Form Approved OMB No. 0920-XXXX Exp. Date 00/00/0000
NOTICE – Public reporting burden of this collection of information is estimated to average 30 minutes per response, 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, MS E-11, Atlanta, GA 30333, ATTN: PRA (0920-XXXX).
Assurance of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
Attachment I
Pretest Resident Questionnaire
INSTRUCTIONS: SELECT SAMPLE OF RESIDENTS WITH SITE CONTACT. ONCE YOU HAVE SELECTED THE RESIDENTS, DETERMINE WHICH STAFF WILL BE COMPLETING A QUESTIONNAIRE ON EACH SELECTED RESIDENT.
In order to obtain national level data about the residents of residential care facilities such as this one, we are collecting information from a sample of current residents. I will be asking questions about the background, health status, and charges for each sampled resident.
Any identifiable information will be held confidential and will be used only by NCHS staff, contractors or agents, only when necessary and with strict controls, and will not be disclosed to anyone else without the consent of your facility. By law, every employee as well as every agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. This questionnaire should take about 30 minutes to complete per person.
Do you have the resident records for sampled resident number: {NUMBER OF SAMPLED RESIDENT) from the resident roster? You may want to use the resident file in answering a few of the questions in this survey. If you have not retrieved the records and would like to do so now, I can wait a few minutes while you obtain them.
REVIEW CONSENT WITH STAFF MEMBER
As discussed in the consent form, the information we are collecting will be kept confidential by project staff. The responses you provide will not be linked to any information that would identify you, the resident, or the facility. The only exception is that we will ask you for the first name or initials of the resident that was sampled. This will be used to personalize each question. |
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Resident Survey
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R_A Background
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R_A_INTRO1
INTERVIEWER READ:
In order to obtain national level data about the residents of residential care facilities such as this one, we
are collecting information from a sample of current residents. I will be asking questions about the
background, health status, and charges for each sampled resident. The information you provide will be
held in strict confidence and will be used only by persons involved in the survey and only for the purpose
of the survey. The interview for each of the selected respondents should take about 30 minutes to
complete.
PRESS "1" AND ENTER TO CONTINUE.
Question Type: TContinue
CONTINUE 1 CONTINUE
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R_A_INTRO1A
I am going to ask questions about the following resident -- ^R_A_Name.
PRESS "1" AND ENTER TO CONTINUE.
Question Type: TContinue
CONTINUE 1 CONTINUE
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R_A_INTRO2
Do you have the resident records for ^R_A_Name?
You may want to use the resident file in answering a few of the questions in this survey. If you have not
retrieved the records and would like to do so now, I can wait a few minutes while you obtain them.
Question Type: TRecords
record_ 1 RECORD OBTAINED
norecord_ 2 RECORD NOT OBTAINED
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R_A_INTRO4
As discussed, the information we are collecting will be kept confidential by project staff. The responses
you provide will not be linked to any information that would identify you, the resident, or the facility.
PRESS "1" AND ENTER TO CONTINUE.
Question Type: TContinue
CONTINUE 1 CONTINUE
Friday, March 07, 2008 Page 1 of 44
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R_A1
Please tell me ^R_A_Name's gender?
Question Type: TGender
male 1 MALE
female 2 FEMALE
Logic after:
Use gender to set gender pronoun fills his/her him/her for the rest of the interview
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R_A2
Please tell me ^R_A_Name's age?
Question Type: 0..120
Logic after:
CAPI - IF A2 = 1 - 17 THEN GOTO ENDINT ELSE GOTO A3
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ENDINT
I am sorry but our survey is about residents that are 18 or older. Since this person is not eligible, I won't
complete an interview for this particular resident. I need to check my records for any other selected
residents for whom you were identified as a caregiver.
INTERVIEWER: CHECK YOUR 'RESIDENT SELECTION FORM' FOR OTHER RESIDENTS FOR WHOM THIS
CAREGIVER WAS A DESIGNATED RESPONDENT.
TO EXIT THIS SCREEN, PRESS "1" AND ENTER.
Question Type: TContinue
CONTINUE 1 CONTINUE
Logic after:
CAPI - GOTO END OF INTERVIEW NOTE FROM FC HERE, NEED TO CHECK WITH SAMPLING PEOPLE IF
THIS UNIT GETS DROPPED WITH OR WITHOUT REPLACEMENT
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R_A3
Is ^R_A_Name of Hispanic, Latino, or Spanish origin or descent?
Question Type: TYESNO
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 2 of 44
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R_A4
HAND SHOWCARD R_A4.
Which of these groups best describe ^R_A_Name?
You may select more than one category.
Question Type: TGroupSET
white 1 WHITE/CAUCASIAN
black 2 BLACK OR AFRICAN AMERICAN
Asian 3 ASIAN
Native 4 HAWAIIAN OR OTHER PACIFIC ISLANDER
Amind 5 AMERICAN INDIAN OR ALASKA NATIVE
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Logic before:
Do not allow F3 (Don't know) since Unknown is a response option.
R_A5
What is the highest grade or level of education ^R_A_Name completed?
