNOW......................................................... -8

CG54b.

GO TO CG54b
GO TO CG55
GO TO CG55
GO TO CG55

If YES, in the past six months, have you taken any steps toward placement?
(CGNHSTPS)
YES ......................................................................... 1
NO .......................................................................... 2
REFUSED............................................................... -7
DON’T KNOW......................................................... -8

FAMILY CAREGIVER

Page 56

CG55.

Are you responsible for providing help or supervision to [NAME OF CARE RECIPIENT] on a
24-hour basis?
(CGBASIS)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
CG55a.

GO TO CG55a
GO TO CG56
GO TO CG56
GO TO CG56

If YES, since you say you provide 24-hour care, let me ask you a question about the
intensity of care provided. On a scale from 1 to 5 where 1 is not very intense and 5
is very intense, how intense is the care you provide?
(CGINSTY)
Not Very Intense
1

CG56.

2

3

4

Very Intense
5

Would you recommend the caregiving support services to a friend?
(CGREMND)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

CG57.

Do you have any recommendations to improve the caregiver support service?
(CGRECMND)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
CG57a.

GO TO CG57a
GO TO CG58
GO TO CG58
GO TO CG58

IF YES, what recommendations do you have for improving the service?
(IMPRVSVC)
___________________________________________________________________
___________________________________________________________________

FAMILY CAREGIVER

Page 57

CG58.

Overall, do you feel like you have enough support?
(CGSUPP)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

PROGRAMMER NOTE:
GO TO ADDITIONAL SERVICE LIST MODULE.
CG59.

In your judgment, if the services that you and {CARE RECIPIENT} have received had not
been available, would {CARE RECIPIENT} be able to continue to live in the same
residence?
(CGDFPLC)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
CG59a.

GO TO CGPF1
GO TO CG59a
GO TO CG59a
GO TO CG59a

Where would {CARE RECIPIENT} be living?
(CGWHER AND CGWHEROS)

INTERVIEWER NOTE:
CHOOSE ONLY ONE ANSWER, DO NOT READ LIST.
IN CAREGIVER’S HOME ....................................... 1
IN THE HOME OF ANOTHER FAMILY
MEMBER OR FRIEND ......................................... 2
IN AN ASSISTED LIVING FACILITY ..................... 3
IN A NURSING HOME ........................................... 4
CARE RECIPIENT WOULD HAVE DIED .............. 5
OTHER ................................................................... 91
(SPECIFY: ______________________________)
REFUSED............................................................... -7
DON’T KNOW......................................................... -8

FAMILY CAREGIVER

Page 58

CGINTRO9. The next few questions are about {CARE RECIPIENT’S} health.
CG60.

In general, would you say {CARE RECIPIENT’S} health is…
(CGCRHL)
Excellent, ............................................................................. 1
Very Good, .......................................................................... 2
Good, ................................................................................... 3
Fair, or ................................................................................. 4
Poor? ................................................................................... 5
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
CG60a.

Has a doctor ever told you that {CARE RECIPIENT} has...

(CGPFDSA - CGPFDSU AND CGPFDSOS)

YES

NO

RF

DK

N/A

a. Arthritis or rheumatism? .................................................................

1

2

-7

-8

-9

b. High blood pressure or hypertension? ...........................................

1

2

-7

-8

-9

c. A heart attack, coronary heart disease, angina, congestive heart
failure, or other heart problems? ....................................................

1

2

-7

-8

-9

d. High cholesterol? ...........................................................................

1

2

-7

-8

-9

e. Diabetes or high blood sugar? .......................................................

1

2

-7

-8

-9

Allergies/asthma/emphysema/chronic bronchitis/other breathing
and lung problems? .......................................................................

1

2

-7

-8

-9

g. Cancer or a malignant tumor, excluding minor skin cancer? .........

1

2

-7

-8

-9

h. Stroke? ...........................................................................................

1

2

-7

-8

-9

i.

Anemia? .........................................................................................

1

2

-7

-8

-9

j.

Osteoporosis? ................................................................................

1

2

-7

-8

-9

k. Kidney disease? .............................................................................

1

2

-7

-8

-9

1

2

-7

-8

-9

m. Hearing problems?.........................................................................

1

2

-7

-8

-9

n. Emotional, nervous or psychiatric problems? ................................

1

2

-7

-8

-9

o. Memory related disease such as Alzheimer’s or dementia? .........

1

2

-7

-8

-9

p. Seizures or epilepsy? .....................................................................

1

2

-7

-8

-9

q. Parkinson’s?...................................................................................

1

2

-7

-8

-9

1

2

7

-8

-9

f.

l.

r.

Eye or vision conditions such as glaucoma, cataracts, macular
degeneration or other medical conditions? ..................................
[INTERVIEWER NOTE: THIS DOES NOT INCLUDE ONLY
WEARS GLASSES OR CONTACTS]

Persistent pain, aching, stiffness or swelling around a joint? .......

FAMILY CAREGIVER

Page 59

(CGPFDSA - CGPFDSU AND CGPFDSOS)
[INTERVIEWER NOTE: INCLUDES BROKEN BONES;
SPRAINED MUSCLES; AND BAD BACKS, KNEES,
SHOULDERS, ETC.]

YES

NO

RF

DK

N/A

s. Multiple sclerosis? ..........................................................................

1

2

-7

-8

-9

t.

A serious problem with urinary incontinence? ...............................

1

2

-7

-8

-9

u. Something else? ...........................................................................
(SPECIFY: __________________________________________)

1

2

-7

-8

-9

FENCEPOST
CGOHINTRO. Now we would like to ask about the care recipient’s oral or dental health (that is, the
health of the care recipient’s teeth and gums)...
CG61 About how long has it been since the care recipient last visited a dentist? Include all types of
dentists, such as, orthodontists, oral surgeons, and all other dental specialists, as well as dental
hygienists.
(CGOHQ1)
6 MONTHS OR LESS ................................................. …… 1
MORE THAN 6 MONTHS, BUT NOT MORE THAN
1 YEAR AGO ....................................................................... 2
MORE THAN 1 YEAR, BUT NOT MORE THAN 2
YEARS AGO ....................................................................... 3
MORE THAN 2 YEARS, BUT NOT MORE THAN 3
YEARS AGO ....................................................................... 4
MORE THAN 3 YEARS, BUT NOT MORE THAN 5
YEARS AGO ....................................................................... 5
MORE THAN 5 YEARS AGO ............................................. 6
NEVER HAVE BEEN .......................................................... 7
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
HELP SCREEN:
Dentist: Medical persons whose primary occupation is caring for teeth, gums, and jaws. Dental care
includes general work such as fillings, cleaning, extractions, and also specialized work such as root
canals, fittings for braces, etc.

CG62 During the past 12 months, was there a time when the care recipient needed dental care but could
not get it at that time?
(CGOHQ2)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FAMILY CAREGIVER

[skip to CG64?]

Page 60

CG63 What were the reasons that the care recipient could not get the dental care he/she needed?
(CGOHQ301 - CGOHQ312)

COULD NOT AFFORD THE COST .................................... 10
DID NOT WANT TO SPEND THE MONEY ........................ 11
INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES ................................................................... 12
DENTAL
OFFICE IS TOO FAR AWAY ............................................. 13
DENTAL OFFICE IS NOT OPEN AT CONVENIENT
TIMES ................................................................................. 14
ANOTHER DENTIST RECOMMENDED NOT DOING IT .. 15
AFRAID OR DO NOT LIKE DENTISTS .............................. 16
UNABLE TO TAKE TIME OFF FROM WORK .................... 17
TOO BUSY .......................................................................... 18
DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED DENTAL PROBLEMS TO GO
AWAY .................................................................................. 19
DID NOT HAVE TRANSPORTATION ................................ 20
OTHER ................................................................................ 21
REFUSED ........................................................................... -7
DON'T KNOW ..................................................................... -8

CG64 Overall, how would you rate the health of the care recipient’s teeth and gums?
(CGOHQ4)
EXCELLENT ....................................................................... 1
VERY GOOD ....................................................................... 2
GOOD, ................................................................................ 3
FAIR .................................................................................... 4
POOR .................................................................................. 5
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
FENCEPOST
CGINTRO10. We would like to ask about {CARE RECIPIENT’s} abilities to perform some common
activities of everyday life and whether {CARE RECIPIENT} needs assistance performing these activities.
We are only interested in long-term conditions, not temporary conditions.
CG65.

Does {CARE RECIPIENT} have difficulty getting around inside the home?
(PFDFINC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

FAMILY CAREGIVER

1
2 [GO TO CG67]
-7 [GO TO CG67]
-8 [GO TO CG67]

Page 61

CG66.

{Does s/he} need the help of another person to perform this activity?
(PFDFINBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

CG67.

