Baseline survey

STEADI Baseline for CATI

Form Approved

OMB No: 0920-1281

Exp. Date: 01/31/2023

Public Reporting burden of this collection of information is estimated at 15 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn:  PRA (0920-1281).

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

00 Continue without recording

01 Continue with recording

…other standard outcomes

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

01 YES [continue to intro_2]

02 NO [continue to SCREEN_EXIT]

AVAIL Is [she/he] available?

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

02 NO [continue to SCREEN_EXIT]

SCREEN_EXIT

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

INTRO_2. Welcome to the Patient Falls Survey. We appreciate your help with this important study. Your participation is voluntary. You can refuse to answer a question or stop the survey at any time, and all information you provide is confidential, and will only be used for the purposes of this study. I’d like to continue now unless you have any questions.

01 Continue

02 Set callback

99 Refused to participate

Q1_INTRO. For purposes of this survey, you will be asked a series of questions about your health with a particular focus on falls. A fall is being defined as an event that resulted in a person unintentionally coming to rest on the ground, floor, or other lower level. Please keep this definition in mind as you complete the survey.

Q1. In the past 12 months, how many times have you fallen?

_____ Number of falls

If 0, go to Q3. Else go to Q2.

Q2. How many of these falls caused an injury? By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor.

_____Number of falls causing injury

Q3_INTRO Recently you had a primary care appointment with your Emory provider and completed a falls risk screening questionnaire. Our records indicate that visit took place on [FILL DATE FROM SAMPLE FILE]. Throughout this survey we are going to refer to this visit, which may have occurred over telemedicine or in person at an Emory facility. Please answer the following questions, thinking about your life in the 12 months before that visit.

Q3. In general, would you say that your health was excellent, very good, good, fair, or poor?

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

Q4. In the 12 months before the Emory visit: On a scale of 1 to 5, where 1 means “not at all afraid” and 5 means “very afraid,” how afraid were you of falling?

1 Not at all Afraid	2	3	4	5 Very Afraid	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q5. In the 12 months before the Emory visit: On a scale of 1 to 5, where 1 means "not at all important" and 5 means "most important," how important was falling compared with your other health concerns?

1 Not at all Important	2	3	4	5 Most Important	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q6. In the 12 months before the Emory visit: On a scale from 1 to 5, where 1 means "not at all likely" and 5 means "very likely," how likely were you to fall?

1 Not at all Likely	2	3	4	5 Very Likely	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q7. In the 12 months before the Emory visit: On a scale from 1 to 5, where 1 means "not at all likely" and 5 means "very likely," if you fell, how likely was it that you would be hurt?

1 Not at all Likely	2	3	4	5 Very Likely	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q8. Think about your level of physical activity in the 12 months before the Emory visit. Compared to other people your own age, do you think you were:

1 Much Less Active	2 Less Active	3 About as Active	4 More Active	5 Much More Active	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

Q9. Now thinking about your friends, in the 12 months before the Emory visit, compared to other people their own age, do you think your friends were:

1 Much Less Active	2 Less Active	3 About as Active	4 More Active	5 Much More Active	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□

I’m going to read a series of statements. On a scale of 1 to 5, where 1 means “Strongly Disagree” and 5 means “Strongly Agree,” please indicate your agreement with the each statement, thinking about your life in the 12 months before the Emory visit:	1 Strongly Disagree	2 Disagree	3 Neither Agree nor Disagree	4 Agree	5 Strongly Agree	77 Don’t Know	99 Prefer not to Answer
Q10. I would be embarrassed if my friends knew I fell. Would you say you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?	□	□	□	□	□	□	□
Q11. My friends and I talked about the risk of falling. Would you say you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?	□	□	□	□	□	□	□
Q12. My friends were worried about falling. [READ IF NECESSARY] Would you say you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?	□	□	□	□	□	□	□
Q13. Older people fall and there is nothing that can be done about it. [READ IF NECESSARY] Would you say you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?	□	□	□	□	□	□	□
Q14. There are things I can do to reduce my risk of falling. [READ IF NECESSARY] Would you say you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?	□	□	□	□	□	□	□

In the 12 months before the Emory visit:	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q15. Did you have your vision tested?	□	□	□	□
Q16. Did you visit a foot doctor?	□	□	□	□
Q17. Did you see a mental health professional, such as a therapist, counselor, or psychiatrist?	□	□	□	□
Q18. Did you make any changes to your home to help prevent falls?	□	□	□	□
Q19. Did you have any physical or occupational therapy?	□	□	□	□
Q20. Did you have a balance disorder or other condition that caused you to feel unsteady or dizzy?	□	□	□	□
Q21. Did you speak with a health care provider about preventing falls?	□	□	□	□

	1 Tai Chi	2 Matter of Balance	3 Other Exercise	77 Don’t know	99 Prefer not to Answer
Q22. In the 12 months before the Emory visit, did you participate in any of the following exercise programs: Tai Chi, Matter of Balance, or some other exercise?	□	□	□	□	□