Question Type: TSchool, nodk
High 1 High school or less
Coll 2 Some college or more
Unk 3 UNKNOWN
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Logic before:
Do not allow F3 (Don't know) since Unknown is a response option.
R_A6
Is ^R_A_Name currently married, divorced, legally separated, widowed or never married?
Question Type: TMaritalStatus, nodk
Married 1 Married
Divorced 2 Divorced
Legally 3 Legally separated
Widowed 4 Widowed
Never 5 Never married
Unknown 6 UNKNOWN
Friday, March 07, 2008 Page 3 of 44
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R_A7
How well does ^R_A_Name speak English?
Question Type: TEnglish
Excellent 1 Excellent
Verywell 2 Very well
Well 3 Well
Fair 4 Fair
Poor 5 Poor or not at all
NA 6 RESIDENT DOES NOT SPEAK BECAUSE OF A DISABILITY
Logic after:
IF R_A7 = 6 skip to R_A9_INTRO, else continue.
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R_A8
Is ^R_A_Name more comfortable speaking English or another language?
Question Type: TEng_oth
English 1 ENGLISH
ANOTHLANG 2 ANOTHER LANGUAGE
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R_A9_INTRO
The next few questions are about ^R_A_Name's living arrangements.
For these questions, please consider these definitions of apartments and rooms. An @bapartment@b is a
living unit that includes lockable doors, a bathroom with a sink, toilet, and shower or bath, and a kitchen
area which includes a sink, a refrigerator, and at least a cook top, hotplate, or microwave.
A @broom@b may be attached to a bathroom and contain a bed, but will not include a kitchen or private
entrance.
Question Type: TContinue
CONTINUE 1 CONTINUE
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R_A9
Does ^R_A_Name live in a. . .?
Question Type: TRoom
studio 1 Studio apartment
onebed 2 One-bedroom apartment
twobed 3 Two-bedroom apartment
ROOM1 4 Room designed for one person
ROOM2 5 Double occupancy room
ROOM3 6 Room for three or more residents
Friday, March 07, 2008 Page 4 of 44
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Logic before:
IF R_A9 ne ROOM1 continue, else go to R_A13
R_A10
Does ^R_A_Name currently share this room or apartment with another person?
Question Type: TYesNo
Yes 1 YES
No 2 NO
Question Fill: ^FillR_A10
apartment apartment
room room
Logic after:
If R_A10 NE YES goto R_A13
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R_A11
Is this person the resident's spouse or other relative? Other relative can include a sibling, a parent, child,
or cousin.
Question Type: TYesNo
Yes 1 YES
No 2 NO
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Logic before:
If R_A10 eq yes continue, else go to R_A13
R_A12
How many other residents not counting ^R_A_Name live in the room or apartment?
Question Type: TOthres
one 1 One other resident
twomore 2 Two or more other residents
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R_A13
Does ^R_A_Name live in a Dementia/Alzheimer's Special Care Unit?
Question Type: TYesno
Yes 1 YES
No 2 NO
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R_A14a
Does ^R_A_Name's room or apartment include a kitchen area that contains:
A cook top or hotplate?
Question Type: TYesNo
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 5 of 44
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R_A14b
(Does ^R_A_Name's room or apartment include a kitchen area that contains:)
a microwave?
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A14c
(Does ^R_A_Name's room or apartment include a kitchen area that contains:)
an oven?
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A15
Does ^R_A_Name's room or apartment have a door to the hallway that can be locked?
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A15A
Does ^R_A_Name's room or apartment have a bathroom located inside the room?
Question Type: TYesNo
Yes 1 YES
No 2 NO
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Logic before:
IF R_A15a = yes then ask R_A15Bath else skip to R_A16a
R_A15Bath
Does ^R_A_Name's room or apartment. . .
Question Type: TRoomType
fullbath 1 have a @bfull bathroom@b including a toilet, sink, and shower or tub located
within the room
halfbath 2 have a @bhalf-bath@b including a sink and toilet located within the room
Friday, March 07, 2008 Page 6 of 44
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R_A16a
I am going to read a list of activities. Please tell me whether ^R_A_Name regularly participates in each
activity whether or not it is offered or arranged by the facility.
Cards, board games, bingo
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16b
(I am going to read a list of activities. Please tell me whether ^R_A_Name regularly participates in each
activity whether or not it is offered or arranged by the facility.)
Arts, or crafts, such as sewing, knitting
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16c
(I am going to read a list of activities. Please tell me whether ^R_A_Name regularly participates in each
activity whether or not it is offered or arranged by the facility.)
Exercise or sports
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16d
(I am going to read a list of activities. Please tell me whether ^R_A_Name regularly participates in each
activity whether or not it is offered or arranged by the facility.)
Playing or listening to music
Question Type: TYesNo
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 7 of 44
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R_A16e
(I am going to read a list of activities. Please tell me whether ^R_A_Name regularly participates in each
activity whether or not it is offered or arranged by the facility.)