Does {s/he} have difficulty going outside the home, for example to shop or visit a doctor’s
office?
(PFDFOUC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
CG67a.

1
2 [GO TO CG68]
-7 [GO TO CG68]
-8 [GO TO CG68

Does {s/he} need the help of another person to perform this activity?
(PFDFOUBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

CG68.

Does {CARE RECIPIENT} have difficulty getting in or out of bed or a chair?
(PFBEDC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
CG68a.

1
2 [GO TO CG69]
-7 [GO TO CG69]
-8 [GO TO CG69]

Does {s/he} need the help of another person to perform this activity?
(PFBEDBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

FAMILY CAREGIVER

Page 62

CG69.

Does {s/he} have difficulty when taking a bath or shower?
(PFBATHC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
CG69a.

1
2 [GO TO CG70]
-7 [GO TO CG70]
-8 [GO TO CG70]

Does {s/he} need the help of another person to perform this activity?
(PFBATHBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

CG70.

Does {CARE RECIPIENT} have difficulty when dressing?
(PFDRESC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
PF5BCG70a.

1
2 [GO TO CG71]
-7 [GO TO CG71]
-8 [GO TO CG71]

Does {s/he} need the help of another person to perform this activity?

(PFDRESBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

PF6CG71.

Does {s/he} have difficulty when walking?
(PFWALKC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

FAMILY CAREGIVER

1
2 [GO TO CG72]
-7 [GO TO CG72]
-8 [GO TO CG72]

Page 63

PF6BCG71a.

Does {s/he} need the help of another person to perform this activity?

(PFWALKBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

CG72.

Does {CARE RECIPIENT} have difficulty eating?
(PFEATC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
CG72a.

1
2 [GO TO CG73]
-7 [GO TO CG73]
-8 [GO TO CG73]

Does {s/he} need the help of another person to perform this activity?
(PFEATBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

CG73.

Does {s/he} have difficulty using the toilet or getting to the toilet?
(PFWCC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
CG73a.

1
2 [GO TO CG74]
-7 [GO TO CG74]
-8 [GO TO CG74]

Does {s/he} need the help of another person to perform this activity?
(PFWCBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

FAMILY CAREGIVER

Page 64

CG74.

Does {CARE RECIPIENT} have difficulty keeping track of money or bills?
(PFDLRC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
CG74a.

1
2 [GO TO CG75]
-7 [GO TO CG75]
-8 [GO TO CG75]

Does {s/he} need the help of another person to perform this activity?
(PFDLRBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

CG75.

Does {s/he} have difficulty preparing meals?
(PFMEALC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
CG75a.

1
2 [GO TO CG76]
-7 [GO TO CG76]
-8 [GO TO CG76]

Does {s/he} need the help of another person to perform this activity?
(PFMEALBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

CG76.

Does {CARE RECIPIENT} have difficulty doing light housework, such as washing dishes or
sweeping a floor?
(PFCLENC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

FAMILY CAREGIVER

1
2 [GO TO CG77]
-7 [GO TO CG77]
-8 [GO TO CG77]

Page 65

CG76a.

Does {s/he} need the help of another person to perform this activity?
(PFCLENBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

CG77.

Does {s/he} have difficulty doing heavy housework, such as scrubbing floors or washing
windows?
(PFHCLNC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CG77a.

1
2 [GO TO CG78]
-7 [GO TO CG78]
-8 [GO TO CG78]

Does {s/he} need the help of another person to perform this activity?
(PFHCLNBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

CG78.

Does {s/he} have difficulty taking the right amount of prescribed medicine at the right time?
(PFTKDGC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
CG78a.

1
2 [GO TO CG79]
-7 [GO TO CG79]
-8 [GO TO CG79]

Does {s/he} need the help of another person to perform this activity?
(PFTKDGBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
-7
-8

FENCEPOST

FAMILY CAREGIVER

Page 66

CG79.

Does {CARE RECIPIENT} have difficulty using the telephone?
(PFFONEC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
CG79a.

1
2 [GO TO CG80]
-7 [GO TO CG80]
-8 [GO TO CG80]

Does {s/he} need the help of another person to perform this activity?
(PFFONEBC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

CG80.

1
2
-7
-8

Is there a car or personal motor vehicle in working condition in {CARE RECIPIENT’s}
household?
(CGISCAR)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CG80a.

1
2 [GO TO CG81]
-7 [GO TO CG81]
-8 [GO TO CG81]

Does {s/he} have difficulty driving a car or other personal motor vehicle?
(PFDRIVEC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CG81.

1
2
-7
-8

Is there a public bus or transit stop within three-quarters of a mile from {his/her} home?
(PFBUSC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
CG81a.

1
2 [GO TO CGINTRO10]
-7 [GO TO CGINTRO10]
-8 [GO TO CGINTRO10]

Does {s/he} have difficulty using this transportation?
(PFUSBSC)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

FAMILY CAREGIVER

1
2 [GO TO CGINTRO10
-7 [GO TO CGINTRO10]
-8 [GO TO CGINTRO10

Page 67

CCG81b. Does {s/he} need the help of another person to perform this activity?
(PFUSBSBC)
YES ........................................................................... 1 NO 2
REFUSED ................................................................. -7
DON’T KNOW ........................................................... -8
FENCEPOST

CGINTRO10. We are interested in knowing more about the demographic characteristics of people
receiving services. All this information will be kept confidential to the extent allowed by law.
CG82.

What is {CARE RECIPIENT’s} date of birth?
(CGPMM, CGPDD, CGPYYYY)
_____/____/________
MM DD YYYY
REFUSED ..............................................................................
DON’T KNOW ........................................................................

-7
-8

PROGRAMMER NOTE: PLEASE COMPUTE AGE BASED ON DATE OF INTERVIEW AND STORE
AS CONSTRUCTED VARIABLE NAME: CGPAGE

PROGRAMMER NOTE: FOR CGDE3, SOFT RANGE = 0-5. HARD RANGE = 0-50. IF RESPONSE
IS ZERO (0), -7 OR -8, SKIP TO MODULE 4. IF CGDE3 IS 1 OR MORE, ASK CGDE4.

CG84.

How many persons total {are you/is NAME OF CAREGIVER} caring for not counting {CARE
RECIPIENT}?
(CGMANY)
NUMBER ...............................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

CG85.

|___|___|
-7
-8

Who are those people?

INTERVIEWER NOTE: CODE ALL THAT APPLY. PROBE: Anyone else?
(CGWHO1-8, CGWHO01-08 AND CGWHOOS)
HUSBAND OR WIFE .............................................................
SON(S) OR DAUGHTER(S) ..................................................
FATHER .................................................................................
MOTHER ................................................................................
BROTHER(S) OR SISTER(S) ................................................
GRANDSON(S) OR GRANDDAUGHTER(S) ........................
OTHER RELATIVE(S) NOT MENTIONED ABOVE ...............
FRIEND(S) OR NEIGHBOR(S) ..............................................

FAMILY CAREGIVER

1
2
3
4
5
6
7
8

Page 68

OTHER PERSONS NOT MENTIONED ABOVE
(SPECIFY:______________________) ............................ 91
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8
FENCEPOST

GO TO DEMOGRAPHIC INTAKE MODULE

FAMILY CAREGIVER

Page 69

ADDITIONAL SERVICE LIST MODULE

CASE MANAGEMENT IS CS16 (CSKNOW).
CONGREGATE MEALS IS CNR29 (CMENUF).
HOME DELIVERED MEALS QUESTION JUST PRIOR TO THIS MODULE IS HNR33 (HMSKP).
HOMEMAKER IS HC9 (HCSTAYHM).
TRANSPORTATION QUESTION JUST PRIOR TO THIS MODULE IS TR22 (TRDRIVE).
FAMILY CAREGIVER QUESTION JUST PRIOR TO THIS MODULE IS CG36 (CGINF09).
PROGRAMMER NOTE: FOR QUESTION SVC1,
SKIP QUESTION A FOR CONGREGATE MEALS.
SKIP QUESTION B FOR HOME DELIVERED MEALS RESPONDENTS.
SKIP QUESTION C FOR HOMEMAKER.
SKIP QUESTION D FOR CASE MANAGEMENT RESPONDENTS.
SKIP QUESTION E FOR TRANSPORTATION RESPONDENTS.
FOR HOME DELIVERED MEALS, CONGREGATE MEALS, HOMEMAKER, CASE MANAGEMENT
AND TRANSPORTATION CLIENTS, USE FIRST DISPLAY.
FOR FAMILY CAREGIVER RESPONDENTS, USE CARE RECIPIENT NAME (OR RELATION)
DISPLAY IN SVC1, SVC2, SVC3 AND SVC4. WE ARE NOT INTERESTED IN INFORMATION ON
SERVICES THE CAREGIVER RECEIVES. FOR CAREGIVERS, WE WANT TO KNOW ONLY ABOUT
THE SERVICES THEIR CARE RECIPIENT RECEIVES.
SVC1.

