Appendix L. Client Process Evaluation Interview Form OAHM_Final

Appendix L

Client Process Evaluation Interview

Older Adults Home Modification Program

Client Process Evaluation Interview¹

Study ID:			Today’s Date (mm/dd/yyyy)	Form Completed By:
Site ID	Client ID			Name	Job Title
					(dropdown menu: SC, other [Specify])

OMB Control No. 2528-XXXX, expiration date XX/XX/2024. This form is designed to provide HUD with information about how effective its Older Adults Home Modification Grant Program is. The information you provide is voluntary. Your home can be enrolled in the program whether you decide to participate or not. The public reporting burden for collection of this information is estimated to be 30 minutes per response. HUD may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.

Site Coordinator Instructions: Before beginning the interview, look up the client’s baseline response to question B.1b in the Client Impact Evaluation Interview for use in #4 below. Additionally, be sure you know the name of the grantee organization and the name of its older adult home modification program.

“Thank you for participating in this survey today. My name is [insert your name], and I work for Healthy Housing Solutions. My organization is evaluating HUD’s Older Adults Home Modification program, and we are collecting feedback from you and other clients to determine how the program can be improved. We will not include any personally identifying information like your name or address when we summarize all the clients’ feedback. We would like your input on your experiences, feelings, and opinions about the [insert grantee’s name for its older adult home mod program] services provided to you by [insert grantee organization name]. You can choose not to answer a question. Your information will be kept private. We will not share any of your answers with [insert grantee name] staff.

1. How did you hear about the [insert grantee’s name for its older adult home mod program]? Check all that apply.

□ Posted Flyer. Where was the flyer posted? _______________________________________

□ Recruitment materials mailed to me

□ Older adult services or other organization that helps me. Organization Name:________________

□ Physician or other healthcare provider referral

□ Senior Day Center

□ Meeting or exhibit at a local community event or location (e.g., library, church)

□ A friend or family member

□ Social media ad (e.g., Facebook, Twitter, Instagram)

□ Local media (e.g., TV or radio public service announcements)

□ Home repair, handyman, or other home contractor (Specify):_____________________

□ Phone call from [insert grantee organization name]

□ [insert grantee organization name] knocked on my door

□ Another method not mentioned. Describe:_____________________________________

□ Don’t know/not answered

2. Why did you decide to apply for the [insert grantee’s name for its older adult home mod program]? SC: You may need to read this list to the client or provide examples, particularly if they seem reluctant to answer or can’t think of a reason. You can check more than one answer.

□ To help me to keep living in my home

□ A family member or friend recommended it to me

□ I was already on a waiting list with the organization

□ Anxious about coming back home after medical events

□ Anxious about tripping, slipping, or falling inside my home

□ Anxious about falling on my property (for example, in my yard, my deck, my porch, or my driveway)

□ Anxious about using particular room(s) in my home (Specify): (Dropdown menu: bathroom, bedroom, kitchen, living room, other)

□ Trouble moving around inside my home (for example, I couldn’t reach my bathroom/bedroom on an upper floor)

□ Trouble getting in and out of my home

□ Could not reach needed items in my kitchen, bathroom, or other rooms

□ Needed help with home maintenance or installing home modifications

□ My healthcare provider recommended home modifications, for example, grab bars

□ Another reason not mentioned: ______________

3. Before this program, had you done any additional home modifications to help you age in place? SC: You can prompt with examples such as removing area rugs, buying assistive equipment like a raised toilet seat, etc.

□ Yes (Go to 3a)

□ No (Go to 4)

□ Don’t know/not answered (Go to 4)

3a. Could you please share what some of these home modifications included:_____

4. In a previous interview, you indicated it’s [SC: Fill in the client’s baseline response to Questions B.1b from the Client Impact Evaluation Interview, e.g., extremely important, very, somewhat, not very, not at all important, not sure] for you to remain in this home for as long as possible. Why do you feel this way? __________________________________________________

“Now I’m going to read you 12 statements. For each statements I read, I’d like you to say whether you strongly agree, agree, disagree, or strongly disagree.” REDCap programming: Allow SCs to choose only one answer.

Statement	Strongly agree	Agree	Disagree	Strongly Disagree	Not answered
[Insert grantee’s name for its older adult home mod program] staff treated me with respect over the course of this program.	□	□	□	□	□
[Insert grantee’s name for its older adult home mod program] staff explained the program in a way that was easy to understand.	□	□	□	□	□
When figuring out the modifications to be done in my home, [insert grantee’s name for its older adult home mod program] staff asked me about my personal needs and goals.	□ (Go to 7a)	□ (Go to 7a)	□ (Go to 8)	□ (Go to 8)	□ (Go to 8)
7a. The installed home modifications met the personal needs and goals I discussed with [insert grantee’s name for its older adult home mod program] staff.	□	□	□	□	□
I use the home modifications regularly.	□	□	□	□	□
Overall, I benefitted from this program.	□	□	□	□	□
This program has made my life easier.	□	□	□	□	□
This program has made my home safer.	□	□	□	□	□
This program will help me keep living in this home.	□	□	□	□	□
This program has given me more confidence about managing daily challenges in my home.	□	□	□	□	□
This program has helped me feel less anxious about remaining in my home.	□	□	□	□	□
This program required a lot of work or effort on my part.	□	□	□	□	□
[Insert grantee’s name for its older adult home mod program] installed the home modifications quickly.	□	□	□	□	□
I will recommend this program to a family member, friend, or neighbor.	□	□	□	□	□

18. Did [insert grantee organization name] recommend home modifications that you turned down?

□ Yes (Go to 18.a.)

□ No (Go to 19)

□ Don’t know (Go to 19)

18.a. What were these home modifications?

18.b. Why did you turn them down?

19. Did you ask [insert grantee organization name] for any home modifications that did were not done?

□ Yes (Go to 19a)

□ No (Go to 20)

19.a. What were these requested home modifications? _______________________________

19.b. Why did you request them? _________________________________________________

19.c. Did [insert grantee organization name] explain why they could not do these home modifications?

□ Yes

□ No

19.d Did the [insert grantee’s name for its older adult home mod program] refer you to another program that could address these items?

□ Yes

□ No

20. Would you like to tell me what you liked the most or the least about [insert grantee’s name for its older adult home mod program]? SC: If the client is reluctant to answer, you could prompt with “Feel free to share an example that gives more information about your answers to any of the above questions.”

Grantee Comments about Interview (optional):

1 Code for this document: Black font=Question asked of the person being surveyed; Blue italics = Instruction for the interviewer; “Black bold in quotes”=Script for interviewer; yellow highlighted italics: Instruction for REDCap programmer.