Reading or writing
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16f
(I am going to read a list of activities. Please tell me whether ^R_A_Name regularly participates in each
activity whether or not it is offered or arranged by the facility.)
Spiritual or religious activities
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16g
(I am going to read a list of activities. Please tell me whether ^R_A_Name regularly participates in each
activity whether or not it is offered or arranged by the facility.)
Shopping or trips
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16h
(I am going to read a list of activities. Please tell me whether ^R_A_Name regularly participates in each
activity whether or not it is offered or arranged by the facility.)
Watching television
Question Type: TYesNo
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 8 of 44
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R_A16i
(I am going to read a list of activities. Please tell me whether ^R_A_Name regularly participates in each
activity whether or not it is offered or arranged by the facility.)
Walking, or getting outside
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16j
(I am going to read a list of activities. Please tell me whether ^R_A_Name regularly participates in each
activity whether or not it is offered or arranged by the facility.)
Talking with friends or relatives
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16k
(I am going to read a list of activities. Please tell me whether ^R_A_Name regularly participates in each
activity whether or not it is offered or arranged by the facility.)
Going out to the movies or other social activities
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16l
(I am going to read a list of activities. Please tell me whether ^R_A_Name regularly participates in each
activity whether or not it is offered or arranged by the facility.)
Any other hobbies or activities
Question Type: TYesNo
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 9 of 44
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R_A16_outside_1
Does ^R_A_Name go outside the facility to
work at a job for pay
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16_outside_2
(Does ^R_A_Name go outside the facility to)
participate in a sheltered workshop
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16_outside_3
(Does ^R_A_Name go outside the facility to)
participate in a work training program
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16_outside_4
(Does ^R_A_Name go outside the facility to)
attend day programs for social or recreational activities
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_A16_outside_5
(Does ^R_A_Name go outside the facility to)
attend an educational program
Question Type: TYesNo
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 10 of 44
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R_A17
Does ^R_A_Name still drive?
Question Type: Tyesno
Yes 1 YES
No 2 NO
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Logic before:
IF R_A17 = 1 (YES) then ask R_A18
R_A18
How often does ^R_A_Name drive?
Question Type: THowOftenDrive
daily 1 Daily or every other day
onceTwiceWeek 2 Once or twice a week
lessOnceWeek 3 Less than once per week
notAtAll 4 Not at all
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R_AEND
PRESS "1" AND ENTER TO CONTINUE.
Question Type: TContinue
CONTINUE 1 CONTINUE
Friday, March 07, 2008 Page 11 of 44
R_B Characteristics
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R_B1Month
The next set of questions ask about the resident's characteristics.
When did ^R_A.R_A_Name first move into this facility?
MONTH
Question Type: TMonth
jan 1 January
feb 2 February
mar 3 March
apr 4 April
may 5 May
jun 6 June
jul 7 July
aug 8 August
sep 9 September
oct 10 October
nov 11 November
dec 12 December
Logic after:
Programmer note, this table should be setup as follows - 1 Month : 1-12 2 Year : 1990-2009.
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R_B1Year
When did ^R_A.R_A_Name first move into this facility?
YEAR
Question Type: TInt1990_2009
_1990_2009 1 1970..2009
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Logic before:
if R_B1year = DK or R_B1year > 2002 then ask R_B1Range, else skip to R_B2
R_B1Range
SHOWCARD R_B1RANGE
Please look at this card and tell me approximately how long it has been since ^R_A.R_A_Name first moved
into this facility?
Question Type: TMoveRange
_0_3 1 0 to 3 months
More3_6 2 More than 3 months to 6 months
More6_yr 3 More than 6 months to 1 year
More1_3 4 More than 1 year to 3 years
More3_5 5 More than 3 years to 5 years
More5 6 More than 5 years
Friday, March 07, 2008 Page 12 of 44
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R_B2
Was ^R_A.R_A_Name directly admitted from a @bshort-term stay@b at a:
Question Type: TAdmit
Hosp 1 Hospital
Rehab 2 Rehabilitation facility
Nurse 3 Nursing home
None 4 NONE OF THE ABOVE
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R_B3
Where did ^R_A.R_A_Name live prior to entering this facility? If directly admitted from a hospital,
rehabilitation facility, or nursing home, where did ^R_A.R_A_Name live @bbefore@ that? Was it a…
Question Type: Tlivepr
Private 1 Private home, apartment, rented room, or family residence
different 2 Different residential care, assisted living, or group home facility
retirement 3 Retirement or independent living community
nursing 4 Nursing home (this excludes short nursing home stays for rehabilitation)
other 5 Other
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Logic before:
if R_B3 = 5 (other) ask R_B3OTH
R_B3OTH
What was that other location?
Question Type: STRING[50]
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R_B4
For last month, what was the total charge for ^R_A.R_A_Name to live in this facility? Include the basic
monthly charge and charges for any additional services.
INTERVIEWER: ENTER AMOUNT PER MONTH
Question Type: 0..9995
Logic after:
Put in a soft edit so that if response is < 1000 or more than 2500, it asks "I have recorded __________, is
that correct?"