I’d like to ask about additional help {you/NAME OF PARTICIPANT} {CARE RECIPIENT}
may have received from {PROVIDER NAME} or {AGENCY NAME}.

a. In the past year {have you/has NAME OF PARTICIPANT}
{has CARE RECIPIENT} attended a lunch program at a
senior center or other meal site?
[IF NEEDED: A lunch program or Congregate Meal is a
meal which is provided in a group setting, such as at a
senior center.]
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(SVCCM)
b. In the past year {have you/has NAME OF PARTICIPANT}
{has CARE RECIPIENT} received meals from the meals
program?
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(SVCHDM)
c. In the past year {have you/has NAME OF PARTICIPANT}
{has CARE RECIPIENT} received Homemaker or
Housekeeping services?
[IF NEEDED: Homemaker or Housekeeping Services are
services that may include help with doing light housework,
laundry, preparing meals or shopping.]
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(SVCHOUSE)

ADDITIONAL SERVICE LIST

YES

NO

RF

DK

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

Page 70

d. In the past year {have you/has NAME OF PARTICIPANT}
{has CARE RECIPIENT} received case management
services?
[IF NEEDED: When someone receives case
management, they have a case manager who may set up
in-home services, such as homemaker or personal care
services for them. The case manager may also call to
check on how they are doing, or how they like the
services.]
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(SVCCSEMG)
e. In the past year {have you/has NAME OF PARTICIPANT}
{has CARE RECIPIENT} received transportation
services?
[IF NEEDED: Transportation is a bus or other vehicle that
picks people up and takes them places such as to the
doctor, the senior center, or shopping.]
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(SVCTRAN)
f. In the past year {have you/has NAME OF PARTICIPANT}
{has CARE RECIPIENT} received adult day care
services?
[IF NEEDED: Adult Day Care or adult day health is when
people go to a place and spend the day.]
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(SVCDYCR)
FENCEPOST
g. In the past year {have you/has NAME OF PARTICIPANT}
{has CARE RECIPIENT} received personal care services?
[IF NEEDED: Personal care services are help with care
like dressing or bathing.]
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(SVCPCR)
h. In the past year {have you/has NAME OF PARTICIPANT}
{has CARE RECIPIENT} received chore services?
[IF NEEDED: Chore Services help with heavier
housecleaning and yard work.]
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(SVCHORE)
i. In the past year {have you/has NAME OF PARTICIPANT}
{has CARE RECIPIENT} received legal assistance?
[IF NEEDED: Legal Assistance may help with making a
will or understanding a bill and other legal matters.]
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(SVCLGL)

YES

NO

RF

DK

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

FENCEPOST

ADDITIONAL SERVICE LIST

Page 71

In the past year {have you/has NAME OF PARTICIPANT}
{has CARE RECIPIENT} received information and
assistance services?
[IF NEEDED: Information and Assistance helps people
find out about services that are available to them.]
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(SVCIAA)
k. {Do you/Does NAME OF PARTICIPANT} {Does s/he}
have a nutrition counselor who gives {you/him/her}
{him/her} individual advice on what {you/s/he} {s/he}
should eat based on {your/his/her} {his/her} general
health, chronic conditions, medications, and {your/his/her}
{his/her} usual food choices?
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(HNREDUYN)
l. {Have you/Has s/he} {Has CARE RECIPIENT} received
health screenings such as blood pressure checks or
mammograms other than those from {your/his her}
{his/her} own doctor?
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(HLTHSCRN)
m. {Have you/Has s/he} {Has s/he} received flu shots,
pneumonia shots or other immunizations other than those
from {your/his/her} {his/her} own doctor?
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(SHOTS)

YES

NO

RF

DK

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

j.

FENCEPOST
n. {Have you/Has NAME OF PARTICIPANT} {Has CARE
RECIPIENT} taken exercise or fitness classes or {do
you/does s/he} {does s/he} use the exercise equipment at
a senior center or other program for older adults?
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(EXERCISE)
o. {Have you/Has NAME OF PARTICIPANT} {Has CARE
RECIPIENT} received assistance in administering or
monitoring the side effects of medicine?
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(MEDS)
p. {Have you/Has NAME OF PARTICIPANT} {Has CARE
RECIPIENT} received help getting benefits like SNAP or
Food Stamps and other public assistance?
[IF NEEDED: Remember, we are talking about services
received from {PROVIDER NAME} or {AGENCY NAME}.]
(BENEFITS)

ADDITIONAL SERVICE LIST

Page 72

PROGRAMMER NOTE: DO NOT ASK SVC2 IF ALL OF SVC1A THROUGH SVC1Q ARE ALL 2, -7
AND/OR -8. SKIP TO SVC3.
SVC2.

Overall, how would {you/s/he} {you/s/he} rate the group of services {you receive/s/he
receives} {CARE RECIPIENT RECEIVES}? Would {you/NAME OF PARTICIPANT}
{you/NAME OF CAREGIVER} say…
(SVCRATE)
Excellent, ................................................................................
Very good, ..............................................................................
Good, ......................................................................................
Fair, or ....................................................................................
Poor? ......................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
-7
-8

PROGRAMMER NOTE: FOR CAREGIVER, SKIP TO SVC4
INTRO: Now, I would like to ask about how these services help {you/him/her}.
SVC3.

Thinking about {your/NAME OF PARTICIPANT’s} {CARE RECIPIENT’s} services in general,
{do you/does s/he} {do you/does s/he} agree or disagree with these statements?
(SVC3A TO SVC3D)
a. As a result of the services {you receive/s/he
receives} {are you/is s/he} able to live
independently? (SVCIND)
b. As a result of the services {you receive/s/he
receives} {do you/does s/he} feel more secure?
(SVCSECUR)
c. As a result of the services {you receive/s/he
receives} {are you/is s/he} better able to care for
{yourself/himself/herself}? (SVCSELFC)
d. Since you started receiving services, {do
you/does s/he} have a better idea of how to get
any additional help that {you need/s/he needs}?
(SVCIDEA)

ADDITIONAL SERVICE LIST

Yes

No

RF

DK

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

Page 73

SVC4.

Thinking about {your/NAME OF PARTICIPANT’s} {CARE RECIPIENT’s} services in general,
{do you/does s/he} {do you/does s/he} agree or disagree with these statements?
(SVC4A TO SVC4B)

Agree

Disagree

RF

DK

a. The people who give these services are
generally courteous. Would {you/s/he} {s/he}
say… (SVCCURT)

1

2

-7

-8

b. The people who give these services do the
things they are supposed to do. Would
{you/s/he} {s/he} say… (SVCSUPOS)

1

2

-7

-8

FENCEPOST

SVC5.

{Are you/Is NAME OF PARTICIPANT/Is CARE RECIPIENT} receiving any other types of
assistance, such as…
Yes
1

No
2

RF
-7

DK
-8

b. Energy Assistance? (SVC5B)

1

2

-7

-8

c. Medicaid? (SVC5C)

1

2

-7

-8

d. Housing Assistance? (SVC5D)

1

2

-7

-8

(SVC5A TO SVC5D)
a. Food stamps or SNAP? (SVC5A)

SVC6.

{Do your/his/her} family or friends help arrange for the services {you receive/s/he receives}?
(CSARRNG)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

SVC7.

1
2
-7
-8

{Do your/his/her} family or friends provide assistance that helps {you/NAME OF
PARTICIPANT} live independently?
(CSHOME)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

FENCEPOST

ADDITIONAL SERVICE LIST

Page 74

PROGRAMMER NOTE:
IF CASE MANAGEMENT, GO TO PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE.
IF CONGREGATE MEALS, GO TO PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE
IF HOME-DELIVERED MEALS, GO TO PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING
MODULE
IF HOMEMAKER, GO TO PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE
IF TRANSPORTATION, GO TO PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE
THEN GO TO DEMOGRAPHIC INTAKE MODULE.
NEED TO ASK UNLESS:
IF HMDAYS=5, GO TO DEMOGRAPHIC INTAKE MODULE.
IF HCDAYS=5 AND/OR HCMOFT=L, GO DEMOGRAPHIC INTAKE MODULE.
IF TROFTEN=6 AND/OR TRDAYS=5, GO TO DEMOGRAPHIC INTAKE MODULE.
IF CMDAYS=5, GO TO DEMOGRAPHIC INTAKE MODULE.
IF FAMILY CAREGIVER, GO TO CGDFPLC.

ADDITIONAL SERVICE LIST

Page 75

USDA MODULE

HH3.