	1 Yes	2 No	77 Don’t know	99 Prefer not to Answer
Q23. In the 12 months before the Emory visit, did you take medicine prescribed for you to help you sleep such as zolpidem (Ambien), zaleplon (Sonata), or eszopiclone (Lunesta)?	□	□	□	□
Q24. In the 12 months before the Emory visit, did you take over-the-counter medicine to help you sleep such as diphenhydramine (Benedryl, ZZZQuil, Tylenol PM) or doxylamine (Unisom)?	□	□	□	□
Q25a. In the 12 months before the Emory visit, did you take opioid medicine prescribed for you to help with pain? These might include tramadol (Ultram), oxycodone (Roxicodone, Percocet, Oxycontin), hydrocodone (Lortab, Vicodin), morphine (MsContin), hydromorphone (Dilaudid), or fentanyl (Duragesic).	□	□	□	□
Q25b. Did you take non-opioid medicine prescribed for you to help with pain, such as ibuprofen (Motrin), naproxen (Naprosyn), or diclofenac (Voltaren)?	□	□	□	□
Q26. Did you take over the counter medicine to help with pain such as ibuprofen (Motrin, Advil), acetaminophen (Tylenol) or naproxen (Aleve)?	□	□	□	□
Q27. In the 12 months before the Emory visit, did you take medicine prescribed for you to help your mood or for sadness, such as sertraline (Zoloft), citalopram (Celexa), or duloxetine (Cymbalta)?	□	□	□	□
Q28. Did you take medicine prescribed for you to help with anxiety or nervousness, such as alprazolam (Xanax), lorazepam (Ativan), or diazepam (Valium)?	□	□	□	□
Q29. Did you take medicine prescribed for you to help with mood stability such as risperidone (Risperdal), aripiprazole (Abilify), or quetiapine (Seroquel)?	□	□	□	□
Q30. Did you take Vitamin D or a multivitamin?	□	□	□	□

Q31. How many prescription medications do you take regularly?

______ number of medications

Q32. In the last three months, on average, how many days per week did you have any alcohol to drink?

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

Q33. Did you use marijuana in the last 30 days?

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

Q34. Over the past month, how many times did you most typically get up to urinate, from the time you went to bed at night until the time you got up in the morning?

0	1	2	3	4	5	77 Don’t Know	99 Prefer not to Answer
□	□	□	□	□	□	□	□

Q36. What is your ethnicity? Are you Hispanic or Latino?

01 Hispanic or Latino

02 Not Hispanic or Latino

77 Don’t Know

99 Prefer not to Answer

Q37. What is your race? Are you American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, or White? You can select one or more.

01 American Indian or Alaska Native

02 Asian

03 Black or African American

04 Native Hawaiian or Other Pacific Islander

05 White

77 Don’t Know

99 Prefer not to Answer

Q38. You previously indicated that you were able to have someone available to help you participate in an at-home falls risk assessment, or you had someone help you with the assessment when it was conducted, is this person someone who:

01 Lives in your home

02 A friend or family member who does not live in your home

03 A home health care worker

04 Other

77 Don’t Know

99 Prefer not to Answer

TOKEN. Those are all the questions I have. Thank you for taking the time to participate today. You will be contacted again in approximately three months to answer follow-up questions about your experience with falls. Please remember to track your survey participation and falls in your falls tracking log, which was provided in your survey invitation. If you don’t have the falls tracking log, you can use any calendar. Tracking this information will make it easier to answer the questions in the follow-up survey.

[pause for questions about log]

As a token of our appreciation, we will send you postage stamps valued at $3.

Please confirm that your mailing address is:

[FILL NAME AND MAILING ADDRESS FROM SAMPLE FILE]

01 My address is correct. [Go to Q35]

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

03 Please do NOT send stamps. [Go to Q35]

TOKENADD.

Please enter your mailing address.

FIRST AND LAST NAME _____________

STREET ADDRESS __________________________

CITY ____________________

STATE ________________________

ZIP CODE _________________________

[GO TO Q35]

Q35. How would you like to be contacted to complete the follow-up survey? Would you like to complete a web survey online, complete a paper survey and mail it back to us, or do you prefer that we call you again to complete the survey over the phone?

1. I prefer to complete the survey on the internet [GO TO Q35E]

2. I prefer to complete a paper survey and mail it back

[if TOKEN=03 GO TO Q35A. Else go to thank you screen]

3. I prefer for someone to call me so I can complete the survey over the phone [GO TO Q35P]

Q35E. Please provide an email address where we may contact you.

_________________________________________

[Go to thank you screen]

Q35A. Please confirm that your mailing address is:

[FILL NAME AND MAILING ADDRESS FROM SAMPLE FILE]

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

02 My address is NOT correct. [go to Q35ADD]

03 Please do NOT send a gift card. [Go to thank you screen]

Q35ADD.

Please enter your mailing address.

FIRST AND LAST NAME _____________

STREET ADDRESS __________________________

CITY ____________________

STATE ________________________

ZIP CODE _________________________

[Go to thank you screen]

Q35P. Please provide a telephone number, including area code, where an interviewer can reach you.

_ _ _-___-____

[Go to thank you screen]

[thank you screen]

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