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R_B5
During the last 30 days did ^R_A.R_A_Name have @bsome or all@b of ^Fills.HisHer long-term care
services @bat this facility@b paid by Medicaid?
Question Type: TYesNo
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 13 of 44
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R_B6
Is ^R_A.R_A_Name a veteran of U.S. Military service?
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_BEND
PRESS "1" AND ENTER TO CONTINUE.
Question Type: TContinue
CONTINUE 1 CONTINUE
Friday, March 07, 2008 Page 14 of 44
R_C Health Status and Physical Functioning
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R_C_INTRO
The next questions are about ^R_A.R_A_Name's health status and physical functioning.
Question Type: TContinue
CONTINUE 1 CONTINUE
Friday, March 07, 2008 Page 15 of 44
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R_C1
SHOWCARD R_C1
As far as you know, has a doctor or other health professional ever diagnosed ^R_A.R_A_Name with any
of the following conditions? Please tell me the numbers that apply from this card.
Question Type: Tdiagnoses
diab 1 DIABETES
paralys 2 PARTIAL OR TOTAL PARALYSIS
alzheim 3 ALZHEIMER’S DISEASE OR OTHER DEMENTIA
arthritis 4 ARTHRITIS OR RHEUMATOID ARTHRITIS
gout 5 GOUT, LUPUS, OR FIBROMYALGIA
hbp 6 HIGH BLOOD PRESSURE OR HYPERTENSION
heartfail 7 CONGESTIVE HEART FAILURE
coronary 8 CORONARY HEART DISEASE
myocard 9 HEART ATTACK (MYOCARDIAL INFARCTION)
othheart 10 ANY OTHER KIND OF HEART CONDITION OR HEART DISEASE (OTHER THAN
LISTED ABOVE)
stroke 11 STROKE
kidney 12 KIDNEY DISEASE
cancer 13 CANCER OR MALIGNANT NEOPLASM OF ANY KIND
asthma 14 ASTHMA
emphys 15 EMPHYSEMA
bronch 16 CHRONIC BRONCHITIS
copd 17 COPD
palsy 18 CEREBRAL PALSY
muscular 19 MUSCULAR DYSTROPHY
osteo 20 OSTEOPOROSIS
nerves 21 NERVOUS SYSTEM DISORDERS, INCLUDING MULTIPLE SCLEROSIS,
PARKINSON’S DISEASE, AND EPILEPSY
mental 22 SERIOUS MENTAL PROBLEMS SUCH AS SCHIZOPHRENIA OR PSYCHOSIS
depress 23 DEPRESSION
othment 24 OTHER MENTAL, EMOTIONAL OR NERVOUS CONDITION
devel 25 INTELLECTUAL OR DEVELOPMENTAL DISABILITIES SUCH AS MENTAL
RETARDATION, SEVERE AUTISM, OR DOWN SYNDROME
spine 26 SPINAL CORD INJURY
brain 27 TRAUMATIC BRAIN INJURY
otherspec 28 OTHER
none 29 NONE OF THESE
Friday, March 07, 2008 Page 16 of 44
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Logic before:
If R_C1 eq cancer ask R_C1_Cancer
R_C1_Cancer
SHOWCARD R_C1_CANCER
What kind of cancer? Please tell me the numbers that apply from this card.
Question Type: Tcancer
bladder 1 BLADDER
blood 2 BLOOD
Bone 3 BONE
Brain 4 BRAIN
Breast 5 BREAST
Cervix 6 CERVIX
Colon 7 COLON
Esophag 8 ESOPHAGUS
Gallblad 9 GALLBLADDER
Kidney 10 KIDNEY
Larynx 11 LARYNX, WINDPIPE
Leukemia 12 LEUKEMIA
Liver 13 LIVER
Lung 14 LUNG
Lymph 15 LYMPHOMA
Melanoma 16 MELANOMA
Mouth 17 MOUTH, TONGUE, OR LIP
Ovary 18 OVARY
Pancreas 19 PANCREAS
Prostate 20 PROSTATE
Rectum 21 RECTUM
Skin 22 SKIN, NON-MELANOMA
Skin_DK 23 SKIN, DON'T KNOW WHAT KIND
Tissue 24 SOFT TISSUE (MUSCLE OR FAT)
Stomach 25 STOMACH
Testis 26 TESTIS
Throat 27 THROAT, PHARYNX
Thyroid 28 THYROID
Uterus 29 UTERUS
Other 30 OTHER
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Logic before:
If R_C1 = other ask R_C1OTH
R_C1OTH
Specify other condition
Question Type: STRING[50]
Friday, March 07, 2008 Page 17 of 44
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R_C1_impair_4
Which statement best describes ^R_A.R_A_Name's hearing without a hearing aid?
Question Type: Thearing
good 1 ^Fills.HisHerCaps hearing is good
little 2 ^Fills.HeSheCaps has a little trouble hearing
alot 3 ^Fills.HeSheCaps has a lot of trouble hearing
deaf 4 ^Fills.HeSheCaps is Deaf
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R_C1_impair_6
Is ^R_A.R_A_Name blind or unable to see?