I’m going to read you several statements that people have made about their food situation.
For these statements, please tell me whether the statement was often true, sometimes true,
or never true for you in the last 12 months—that is, since last (name of current month).
The first statement is, “The food that I bought just didn’t last, and I didn’t have money to get
more.” Was that often, sometimes, or never true for you in the last 12 months?
(USDAHH3)
Often true ............................................................................ 1
Sometimes true ................................................................... 2
Never true ............................................................................ 3
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

HH4.

“I couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for you in
the last 12 months?
(USDAHH4)
Often true ............................................................................ 1
Sometimes true ................................................................... 2
Never true ............................................................................ 3
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

AD1.

In the last 12 months, since last (name of current month), did you ever cut the size of your
meals or skip meals because there wasn't enough money for food?
(USDAAD1)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

USDA

Page 76

FALLS

The next few questions are about falling down. By falling down, we mean any fall, slip, or trip in which you
lose your balance and land on the floor or ground or at a lower level.
HC14.

In the last month, have you fallen down?
(NHATSHC14)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

HC15.

In the last month, did you worry about falling down?
(NHATSHC15)
YES ..................................................................................... 1
NO ....................................................................................... 2 GO TO HC17.
REFUSED ........................................................................... -7 GO TO HC17.
DON’T KNOW ..................................................................... -8 GO TO HC17.

HC16.

In the last month, did this worry ever limit your activities?
(NHATSHC16)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

PROGRAMMER NOTE: IF HC14=YES; GO TO HC18.

HC17.

In the last 12 months, since {MONTH, YEAR}, have you fallen down?
IF NEEDED: By falling down we mean any fall, slip, or trip in which you lose your balance and
land on the floor or ground or at a lower level.
(NHATSHC17)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FALLS

GO TO LIFECHNG1
GO TO LIFECHNG1
GO TO LIFECHNG1

Page 77

HC18.

In the last 12 months/Since {LAST INT MONTH AND YEAR}, have you fallen down more than
one time?
(NHATSHC18)
YES ..................................................................................... 1
NO ....................................................................................... 2
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FALLS

Page 78

LIFE CHANGES

We are interested in why you initially sought services from [NAME OF AGENCY]
LIFECHNG1.

What was going on in your life that led you to seek services?

(LIFECHANGE)
ILLNESS .............................................................................. 1
ILLNESS OF A PERSON CLOSE TO YOU ........................ 2
DEATH OF A SPOUSE ....................................................... 3
PROBLEMS WITH MOBILITY ............................................ 4
COULD NO LONGER TAKE CARE OF MYSELF .............. 5
COULD NO LONGER TAKE CARE OF MY HOME .......... 6
OTHER ................................................................................ 91
(SPECIFY: ____________________________________ )
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

LIFE CHANGES

Page 79

SOCIAL INTEGRATION

The next few questions are about your contact with other people.
UCLA1.

First, how often do you feel that you lack companionship? Hardly ever, some of the time, or
often?
(SIUCLA1)
Hardly ever .......................................................................... 1
Some of the time ................................................................. 2
Often .................................................................................... 3
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

UCLA2.

How often do you feel left out: Hardly ever, some of the time, or often?
(SIUCLA2)
Hardly ever .......................................................................... 1
Some of the time ................................................................. 2
Often .................................................................................... 3
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

UCLA3.

How often do you feel isolated from others? Hardly ever, some of the time, or often?
(SIUCLA3)
Hardly ever .......................................................................... 1
Some of the time ................................................................. 2
Often .................................................................................... 3
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

HRS1.

How often do you feel alone? Is it hardly ever, some of the time, or often?
(SIHRS1)
Hardly ever .......................................................................... 1
Some of the time ................................................................. 2
Often .................................................................................... 3
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

SOCIAL INTEGRATION

Page 80

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING MODULE

PROGRAMMER NOTE: THIS MODULE IS FOR CASE MANAGEMENT, CONGREGATE MEALS,
HOME-DELIVERED MEALS, HOMEMAKER, AND TRANSPORTATION RESPONDENTS.
UNLESS:
IF HMDAYS=5, GO TO MODULE 4, DEMOGRAPHIC INTAKE.
IF CMDAYS=5, GO TO MODULE 4, DEMOGRAPHIC INTAKE.
IF HCDAYS=5 AND/OR HCMOFT=L, GO TO MODULE 4, DEMOGRAPHIC INTAKE.
IF TROFTEN=6 AND/OR TRDAYS=5, GO TO MODULE 4, DEMOGRAPHIC INTAKE.

PROGRAMMER NOTE: IF PARTICIPANT OR INTERPRETER/TRANSLATOR, DISPLAY FIRST PERSON
TENSE (E.G., “DO YOU” OR “HAVE YOU”) INTO QUESTIONS. IF PROXY, DISPLAY SECOND PERSON
TENSE (E.G., “DOES S/HE” OR “HAS S/HE”) WHERE INDICATED IN THIS MODULE.

PFINTRO1. The next question is about {your/PARTICIPANT’S NAME} health. Please try to answer as
accurately as you can.
SF1.

In general, would you say {your/his/her} health is . . . [READ RESPONSE OPTIONS]
(PFHLTH)
Excellent .................................................................................
Very good ...............................................................................
Good .......................................................................................
Fair, or ....................................................................................
Poor? ......................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
-7
-8

Now I’m going to read a list of activities that {you/s/he} might do during a typical day. As I read each item,
please tell me if {your/his/her} health now limits {you/him/her} you a lot, limits {you/him/her} a little, or does
not limit {you/him/her} at all in these activities.
SF2a.

How about moderate activities, such as moving a table, pushing a vacuum cleaner, bowling,
or playing golf. Does {your/his/her} health now limit {you/him/her} a lot, limit {you/him/her} a
little, or not limit {you/him/her} at all? [READ RESPONSE OPTIONS]
(SFMODACT)
Yes, limited a lot .....................................................................
Yes, limited a little or ..............................................................
No, not limited at all? ..............................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

1
2
3
-7
-8

Page 81

How about…
SF2b.

How about climbing several flights of stairs. Does {your/his/her} health now limit {you/him/her} a
lot, limit {you/him/her} a little, or not limit {you/him/her} at all? [READ RESPONSE OPTIONS]
(SFCLIMB)
Yes, limited a lot .....................................................................
Yes, limited a little or ..............................................................
No, not limited at all? ..............................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
-7
-8

The following two questions ask you about {your/his/her} physical health and {your/his/her} daily activities.
SF3a.

During the past four weeks, how much of the time {have you/has s/he} accomplished less than
{you/s/he} would like as a result of {your/his/her} physical health? [READ RESPONSE
OPTIONS]
(SFACCOMP)
All of the time..........................................................................
Most of the time ......................................................................
Some of the time ....................................................................
A little of the time, or...............................................................
None of the time? ...................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

SF3b.

1
2
3
4
5
-7
-8

During the past four weeks, how much of the time {were you/was s/he} limited in the kind of work
or other regular daily activities {you/she/he} did as a result of your physical health?
(SFLIMITD)
All of the time..........................................................................
Most of the time ......................................................................
Some of the time ....................................................................
A little of the time, or...............................................................
None of the time? ...................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

SF4a.

1
2
3
4
5
-7
-8

During the past four weeks, how much of the time (have you/has s/he} accomplished less than
{you/he/she} would like as a result of any emotional problems, such as feeling depressed or
anxious? [READ RESPONSE OPTIONS]
(SFEMOT)
All of the time..........................................................................
Most of the time ......................................................................
Some of the time ....................................................................
A little of the time, or...............................................................
None of the time? ...................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

1
2
3
4
5
-7
-8

Page 82

SF4b.

During the past four weeks, how much of the time did {you/he/she} do work or other regular daily
activities less carefully than usual as a result of any emotional problems, such as feeling
depressed or anxious? [READ RESPONSE OPTIONS]
(SFCAREFL)
All of the time..........................................................................
Most of the time ......................................................................
Some of the time ....................................................................
A little of the time, or...............................................................
None of the time? ...................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

SF5a.

1
2
3
4
5
-7
-8

During the past four weeks, how much did pain interfere with (your/his/her} normal work
(including both work outside the home and housework)? [READ RESPONSE OPTIONS]
(SFPAIN)
Not at all .................................................................................
A little bit .................................................................................
Moderately ..............................................................................
Quite a bit, or ..........................................................................
Extremely? .............................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
-7
-8

The next few questions are about how {you feel/he feels/she feels} and how things have been with {you/
him/her} during the past four weeks.
As I read each statement, please give me the one answer that comes closest to the way {you have/he
has/she has} been feeling; is it all of the time, most of the time, some of the time, a little of the time, or none
of the time?
SF6a.

How much of the time during the past four weeks . . . {have you/has s/he} felt calm and peaceful?
[READ RESPONSE OPTIONS]
(SFCALM)
All of the time..........................................................................
Most of the time ......................................................................
Some of the time ....................................................................
A little of the time, or...............................................................
None of the time? ...................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

1
2
3
4
5
-7
-8

Page 83

SF6b.

