OAHM Client Program Questionnaire (Baseline)

Appendix C

OAHM Client Program Questionnaire

Older Adults Home Modification Program

Client Program Questionnaire¹

Study ID:		Visit		Today’s Date (mm/dd/yyyy)	Form Completed By:
Site ID	Client ID				Name	Job Title
		__ Baseline __ Follow-Up				(dropdown menu: OT, OTA, CAPS, 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 6 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. 

Grantee Guidance: Administer this questionnaire only to a client you have enrolled in the OAHM Program, i.e., the beneficiary receiving direct services from your program who has been identified as the client by the licensed occupational therapist (OT), or a licensed OT Assistant (OTA) or Certified Aging-in-Place Specialist (CAPS) whose work is overseen by a licensed OT. Make sure this client’s information has been correctly entered into Item 9 of the Client Eligibility Documentation Form. For each question, do not give “not answered” as an answer choice. Instead, gently probe for answers and record “not answered” as a last resort.

Section A: ACTIVITIES OF DAILY LIVING DIFFICULTIES DETERMINATION (Source: Katz et al., 1963)

Hand the client Card A/B [Baseline Visit: “To help us work with you to determine what home modifications are needed, . . .] [Follow-up visit: “To help us evaluate our older adults home modification program . . .] . . . I’d like to know a little more about your ability to perform some everyday activities. Please use the answer choices shown on Card A/B: ‘No and don’t need help,’ ‘yes but don’t need help,’ or ‘need help regardless of difficulty’ when answering these questions. You can read your answer out loud or point, whichever you prefer.”

	No and don't need help (0)	Yes but don't need help (1)	Need help regardless of difficulty (2)	Not answered
A.1 Do you have any difficulty bathing or showering?	□	□	□	□
A.2 Do you have any difficulty dressing (upper body)?	□	□	□	□
A.3 Do you have any difficulty dressing (lower body)?	□	□	□	□
A.4 Do you have any difficulty getting in and out of bed or chairs?	□	□	□	□
A.5 Do you have any difficulty eating?	□	□	□	□
A.6 Do you have any difficulty using the toilet, including getting to/on/off the toilet?	□	□	□	□
A.7 Do you have any difficulty walking across a small room?	□	□	□	□
A.8 Do you have any difficulty grooming?	□	□	□	□
If any of the 8 questions were not answered, try to obtain answers.

Section B: INSTRUMENTAL ACTIVITIES OF DAILY LIVING DIFFICULTIES DETERMINATION (Lawton & Brody, 1969)

Continue to use Card A/B to answer these 8 IADL questions.

	No and don't need help (0)	Yes but don't need help (1)	Need help regardless of difficulty (2)	Not answered
B.1 Do you have any difficulty or are you unable to prepare meals?	□	□	□	□
B.2 Do you have any difficulty doing light housework, such as cleaning dishes, straightening up, or light cleaning?	□	□	□	□
B.3 Do you have any difficulty shopping for personal items such as medicines or toilet items?	□	□	□	□
B.4 Do you have any difficulty using the telephone?	□	□	□	□
B.5 Do you have any difficulty washing laundry?	□	□	□	□
B.6 Do you have any difficulty traveling independently, by yourself without help from another person?	□	□	□	□
B.7 Do you have difficulty taking your medications?	□	□	□	□
B.8 Do you have any difficulty managing your money, for example, paying bills or keeping a bank account, by yourself and without help from another person?	□	□	□	□
If any of the 8 questions were not answered, try to obtain answers.

Section C: Falls Efficacy Scale (Tinetti et al., 1990) *CARD C - Falls Scale*

Hand the client Answer Card C. “On a scale from 1 to 10, with 1 being very confident and 10 being not confident at all, how confident are you that you can do the following activities without falling? Please give me a number on a scale of 1 to 10.” For each question, enter the number between 1 and 10 the person points to on Card C. If any of questions E.1 through E.10 were not answered, try to obtain answers. Enter “99” if the client declines to answer.

Question	Answer
C.1 How confident are you taking a bath or shower without falling
C.2 How confident are you about reaching into cabinets or closets without falling
C.3 How confident are you walking around the house without falling
C.4 How confident are you preparing meals, that don’t require carrying heavy or hot objects, without falling
C.5 How confident are you getting in and out of bed without falling
C.6 How confident are you answering the door or telephone without falling
C.7 How confident are you getting in and out of chairs without falling
C.8 How confident are you getting dressed and undressed without falling
C.9 How confident are you with personal grooming (for example, washing your face) without falling
C.10 How confident are you getting on and off the toilet without falling

Section D: Falls in the Past Year

“A fall is when your body goes to the ground without being pushed.” (CMS HOS)

D.1 Did you fall in the past 12 months? (CMS HOS Q 49)	□ Yes (Go to D.2) □ No (end questionnaire) □ Not answered (end questionnaire)
D.2 In the past 12 months, how many times have you fallen? BRFSS 2014 Q12.1	□ None (end questionnaire)□ Number of times (REDCap: number must be >0. Enter 76 if the person fell more than 75 times □ Not answered (end questionnaire)
D.3 How many of these falls occurred while you were inside your home or on your property (for example, in your yard or your driveway)?	□ None (end questionnaire) □ Number of falls (This number must be ≤number provided in D.2) (Go to D.3a) □ Not answered (end questionnaire)
D.3a Where in your home or on your property did you fall? Check all that apply	□ Bathroom □ Kitchen □ Living room □ Dining room □ Bedroom □ Other room (Specify)_______________ □ My driveway □ My yard □ Other outdoor location on my property (Specify):_______
D.4 Can you please list the approximate date(s) that you fell inside your home or on your property in the past year?	Date 1: Date 2: Etc. □ Not answered
D.5 What was/were the main reason(s) you fell inside your home or on your property? Do not read answer choices to client. Check all that client mentions.	□ You tripped or stumbled □ You slipped □ You were not paying attention □ You had nothing to hold on to □ You blacked out or fainted □ You lost your balance □ You hurried too much □ You had an issue with your hearing □ You were playing sports or exercising □ You had an issue with your vision □ The lighting was poor □ You were getting up after sitting/lying down □ You were walking up/down stairs □ You had slow reactions or reflexes □ You had weakness or numbness in one or both legs □ You had a problem with medicine □ You drank too much alcohol □ You had a problem using a walker, cane or other aid that helps you get around □ You had a problem with shoes, sandals, or socks □ You had a health condition □ Another reason not yet mentioned Specify:___________ □ Not answered

CLIENT PROGRAM QUESTIONNAIRE ANSWER CARDS

PROGRAM QUESTIONNAIRE ANSWER CARD A/B

No and don’t need help

Yes but don’t need help

Need help regardless of difficulty

PROGRAM QUESTIONNAIRE ANSWER CARD C

Scale of 1 to 10:

1--------2--------3--------4--------5--------6--------7--------8--------9--------10

Very Not

Confident Confident

At All

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