Question Type: tYesNo
Yes 1 YES
No 2 NO
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Logic before:
If R_C1_impair_6 eq yes skip to R_C2a, else continue
R_C1_impair_5
Does ^R_A.R_A_Name have any trouble seeing even when wearing glasses or contact lenses?
Question Type: TYesNo
Yes 1 YES
No 2 NO
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Logic before:
If R_B1 < 12 MONTHS AGO, then (FILL: TODAYMONTHYEAR - R_B1MONTHYEAR) (FILL: since
^R_A_NAME moved into this residential care facility.)
If R_B1 >= TO 12 MONTHS, then ' (FILL: <empty>) (FILL: last 12 months.)
IF R_B1 = DK OR RF THEN USE RESPONSE TO R_B1Range FOR TIME REFERENCE FILL
R_C2a
^Fills.R_C2a ^NUMMONTHSSTR^FILLS.R_C21 ^TEMPNAME^FILLS.R_C22 ^Fills.R_C2b ^R_A.R_A_Name:
been treated in a hospital emergency room
Question Type: TYesNo
Yes 1 YES
No 2 NO
Question Fill: ^FillR_C21
LT12MO11 months since
GE12MO12
Question Fill: ^FillR_C22
LT12MO21 moved into this residential care facility.
GE12MO22 last 12 months.
Friday, March 07, 2008 Page 18 of 44
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Logic before:
If R_B1 < 12 MONTHS AGO, then (FILL: TODAYMONTHYEAR - R_B1MONTHYEAR) (FILL: since
^R_A_NAME moved into this residential care facility.)
If R_B1 >= TO 12 MONTHS, then ' (FILL: <empty>) (FILL: last 12 months.)
IF R_B1 = DK OR RF THEN USE RESPONSE TO R_B1Range FOR TIME REFERENCE FILL
R_C2b
(^Fills.R_C2a ^NUMMONTHSSTR^FILLS.R_C21 ^TEMPNAME^FILLS.R_C22 ^Fills.R_C2b ^R_A.R_A_Name:)
been a patient in a hospital overnight or longer excluding trips to the emergency room that did not result in
a hospital stay
Question Type: TYesNo
Yes 1 YES
No 2 NO
Question Fill: ^FillR_C21
LT12MO11 months since
GE12MO12
Question Fill: ^FillR_C22
LT12MO21 moved into this residential care facility.
GE12MO22 last 12 months.
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Logic before:
If R_B1 < 12 MONTHS AGO, then (FILL: TODAYMONTHYEAR - R_B1MONTHYEAR) (FILL: since
^R_A_NAME moved into this residential care facility.)
If R_B1 >= TO 12 MONTHS, then ' (FILL: <empty>) (FILL: last 12 months.)
IF R_B1 = DK OR RF THEN USE RESPONSE TO R_B1Range FOR TIME REFERENCE FILL
R_C2c
(^Fills.R_C2a ^NUMMONTHSSTR^FILLS.R_C21 ^TEMPNAME^FILLS.R_C22 ^Fills.R_C2b ^R_A.R_A_Name:)
had a stroke
Question Type: TYesNo
Yes 1 YES
No 2 NO
Question Fill: ^FillR_C21
LT12MO11 months since
GE12MO12
Question Fill: ^FillR_C22
LT12MO21 moved into this residential care facility.
GE12MO22 last 12 months.
Friday, March 07, 2008 Page 19 of 44
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Logic before:
If R_B1 < 12 MONTHS AGO, then (FILL: TODAYMONTHYEAR - R_B1MONTHYEAR) (FILL: since
^R_A_NAME moved into this residential care facility.)
If R_B1 >= TO 12 MONTHS, then ' (FILL: <empty>) (FILL: last 12 months.)
IF R_B1 = DK OR RF THEN USE RESPONSE TO R_B1Range FOR TIME REFERENCE FILL
R_C2d
(^Fills.R_C2a ^NUMMONTHSSTR^FILLS.R_C21 ^TEMPNAME^FILLS.R_C22 ^Fills.R_C2b ^R_A.R_A_Name:)
had a heart attack
Question Type: TYesNo
Yes 1 YES
No 2 NO
Question Fill: ^FillR_C21
LT12MO11 months since
GE12MO12
Question Fill: ^FillR_C22
LT12MO21 moved into this residential care facility.
GE12MO22 last 12 months.
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Logic before:
If R_B1 < 12 MONTHS AGO, then (FILL: TODAYMONTHYEAR - R_B1MONTHYEAR) (FILL: since
^R_A_NAME moved into this residential care facility.)
If R_B1 >= TO 12 MONTHS, then ' (FILL: <empty>) (FILL: last 12 months.)
IF R_B1 = DK OR RF THEN USE RESPONSE TO R_B1Range FOR TIME REFERENCE FILL
R_C2e
(^Fills.R_C2a ^NUMMONTHSSTR^FILLS.R_C21 ^TEMPNAME^FILLS.R_C22 ^Fills.R_C2b ^R_A.R_A_Name:)
had a fall that caused a hip fracture
Question Type: TYesNo
Yes 1 YES
No 2 NO
Question Fill: ^FillR_C21
LT12MO11 months since
GE12MO12
Question Fill: ^FillR_C22
LT12MO21 moved into this residential care facility.