How much of the time during the past four weeks . . . did {you/s/he} have a lot of energy? [READ
RESPONSE OPTIONS]
(SFENERGY)
All of the time..........................................................................
Most of the time ......................................................................
Some of the time ....................................................................
A little of the time, or...............................................................
None of the time? ...................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

SF6c.

1
2
3
4
5
-7
-8

How much of the time during the past four weeks . . . {have you/has he/has she} felt downhearted
and depressed? [READ RESPONSE OPTIONS]
(SFDOWN)
All of the time..........................................................................
Most of the time ......................................................................
Some of the time ....................................................................
A little of the time, or...............................................................
None of the time? ...................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

SF7.

1
2
3
4
5
-7
-8

During the past four weeks, how much of the time has {your/his/her} physical health or emotional
problems interfered with {your/his/her} social activities (like visiting friends, relatives, etc.)?
[READ RESPONSE OPTIONS]
(SFINTERF)
All of the time..........................................................................
Most of the time ......................................................................
Some of the time ....................................................................
A little of the time, or...............................................................
None of the time? ...................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

SF8.

1
2
3
4
5
-7
-8

Compared with {your/his/her} health one year ago, would you say {your/his/her} health is ...
(SFHEALTH)
Much better than one year ago, .............................................
A little better than one year ago, ............................................
About the same as one year ago, ..........................................
A little worse than one, or .......................................................
Worse than one year ago? .....................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

1
2
3
4
5
-7
-8

Page 84

Regarding {your/ NAME OF PARTICIPANT’s} present social activities, {do you/does s/he} feel
that {you are/s/he is} doing…

SF9.

(SFACTIVE)
About enough, ........................................................................ 1
Too much, or .......................................................................... 2
{You/ NAME OF PARTICIPANT} would like to be doing more? 3
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8
FENCEPOST

SF10.

Have {your/NAME OF PARTICIPANT’s} social opportunities increased since {you/s/he}
became involved with {PROVIDER NAME’s/AGENCY NAME’s} services?
(SFSOCIAL)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

FENCEPOST

PF1a6.

Now I would like to ask about medical conditions {you/NAME OF PARTICIPANT} may have.
Has a doctor ever told {you/NAME OF PARTICIPANT} that {you have/s/he has} have:
(PFDISA - PFDISU)

YES

NO

RF

DK

N/A

a. Arthritis or rheumatism? .................................................................

1

2

-7

-8

-9

b. High blood pressure or hypertension? ...........................................

1

2

-7

-8

-9

c. A heart attack, coronary heart disease, angina, congestive heart
failure, or other heart problems? ....................................................

1

2

-7

-8

-9

d. High cholesterol? ...........................................................................

1

2

-7

-8

-9

e. Diabetes or high blood sugar? .......................................................

1

2

-7

-8

-9

Allergies/asthma/emphysema/chronic bronchitis/other breathing
or lung problems? ..........................................................................

1

2

-7

-8

-9

g. Cancer or a malignant tumor, excluding minor skin cancer? .........

1

2

-7

-8

-9

h. Stroke? ...........................................................................................

1

2

-7

-8

-9

i.

Anemia? .........................................................................................

1

2

-7

-8

-9

j.

Osteoporosis? ................................................................................

1

2

-7

-8

-9

k. Kidney disease? .............................................................................

1

2

-7

-8

-9

1

2

-7

-8

-9

f.

l.

Eye or vision conditions such as glaucoma, cataracts, macular
degeneration or other medical conditions? ....................................
[INTERVIEWER NOTE: THIS DOES NOT INCLUDE ONLY
WEARS GLASSES OR CONTACTS]

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

Page 85

(PFDISA - PFDISU)

YES

NO

RF

DK

N/A

m. Hearing problems?.........................................................................

1

2

-7

-8

-9

n. Emotional, nervous or psychiatric problems? ................................

1

2

-7

-8

-9

o. Memory related disease such as Alzheimer’s or dementia? .........

1

2

-7

-8

-9

p. Seizures or epilepsy? .....................................................................

1

2

-7

-8

-9

q. Parkinson’s?...................................................................................

1

2

-7

-8

-9

Persistent pain, aching, stiffness or swelling around a joint? .......
[INTERVIEWER NOTE: INCLUDES BROKEN BONES;
SPRAINED MUSCLES; BAD BACKS, KNEES, SHOULDERS,
ETC]

1

2

-7

-8

-9

s. Multiple sclerosis? ..........................................................................

1

2

-7

-8

-9

t.

A serious problem with urinary incontinence? ...............................

1

2

-7

-8

-9

u. Something else? ............................................................................
(SPECIFY:__________________________________________)

1

2

-7

-8

-9

r.

FENCEPOST

PF1a6-1.

During the last 12 months, have you learned how to take care of {any or all of} your chronic
{illness/illnesses} or medical {condition/conditions}?
(PFTKCARE)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

PF1a6-2.

1
2
-7
-8

[GO TO PF1a6-2]
[GO TO PF1a6-3]
[GO TO PF1a6-3]
[GO TO PF1a6-3]

During the last 12 months, how did you learn about taking care of {your/any or all of your} chronic
{illness/illnesses} or medical {condition/conditions}? Did you… [CHECK ALL THAT APPLY]
(PFPCARE - PFLRN)
a. Talk in person to a doctor/health professional within your
primary care practice? (PFPCARE)......................................

YES

NO

RF

DK

1

2

-7

-8

1

2

-7

-8

c. Speak on the telephone with a health professional?
(PFPHON) .............................................................................

1

2

-7

-8

d. Read about it on the Internet? (PFWEB) ..............................

1

2

-7

-8

e. Take a group class? (PFCLASS) .........................................

1

2

-7

-8

1

2

-7

-8

b. Talk in person to a doctor/health professional not in your
primary care practice? (PFNCARE) ....................................

f.

Learn in some other way? (PFLRN) .....................................
(SPECIFY:______________________________________)

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

Page 86

PF1a6-3. Having {an illness/one or more illnesses} often means doing different tasks and activities to
manage your {condition/conditions}. How confident are you that you can do all the things
necessary to manage your chronic {illness/illnesses} or medical {condition/conditions} on a
regular basis? Would you say you are… [READ RESPONSE OPTIONS]
(PFCONF)
Not at all confident,.................................................................
A little confident, .....................................................................
Moderately confident, or .........................................................
Very confident? ......................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

PF1a7.

1
2
3
4
-7
-8

Because of a physical, mental or emotional condition lasting 6 months or more, {do you/does
NAME OF PARTICIPANT} have any difficulty learning, remembering, or concentrating?
(PFLEARN)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

PROGRAMMER NOTE: SOFT RANGE FOR HLM4 = 0 TO 10. IF MORE THAN 10, HAVE
INTERVIEWER PROBE: You told me {you take/s/he takes} {INSERT NUMBER OVER 10} prescription
medications per day. Is that correct?

HLM1.

About how many different prescription medications {do you/does s/he} take every day?
(HLMDRUGS)
[INTERVIEWER NOTE: IF NONE, ENTER 0]
NUMBER OF PRESCRIPTION MEDICINES
PER DAY ..................................................................... |__|__|
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8
HLM1-OV. You told me {you take/NAME OF PARTICIPANT takes} {INSERT NUMBER OVER 10}
prescription medications per day. Is that correct?
(HMDRCHK)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

1
2
-7
-8

Page 87

HLM2.

In the past 12 months, did {you/NAME OF PARTICIPANT} have to stay overnight in a
hospital?
(HLMHOSP)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

HLM3.

1
2
-7
-8

In the past 12 months, did {you/NAME OF PARTICIPANT} have to stay overnight in a nursing
home or rehabilitation center?
(HLMNH)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

OHINTRO. Now we would like to ask about your oral or dental health (that is, the health of your teeth and
gums)...
OHQ.030 About how long has it been since you last visited a dentist? Include all types of dentists, such as,
orthodontists, oral surgeons, and all other dental specialists, as well as dental hygienists.
(OHQ030)
6 MONTHS OR LESS ............................................................ 1
MORE THAN 6 MONTHS, BUT NOT MORE THAN 1
YEAR AGO ............................................................................. 2
MORE THAN 1 YEAR, BUT NOT MORE THAN 2
YEARS AGO .......................................................................... 3
MORE THAN 2 YEARS, BUT NOT MORE THAN 3
YEARS AGO .......................................................................... 4
MORE THAN 3 YEARS, BUT NOT MORE THAN 5
YEARS AGO .......................................................................... 5
MORE THAN 5 YEARS AGO ................................................ 6
NEVER HAVE BEEN ............................................................. 7
REFUSED .............................................................................. .-7
DON'T KNOW ........................................................................ -8
HELP SCREEN:
Dentist: Medical persons whose primary occupation is caring for teeth, gums, and jaws. Dental care
includes general work such as fillings, cleaning, extractions, and also specialized work such as root
canals, fittings for braces, etc.

OHQ.770 During the past 12 months, was there a time when you needed dental care but could not get it at
that time?
(OHQ770)
YES ........................................................................................ 1
NO .......................................................................................... 2 GO TO OHQ.845
REFUSED .............................................................................. -7 GO TO OHQ.845
DON'T KNOW ........................................................................ -8 GO TO OHQ.845

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

Page 88

OHQ.780

What were the reasons that you could not get the dental care you needed?

(OHQ78001 - OHQ78012)
COULD NOT AFFORD THE COST .......................................
DID NOT WANT TO SPEND THE MONEY ...........................
INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES ......................................................................
DENTAL OFFICE IS TOO FAR AWAY ..................................
DENTAL OFFICE IS NOT OPEN AT CONVENIENT TIMES
ANOTHER DENTIST RECOMMENDED NOT DOING IT .....
AFRAID OR DO NOT LIKE DENTISTS .................................
UNABLE TO TAKE TIME OFF FROM WORK .......................
TOO BUSY .............................................................................
DID NOT THINK ANYTHING SERIOUS WAS WRONG/
EXPECTED DENTAL PROBLEMS TO GO AWAY ...............
DID NOT HAVE TRANSPORTATION ...................................
OTHER ...................................................................................
REFUSED ..............................................................................
DON'T KNOW ........................................................................

OHQ.845

10
11
12
13
14
15
16
17
18
19
20
21
-7
-8

Overall, how would you rate the health of your teeth and gums?
(OHQ845)
EXCELLENT ....................................................................... 1
VERY GOOD ....................................................................... 2
GOOD, ................................................................................ 3
FAIR .................................................................................... 4
POOR .................................................................................. 5
REFUSED ........................................................................... -7
DON’T KNOW ..................................................................... -8

FENCEPOST

PFINTRO2. We would like to ask about difficulties with some common activities of everyday life and
whether {you need /NAME OF PARTICIPANT needs} assistance performing these activities.
Please exclude the effects of temporary conditions.
PF1.

{Do you/Does NAME OF PARTICIPANT} have difficulty getting around inside the home?
(PFDFIN)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

1
2 [GO TO PF2]
-7 [GO TO PF2]
-8 [GO TO PF2]

Page 89

PF1b.

{Do you/Does s/he} need the help of another person to perform this activity?
(PFDFINB)
YES ..............................................................................
NO ................................................................................
REFUSED ....................................................................
DON’T KNOW ..............................................................

1
2
-7
-8

FENCEPOST

PF2.

{Do you/Does s/he} have difficulty going outside the home, for example to shop or visit a
doctor’s office?
(PFDFOU)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
PF2b.

1
2 [GO TO PF3]
-7 [GO TO PF3]
-8 [GO TO PF3]

{Do you/Does s/he} need the help of another person to perform this activity?
(PFDFOUB)
YES ..............................................................................
NO ................................................................................
REFUSED ....................................................................
DON’T KNOW ..............................................................

1
2
-7
-8

FENCEPOST

PF3.

{Do you/Does name of participant} have difficulty getting in or out of bed or a chair?
(PFBED)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
PF3b.

1
2 [GO TO PF4]
-7 [GO TO PF4]
-8 [GO TO PF4]

{Do you/Does s/he} need the help of another person to perform this activity?
(PFBEDB)
YES ......................................................................
NO ........................................................................
REFUSED ............................................................
DON’T KNOW ......................................................

1
2
-7
-8

FENCEPOST

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

Page 90

PF4.

{Do you/Does s/he} have difficulty when taking a bath or shower?
(PFBATH)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
PF4b.

1
2 [GO TO PF5]
-7 [GO TO PF5]
-8 [GO TO PF5]

{Do you/Does s/he} need the help of another person to perform this activity?
(PFBATHB)
YES ......................................................................
NO ........................................................................
REFUSED ............................................................
DON’T KNOW ......................................................

1
2
-7
-8

FENCEPOST

PF5.

{Do you/Does NAME OF PARTICIPANT} have difficulty when dressing?
(PFDRES)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
PF5b.

1
2 [GO TO PF6]
-7 [GO TO PF6]
-8 [GO TO PF6]

{Do you/Does s/he} need the help of another person to perform this activity?
(PFDRESB)
YES ......................................................................
NO ........................................................................
REFUSED ............................................................
DON’T KNOW ......................................................

1
2
-7
-8

FENCEPOST

PF6.

{Do you/Does s/he} have difficulty when walking?
(PFWALK)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

1
2 [GO TO PF7]
-7 [GO TO PF7]
-8 [GO TO PF7]

Page 91

PF6b.

{Do you/Does s/he} need the help of another person to perform this activity?
(PFWALKB)
YES ......................................................................
NO ........................................................................
REFUSED ............................................................
DON’T KNOW ......................................................

1
2
-7
-8

FENCEPOST

PF7.

{Do you/Does NAME OF PARTICIPANT} have difficulty eating?
(PFEAT)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
PF7b.

1
2 [GO TO PF8]
-7 [GO TO PF8]
-8 [GO TO PF8]

{Do you/does s/he} need the help of another person to perform this activity?
(PFEATB)
YES .......................................................................
NO .........................................................................
REFUSED .............................................................
DON’T KNOW .......................................................

1
2
-7
-8

FENCEPOST

PF8.

{Do you/Does s/he} have difficulty using the toilet or getting to the toilet?
(PFWC)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
PF8b.

1
2 [GO TO PF9]
-7 [GO TO PF9]
-8 [GO TO PF9]

{Do you/Does s/he} need the help of another person to perform this activity?
(PFWCB)
YES .......................................................................
NO .........................................................................
REFUSED .............................................................
DON’T KNOW .......................................................

1
2
-7
-8

FENCEPOST

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

Page 92

PF9.

{Do you/Does NAME OF PARTICIPANT} have difficulty keeping track of money or bills?
(PFDLR)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
PF9b.

1
2 [GO TO PF10]
-7 [GO TO PF10]
-8 [GO TO PF10]

{Do you/Does s/he} need the help of another person to perform this activity?
(PFDLRB)
YES ......................................................................
NO ........................................................................
REFUSED ............................................................
DON’T KNOW ......................................................

1
2
-7
-8

FENCEPOST

PF10.

{Do you/Does s/he} have difficulty preparing meals?
(PFMEAL)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
PF10b.

1
2 [GO TO PF11]
-7 [GO TO PF11]
-8 [GO TO PF11]

{Do you/Does s/he} need the help of another person to perform this activity?
(PFMEALB)
YES ......................................................................
NO ........................................................................
REFUSED ............................................................
DON’T KNOW ......................................................

1
2
-7
-8

FENCEPOST

PF11.

{Do you/Does NAME OF PARTICIPANT} have difficulty doing light housework, such as
washing dishes or sweeping a floor?
(PFCLEN)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

1
2 [GO TO PF12]
-7 [GO TO PF12]
-8 [GO TO PF12]

Page 93

PF11b.

{Do you/Does s/he} need the help of another person to perform this activity?
(PFCLENB)
YES ......................................................................
NO ........................................................................
REFUSED ............................................................
DON’T KNOW ......................................................

1
2
-7
-8

FENCEPOST

PF12.

{Do you/Does NAME OF PARTICIPANT} have difficulty doing heavy housework, such as
scrubbing floors or washing windows?
(PFHCLEN)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
PF12b.

1
2 [GO TO PF13]
-7 [GO TO PF13]
-8 [GO TO PF13]

{Do you/Does s/he} need the help of another person to perform this activity?
(PFHCLENB)
YES ......................................................................
NO ........................................................................
REFUSED ............................................................
DON’T KNOW ......................................................

1
2
-7
-8

FENCEPOST

PF13.

{Do you/Does s/he} have difficulty taking the right amount of prescribed medicine at the right
time?
(PFTKDG)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
PF13b.

1
2 [SKIP PF13b]
-7 [SKIP PF13b]
-8 [SKIP PF13b]

{Do you/Does s/he} need the help of another person to perform this activity?
(PFTKDGB)
YES .......................................................................
NO .........................................................................
REFUSED .............................................................
DON’T KNOW .......................................................

1
2
-7
-8

FENCEPOST

PROGRAMMER NOTE: ASK PF14 ONLY IF PROXY OR INTERPRETER INTERVIEW. IF
RESPONDENT ON PHONE, DO NOT ASK. IF RESPONDENT ON PHONE, AUTOCODE AS 2 (NO).

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

Page 94

PF14.