GE12MO22 last 12 months.
Friday, March 07, 2008 Page 20 of 44
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Logic before:
If R_B1 < 12 MONTHS AGO, then (FILL: TODAYMONTHYEAR - R_B1MONTHYEAR) (FILL: since
^R_A_NAME moved into this residential care facility.)
If R_B1 >= TO 12 MONTHS, then ' (FILL: <empty>) (FILL: last 12 months.)
IF R_B1 = DK OR RF THEN USE RESPONSE TO R_B1Range FOR TIME REFERENCE FILL
R_C2f
(^Fills.R_C2a ^NUMMONTHSSTR^FILLS.R_C21 ^TEMPNAME^FILLS.R_C22 ^Fills.R_C2b ^R_A.R_A_Name:)
had a fall that caused an injury other than a hip fracture
Question Type: TYesNo
Yes 1 YES
No 2 NO
Question Fill: ^FillR_C21
LT12MO11 months since
GE12MO12
Question Fill: ^FillR_C22
LT12MO21 moved into this residential care facility.
GE12MO22 last 12 months.
--------------------------------------------------------------------------------------
Logic before:
If R_B1 < 12 MONTHS AGO, then (FILL: TODAYMONTHYEAR - R_B1MONTHYEAR) (FILL: since
^R_A_NAME moved into this residential care facility.)
If R_B1 >= TO 12 MONTHS, then ' (FILL: <empty>) (FILL: last 12 months.)
IF R_B1 = DK OR RF THEN USE RESPONSE TO R_B1Range FOR TIME REFERENCE FILL
R_C2g
(^Fills.R_C2a ^NUMMONTHSSTR^FILLS.R_C21 ^TEMPNAME^FILLS.R_C22 ^Fills.R_C2b ^R_A.R_A_Name:)
had a stay in a nursing home
Question Type: TYesNo
Yes 1 YES
No 2 NO
Question Fill: ^FillR_C21
LT12MO11 months since
GE12MO12
Question Fill: ^FillR_C22
LT12MO21 moved into this residential care facility.
GE12MO22 last 12 months.
Friday, March 07, 2008 Page 21 of 44
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Logic before:
If R_B1 < 12 MONTHS AGO, then (FILL: TODAYMONTHYEAR - R_B1MONTHYEAR) (FILL: since
^R_A_NAME moved into this residential care facility.)
If R_B1 >= TO 12 MONTHS, then ' (FILL: <empty>) (FILL: last 12 months.)
IF R_B1 = DK OR RF THEN USE RESPONSE TO R_B1Range FOR TIME REFERENCE FILL
R_C2h
(^Fills.R_C2a ^NUMMONTHSSTR^FILLS.R_C21 ^TEMPNAME^FILLS.R_C22 ^Fills.R_C2b ^R_A.R_A_Name:)
had another health emergency
Question Type: TYesNo
Yes 1 YES
No 2 NO
Question Fill: ^FillR_C21
LT12MO11 months since
GE12MO12
Question Fill: ^FillR_C22
LT12MO21 moved into this residential care facility.
GE12MO22 last 12 months.
--------------------------------------------------------------------------------------
Logic before:
If C2h = yes (OTHER) ask R_C2_oth
R_c2_oth
SPECIFY:
Question Type: STRING[50]
--------------------------------------------------------------------------------------
Logic before:
IF R_C2 includes 1 (emergency) as a response ask R_C3 else goto R_C4
If R_B1 < 12 MONTHS AGO, then (FILL: TODAYMONTHYEAR - R_B1MONTHYEAR) (FILL: since
^R_A_NAME moved into this residential care facility.)
If R_B1 >= TO 12 MONTHS, then ' (FILL: <empty- no number months necessary>) (FILL: last 12 months.)
IF R_B1 = DK OR RF THEN USE RESPONSE TO R_B1Range FOR TIME REFERENCE FILL
R_C3
^Fills.R_C2a ^NUMMONTHSSTR^FILLS.R_C21 ^TEMPNAME^FILLS.R_C22 ^Fills.R_C3a ^R_A.R_A_Name
^Fills.R_C3b
Question Type: 1..35
Question Fill: ^FillR_C21
LT12MO11 months since
GE12MO12
Question Fill: ^FillR_C22
LT12MO21 moved into this residential care facility.
GE12MO22 last 12 months.