{Does NAME OF PARTICIPANT} have difficulty using the telephone?
(PFFONE)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2 [GO TO PF15]
-7 [GO TO PF15]
-8 [GO TO PF15]

PF14b. {Does s/he} need the help of another person to perform this activity?
(PFFONEB)
YES ...........................................................................
NO .............................................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

PF15-A

1
2
-7
-8

Is there a car or personal motor vehicle in working condition in your {his/her} household?
(PFISCAR)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

PF15-B.

1
2 [GO TO PF16]
-7 [GO TO PF16]
-8 [GO TO PF16]

{Do you/Does s/he} have difficulty driving a car or personal motor vehicle?
(PFDRIVE)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

PF16.

1
2
-7
-8

Is there a public bus or transit stop within three-quarters of a mile from {your/his/her} home?
(PFBUS)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
PF16B.

1
2 [GO TO DEMOG. MOD.]
-7 [GO TO DEMOG. MOD.]
-8 [GO TO DEMOG. MOD.]

{Do you/Does s/he} have difficulty using this transportation?
(PFUSEBUS)
YES ......................................................................
NO ........................................................................
NEVER USES BUS………………………………
REFUSED ............................................................
DON’T KNOW ......................................................

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

1
2 [GO TO PF17A.]
3 [GO TO PF17A]
-7
-8

Page 95

PF16BOV. {Do you/Does s/he} need the help of another person to perform this activity?
(PFBUSEB)
YES ..............................................................................
NO ................................................................................
REFUSED ....................................................................
DON’T KNOW ..............................................................

1
2
-7
-8

FENCEPOST

PROGRAMMER NOTE: IF RESPONDENT HAS ANSWERED YES TO QUESTIONS THAT ASK IF
ANOTHER PERSON HELPS THEM (PF1B, PF2B, PF3B, PF4B, PF5B, PF6B, PF7B, PF8B, PF9B,
PF10B, PF11B, PF12B, PF13B, PF14B AND/OR PF16C, GO TO PF17A.
DISPLAY YES RESPONSES ON CATI SCREEN FOR PF16A. WE WANT TO DISPLAY THE ACTUAL
CATEGORIES FOR WHICH THE RESPONDENT SAID THEY RECEIVE HELP, SO DISPLAY THE
PREVIOUS QUESTIONS WHERE THE RESPONDENT SAID “YES, THEY HAVE DIFFICULTY…”
(NUMBERED QUESTIONS 1,2,3,4,5,6,7,8,9,10,11,11A, 12,13,15B) AND ‘YES, THEY RECEIVE HELP.”
(PF1B, PF2B, PF3B, PF4B, PF5B, PF6B, PF7B, PF8B, PF9B, PF10B, PF11B, PF13B, PF13B, PF14B
AND/OR PF16C). DISPLAY APPROPRIATE CATEGORIES LIKE THIS:
PF1
PF2

DIFFICULTY GETTING AROUND INSIDE THE HOME
DIFFICULTY GOING OUTSIDE THE HOME, FOR EXAMPLE TO SHOP OR VISIT A
DOCTOR’S OFFICE
PF3
DIFFICULTY GETTING IN OR OUT OF BED OR A CHAIR
PF4
DIFFICULTY WHEN TAKING A BATH OR SHOWER
PF5
DIFFICULTY WHEN DRESSING
PF6
DIFFICULTY WHEN WALKING
PF7
DIFFICULTY EATING
PF8
DIFFICULTY USING THE TOILET OR GETTING TO THE TOILET
PF9
DIFFICULTY KEEPING TRACK OF MONEY OR BILLS
PF10 DIFFICULTY PREPARING MEALS
PF11 DIFFICULTY DOING LIGHT HOUSEWORK, SUCH AS WASHING DISHES OR SWEEPING A
FLOOR
PF12B DIFFICULTY DOING HEAVY HOUSEWORK, SUCH AS SCRUBBING FLOORS OR
WASHING WINDOWS
PF13 DIFFICULTY TAKING THE RIGHT AMOUNT OF PRESCRIBED MEDICINE AT THE RIGHT
TIME
PF14 DIFFICULTY USING THE TELEPHONE
PF16B DIFFICULTY USING PUBLIC TRANSPORTATION
IF NOT, GO TO DEMOGRAPHIC INTAKE MODULE.

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

Page 96

PF17A.

You have said that {you need/NAME OF PARTICIPANT needs} the help of another person
with … [READ LIST OF ACTIVITIES PARTICULAR TO THIS CLIENT].

PF17B.

We would like to know if family or friends provide help with these activities. If so, who
provides the most help with these activities? Was it…
(FAMFRND)
FAMILY, OR .............................................................. 1
SOMEONE ELSE, LIKE A FRIEND, NEIGHBOR OR
OTHER PERSON? ................................................ 2 GO TO DEINTRO
DID NOT RECEIVE HELP FROM FAMILY/FRIENDS 3 GO TO DEINTRO

PF17C.

Which family member helps the most with these activities?

[INTERVIEWER NOTE: MARK ONLY ONE]
(WHOHELPS)
HUSBAND .................................................................
WIFE .........................................................................
SON, ..........................................................................
SON-IN-LAW ............................................................
DAUGHTER, .............................................................
DAUGHTER-IN-LAW ................................................
FATHER, ...................................................................
MOTHER, ..................................................................
BROTHER, ................................................................
SISTER, ....................................................................
GRANDSON,.............................................................
GRANDDAUGHTER, ...............................................
NEPHEW,..................................................................
NIECE, .....................................................................
OTHER RELATIVE ...................................................
REFUSED .................................................................
DON’T KNOW ...........................................................

1
2
3
4
5
6
7
8
9
10
11
12
13
14
91
-7
-8

GO TO DEMOGRAPHIC INTAKE MODULE

PHYSICAL, SOCIAL, AND EMOTIONAL WELL-BEING

Page 97

DEMOGRAPHIC INTAKE MODULE

NOTE: THIS MODULE IS FOR CASE MANAGEMENT, CONGREGATE MEALS, HOME-DELIVERED
MEALS, HOMEMAKER, TRANSPORTATION, AND FAMILY CAREGIVER.

PROGRAMMER NOTE: SKIP DEINTRO IF CAREGIVER. REPEATS CGINTRO1.

DEINTRO.

We are interested in knowing more about the demographic characteristics of our clients. We
would appreciate it if you would answer the following questions. Your answers will be used
only for the purposes of this research. The reports prepared for this study will summarize
information provided by participants and will not associate responses with a specific individual.
We will not provide information that identifies any individuals to anyone outside the study
team, except as required by law. Remember your answers are private and you don't have to
answer any question you don't want to.

DE1.

[ASK OF ALL]: What is {your/NAME OF PARTICIPANT’s/NAME OF CAREGIVER’s} sex?
(DEGENDR)
MALE ......................................................................................
FEMALE .................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
DE1a.

1
2
-7
-8

Which of the following best represents how you think of yourself?
(DETHINK)
Lesbian or gay*.................................................. 1
Straight, that is, not lesbian or gay** ................. 2
Bisexual ............................................................. 3
Something else .................................................. 4
REFUSED ......................................................... -7
DON’T KNOW ................................................... -8
*For men, the category reads “gay”
**For men, the category reads “straight, that is, not gay”

DE2.

We have {your/NAME OF PARTICIPANT/ NAME OF CAREGIVER’s} date of birth as
{DISPLAY DATE}, is that correct?
(DEBDAY1)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

DEMOGRAPHIC

1
2
-7
-8

Page 98

DE2UPDT. What is {your/NAME OF PARTICIPANT/NAME OF CAREGIVER} date of birth?
(DEBMM-DEBDD-DEBYYYY)
_____/____/________
MM DD YYYY
REFUSED .........................................................
DON’T KNOW ...................................................

-7
-8

FENCEPOST

PROGRAMMER NOTE: CONSTRUCTED VARIABLE-AGEC — PLEASE CONVERT DATE OF BIRTH TO
AGE AS OF INTERVIEW DATE. KEEP ORIGINAL RESPAGE AS WELL.

DE3.

What is {your/ NAME OF PARTICIPANT’s/NAME OF CAREGIVER’s} highest level of
education? Would {you/s/he} say…
(DEEDUC)
Less than high school diploma, ..............................................
High school diploma or GED, .................................................
Some college, including Associate’s degree
{INCLUDES BUSINESS SCHOOL AND VOCATIONAL
OR TECHNICAL SCHOOL}, ..............................................
Bachelor’s degree, or .............................................................
Some post-graduate work or advanced degree? ...................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

DE4.

1
2

3
4
5
-7
-8

{Are you/Is NAME OF PARTICIPANT/NAME OF CAREGIVER} Hispanic or Latino?
(DEHISP)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
-7
-8

FENCEPOST

DEMOGRAPHIC

Page 99

DE5.