Friday, March 07, 2008 Page 22 of 44
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R_C4a
Does ^R_A.R_A_Name currently use any of the following:
Dentures, including a partial plate
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_C4b
(Does ^R_A.R_A_Name currently use:)
Glasses or contact lenses
Question Type: TYesNo
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C4c
(Does ^R_A.R_A_Name currently use:)
Hearing aid
Question Type: TYesNo
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C4d
(Does ^R_A.R_A_Name currently use:)
Cane, including a tripod cane
Question Type: TYesNo
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C4e
(Does ^R_A.R_A_Name currently use:)
Walker
Question Type: TYesNo
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 23 of 44
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R_C4f
(Does ^R_A.R_A_Name currently use:)
Manual wheel chair
Question Type: TYesNo
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C4g
(Does ^R_A.R_A_Name currently use:)
Electric or motorized wheel chair
Question Type: TYesNo
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C4h
(Does ^R_A.R_A_Name currently use:)
Oxygen
Question Type: TYesNo
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C4i
(Does ^R_A.R_A_Name currently use:)
Communication board or other appliance to communicate
Question Type: TYesNo
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C4j
(Does ^R_A.R_A_Name currently use:)
Artificial limb
Question Type: TYesNo
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 24 of 44
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Logic before:
IF C1_impair_6 = YES OR IF C1_impair_5 = YES CONTINUE. ELSE R_C5a
R_C4k
Does ^R_A.R_A_Name now use telescopic lenses, Braille, readers, a guide dog, white cane, or any other
equipment for people with severe visual impairments?
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_C5a
Is ^R_A.R_A_Name @Blimited in any way@B because of difficulty remembering or because
^R_A.R_A_Name experiences periods of confusion?
Question Type: tYesNo
Yes 1 YES
No 2 NO
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R_C5
During the last 7 days, has ^R_A.R_A_Name given evidence of a problem with short-term memory, such
as difficulty remembering what ^Fills.HeShe had for breakfast or something you told ^Fills.HimHer a few
minutes earlier?
Question Type: TYesNo
Yes 1 YES
No 2 NO
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R_C6
During the last 7 days, has ^R_A.R_A_Name given evidence of a problem with long-term memory, such as
forgetting how old ^Fills.HeShe is or forgetting that ^Fills.HeShe was married?
Question Type: TYesNo
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 25 of 44
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R_C7
During the last 7 days, has ^R_A.R_A_Name had any of the following problems with orientation, such as:
READ CHOICES AND CODE ALL THAT APPLY.
Question Type: Torientset
Knowloc 1 Knowing the location of his/her bedroom?
Recface 2 Recognizing staff names/faces?
knowfac 3 Knowing that he/she is in a facility?
knowsea 4 Knowing what the season of the year is?
none 5 NONE OF THE ABOVE
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R_C8
During the last 7 days, which of the following best describes ^R_A.R_A_Name's decision-making about
such things as what to wear, how to organize ^Fills.HisHer day, etc? Would you say:
Question Type: TDecision
Independent 1 Independent - decisions were consistent, reasonable
Modified 2 Modified independence - he/she had some difficulty in new situations
Moderately 3 Moderately impaired - his/her decisions were poor; cues and supervision
were required
Severely 4 Severely impaired- he/she never or rarely made decisions
--------------------------------------------------------------------------------------
R_C9
During the last 7 days, which of the following best describes ^R_A.R_A_Name's ability to make
^Fills.HimselfHerself understood by others? Is ^Fills.HeShe:
Question Type: TUnderstood
always 1 Always understood by others
usually 2 Usually understood - difficulty finding words or finishing thoughts
sometimes 3 Sometimes understood - ability is limited to making concrete requests
Rarely 4 Rarely or never understood
Logic after:
IF R_C9 = 1 SKIP R_C9a; ELSE ASK R_C9a
--------------------------------------------------------------------------------------
R_C9a
Is ^R_A.R_A_Name's difficulty in making ^Fills.HimselfHerself understood by others due to a severe
speech impairment or other disability?
Question Type: TYesNo
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 26 of 44
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R_C10
Next, I would like to ask about everyday activities and whether ^R_A.R_A_Name receives any assistance
in doing them. By assistance, I mean help from special equipment, supervision or cueing by another
person, or hands-on assistance performing the task.
PRESS "1" AND ENTER TO CONTINUE.
Question Type: Tcontinue
CONTINUE 1 CONTINUE
--------------------------------------------------------------------------------------
R_c10a
Does ^R_A.R_A_Name currently receive assistance in bathing or showering?
Question Type: TYesno
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
Logic before:
if C10a = 1 ask R_C10a1
R_c10a1
Does ^R_A.R_A_Name bathe or shower with the help of:
CODE ALL THAT APPLY.
Question Type: TSpecialSET
Special 1 Special Equipment
Another 2 Another Person
--------------------------------------------------------------------------------------
R_c10b
Does ^R_A.R_A_Name currently receive assistance in dressing?
Question Type: TYesno
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
Logic before:
IF c10b = 1 ask R_C10b1
R_c10b1
Does ^R_A.R_A_Name dress with the help of:
CODE ALL THAT APPLY.
Question Type: Tspecialset1
Special 1 Special Equipment, such as zipper pulls or button hook aids
Another 2 Another Person
Friday, March 07, 2008 Page 27 of 44
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R_c10c
Does ^R_A.R_A_Name currently receive assistance in eating, such as cutting up food?