Which one or more of the following best describes {your/NAME OF PARTICIPANT’s} race?
Would (you/s/he) say… (CODE ALL THAT APPLY. CTRL/P TO EXIT)
(DERAC01-06 DERACOS)
White, .....................................................................................
Black or African American, .....................................................
Asian, .....................................................................................
American Indian or Alaska Native, or .....................................
Native Hawaiian or other Pacific Islander ..............................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
-7
-8

FENCEPOST
DE5a.

{Have you/Did NAME OF PARTICIPANT/NAME OF CAREGIVER} previously
served on active duty in the U.S. Armed Forces, military Reserves or National
Guard?
(DEVET)
YES ...................................................................
NO .....................................................................
REFUSED .........................................................
DON’T KNOW ...................................................

DE6.

1
2
-7
-8

Is {your/ his/her} home located in…
(DELOC)
The city, ..................................................................................
The suburbs, or ......................................................................
A rural area? ...........................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

DE7.

1
2
3
-7
-8

What is {your/ NAME OF PARTICIPANT’s/NAME OF CAREGIVER’s} home ZIP code?
(DEZIP)
HOME ZIP CODE................................................................... |___|___|___|___|___|
REFUSED .............................................................................. -7
DON’T KNOW ........................................................................ -8

FENCEPOST
PROGRAMMER NOTE: IF CAREGIVER ANSWERS CG21—CGMINUT—1-LIVES IN SAME HOUSE,
AUTOCODE DE8 “2,” AND GO TO DE8A.

DEMOGRAPHIC

Page 100

DE8.

We’d like to ask about the persons who live in this household. Does anyone else live with
{you/NAME OF PARTICIPANT/NAME OF CAREGIVER}?
(DELIVWI)
YES ........................................................................................
NO ..........................................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................
DE8a.

1
2
-7
-8

[GO TO DE8a.]
[GO TO DE8b.]
[GO TO DE8a ]
[GO TO DE8a]

Do you/Does {NAME OF PARTICIPANT/NAME OF CAREGIVER}

1. Live with {your/his/her} spouse?.......................................
(DELVSP1)
2. Live with {your/his/her} children?......................................
(DELVKID2)
3. Live with other relatives? ..................................................
(DELVREL3)
4. Live with non-relatives? ....................................................
(DELVNRL4)

DEMOGRAPHIC

Yes

No

RF

DK

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

1

2

-7

-8

Page 101

PROGRAMMER NOTE: SOFT RANGE FOR DE8B IS 1 TO 10; HARD RANGE 1-20. IF DE8 = 2 (NO),
AUTOCODE DE8B 1 AND GO TO DE9.
PROGRAMMER NOTE: IF ALL OF DE8A IS NO, PROMPT "YOU TOLD ME YOU LIVE WITH SOMEONE
ELSE. WHO DO YOU LIVE WITH?" THEN ALLOW THE INTERVIEWER TO GO BACK AND CODE THE
RESPONSE "YES" THAT APPLIES.
IF THE RESPONDENT HAS INDICATED IN DE8 THAT HE OR SHE LIVES WITH SOMEONE ELSE (ANY
OF DE8 1-4 IS YES OR CAREGIVER ANSWERS CG21—CGMINUT—1-LIVES IN SAME HOUSE), IF
INTERVIEWER ENTERS 0 IN DE8B, GIVE A PROMPT THAT SAYS, “THE SYSTEM WILL NOT ACCEPT
ZERO, BECAUSE THIS QUESTION ASKS YOU TO INCLUDE YOURSELF.” IF INTERVIEWER ENTERS
ONE, AND DE8 IS YES (1) THEN GIVE A PROMPT THAT SAYS, “YOU TOLD ME YOU LIVE WITH OTHER
PEOPLE. PLEASE INCLUDE YOURSELF WHEN TELLING ME HOW MANY PEOPLE LIVE IN YOUR
HOUSEHOLD.” IF DE8 IS REFUSED OR DON’T KNOW, THEN ACCEPT 1.
IF CAREGIVER AND CGMINUT=1, AND INTERVIEWER ENTERS 0 OR 1 IN DE8B, PROMPT, “You told
me {you live/s/he lives} with {CARE RECIPIENT}. Please include {him/her} when you tell me how many
live in the household.”
VARIABLES:
Variable Name

Available Responses
(Hard Range)

Likely
Responses

Go To

(Soft Range)
A

EXTD.DELVSP1

B

EXTD.DELVKID2

C

EXTD.DELVREL3

D

EXTD.DELVNRL4

1. YES
2. NO
-7 REFUSED
-8 DON’T KNOW
1. YES
2. NO
-7 REFUSED
-8 DON’T KNOW
1. YES
2. NO
-7 REFUSED
-8 DON’T KNOW
1. YES
2. NO
-7 REFUSED
-8 DON’T KNOW

(B)
(B)
(B)
(B)
(C)
(C)
(C)
(C)
(D)
(D)
(D)
(D)
DE8B
DE8B
DE8B
DE8B

FENCEPOST
DE8b.

Including {yourself/himself/herself}, how many people live in {your/NAME OF
PARTICIPANT’S/NAME OF CAREGIVER’S} household?
(DEHHM)
NUMBER OF HOUSEHOLD MEMBERS ................. |__|__|
REFUSED ................................................................. -7
DON’T KNOW ........................................................... -8

FENCEPOST

DEMOGRAPHIC

Page 102

DE9.

What is {your/his/her} marital status? Would {you/NAME OF PARTICIPANT/NAME OF
CAREGIVER} say {you are/s/he is}…
(DEMARST)
Married, ..................................................................................
Living with a partner, ..............................................................
Widowed, ................................................................................
Divorced, ................................................................................
Separated, or ..........................................................................
Never Married? .......................................................................
REFUSED ..............................................................................
DON’T KNOW ........................................................................

1
2
3
4
5
6
-7
-8

FENCEPOST

PROGRAMMER NOTE: IF DE8B (DEHHM) = 1, IN DE10, DE10A AND DE10B, USE FIRST DISPLAY
(YOUR/NAME OF PARTICIPANT’S/NAME OF CAREGIVER’S). IF DEHHM IS GREATER THAN 1, USE
2ND DISPLAY, “YOUR/NAME OF PARTICIPANT’S/NAME OF CAREGIVER’S TOTAL COMBINED
FAMILY” DISPLAY.
ASK ALL RESPONDENTS THE INCOME QUESTIONS.

DE10.

Thinking about the total combined income from all sources for all persons in this household,
including income from jobs, Social Security, retirement income, public assistance, and all other
sources was {your/ NAME OF PARTICIPANT’s/NAME OF CAREGIVER’S} total household
annual income during the year 2020 above or below $20,000?
(DEINAB)
At or below $20,000 {$1,666 PER MONTH OR LESS}, or ....

Above $20,000 {$1,667 PER MONTH OR MORE}? ..............

REFUSED ..............................................................................
DON’T KNOW ........................................................................

DE10A.

1 [GO TO DE10A (SEE
PROGRAMMER NOTE,
ABOVE)]
2 [GO TO DE10B (SEE
PROGRAMMER NOTE
ABOVE)]
-7 [GO TO CLOSING]
-8 [GO TO CLOSING]

Which category best describes {your/NAME OF PARTICIPANT’s/NAME OF
CAREGIVER’s} total household annual income during the year 2020? Would
{you/s(he)} say…
(INCOMEC)
$5,000 or less [$417 OR LESS PER MONTH], ………………. 1
$5,001 - $10,000 [$418 - $833 PER MONTH], ……………..… 2
$10,001 - $15,000, [$834 TO $1,250 PER MONTH],…….……3
$15,001 - $20,000, [$1,251 TO $1,666 PER MONTH]?........... 4
REFUSED………………………………………………………. -7
DON’T KNOW .......................................... …………..
-8

GO TO CLOSING

DEMOGRAPHIC

Page 103

DE10B.

Which category best describes {your/NAME OF PARTICIPANT’s/NAME OF
CAREGIVER’s} total household annual income during the year 2020? Would
{you/NAME OF PARTICIPANT/NAME OF CAREGIVER} say…
(DEINABOV)
$20,001 -$25,000 [$1,667 TO $2,083 PER MONTH]………………... 1
$25,001 - $30,000 [$2,084 TO $2,500 PER MONTH]……….……… 2
$30,001 - $35,000 [$2,501 TO $2,917]……………………………...… 3
$35,001 - 40,000 [$2,918 TO $3,333]……………………………..…… 4
$40,001 - $50,000, or $3,334 TO $4,167 PER MONTH], or ……… 5
Over $50,000? [$4,168 PER MONTH OR MORE]?………………
6
REFUSED ………………………………………………
-7
DON’T KNOW ...........................................................
-8

GO TO CLOSING

DEMOGRAPHIC

Page 104

CLOSING

CLOSE1. That concludes our interview. Thank you very much for your help with this important
national survey. We appreciate your time.

CLOSING

Page 105