Question Type: TYesno
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
Logic before:
if c10c = 1 ask R_C10c1
R_c10c1
Does ^R_A.R_A_Name eat with the help of:
CODE ALL THAT APPLY.
Question Type: TspecialSET
Special 1 Special Equipment
Another 2 Another Person
--------------------------------------------------------------------------------------
R_C10d
Is ^R_A.R_A_Name confined to bed by health problems?
Question Type: Tyesno
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
Logic before:
IF R_C10d = 1 THEN SKIP TO R_C10i
R_C10e
Is ^R_A.R_A_Name confined to a chair by health problems?
Question Type: Tyesno
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C10f
Does ^R_A.R_A_Name currently receive any assistance in transferring in and out of bed or a chair?
Question Type: Tyesno
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 28 of 44
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Logic before:
if R_C10f = 1 ask R_C10f1
R_C10f1
Does ^R_A.R_A_Name transfer in or out of a bed or a chair with the help of:
CODE ALL THAT APPLY.
Question Type: TspecialSET
Special 1 Special Equipment
Another 2 Another Person
--------------------------------------------------------------------------------------
R_c10g
Does ^R_A.R_A_Name currently receive any assistance in walking?
Question Type: Tyesno
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
Logic before:
if R_C10h = 1 ask R_C10g1
R_C10g1
Does ^R_A.R_A_Name walk with the help of:
CODE ALL THAT APPLY.
Question Type: TspecialSET
Special 1 Special Equipment
Another 2 Another Person
--------------------------------------------------------------------------------------
R_C10h
Does ^R_A.R_A_Name go outside the grounds of this facility?
Question Type: Tyesno
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
Logic before:
if R_C10h = 1 ask R_C10h1
R_C10h1
When ^R_A.R_A_Name goes outside the grounds does ^R_A.R_A_Name require the help of:
CODE ALL THAT APPLY.
Question Type: TSPECIALSET
Special 1 Special Equipment
Another 2 Another Person
Friday, March 07, 2008 Page 29 of 44
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R_C10i
Does ^R_A.R_A_Name have an ostomy, an indwelling catheter or similar device?
Question Type: TYESNO
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
Logic before:
if R_C10i = 1 ask R_C10i1
R_C10i1
Does ^R_A.R_A_Name receive any help from another person in caring for this device?
Question Type: Tyesno
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C10j
Does ^R_A.R_A_Name currently receive any assistance using the bathroom?
Question Type: Tassist
yes 1 YES
no 2 NO
doesnot 3 DOES NOT USE TOILET (AN OSTOMY PATIENT, USES CHAIRFAST, ETC.)
--------------------------------------------------------------------------------------
Logic before:
if C10j = 1 ask R_C10j1
R_C10j1
Does ^R_A.R_A_Name require the help of:
CODE ALL THAT APPLY.
Question Type: TspecialSET
Special 1 Special Equipment
Another 2 Another Person
--------------------------------------------------------------------------------------
R_C10k
Has ^R_A.R_A_Name had any episode of bowel incontinence during the last 7 days?
Question Type: Tbincont
yes 1 YES
no 2 NO
notappl 3 NOT APPLICABLE (e.g. Had a colostomy)
Friday, March 07, 2008 Page 30 of 44
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R_C10l
Has ^R_A.R_A_Name had any episode of urinary incontinence during the last 7 days?
Question Type: Tyesnocath
Yes 1 YES
No 2 NO
Norappl 3 NOT APPLICABLE (E.G., HAS AN INDWELLING CATHETER, HAD AN
OSTOMY)
--------------------------------------------------------------------------------------
R_C10m
Is ^R_A.R_A_Name able to get out of the facility without help in case of an emergency?
Question Type: tYesNo
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C11
For the next questions, please respond yes, no, or resident does not perform this activity.
PRESS "1" AND ENTER TO CONTINUE.
Question Type: TContinue
CONTINUE 1 CONTINUE
--------------------------------------------------------------------------------------
R_C11a
Does ^R_A.R_A_Name currently need help from another person with:
Shopping for personal items, such as toilet items or medicine?
Question Type: Tyesnonot
Yes 1 YES
No 2 NO
Doesnotper 3 DOES NOT PERFORM THIS ACTIVITY
--------------------------------------------------------------------------------------
R_C11b
(Does ^R_A.R_A_Name currently need help from another person with:)
Managing money, such as keeping track of expenses or paying bills?
Question Type: Tyesnonot
Yes 1 YES
No 2 NO
Doesnotper 3 DOES NOT PERFORM THIS ACTIVITY
Friday, March 07, 2008 Page 31 of 44
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R_C11c
Does ^R_A.R_A_Name currently need help from another person or a special device with:
Using the telephone? This includes TTY.
Question Type: TYesNoNot
Yes 1 YES
No 2 NO
Doesnotper 3 DOES NOT PERFORM THIS ACTIVITY
--------------------------------------------------------------------------------------
Logic before:
if R_C11c=YES
R_C11c_1
Does ^R_A.R_A_Name receive help using the telephone from another person or a special device?
Question Type: TPersonDevice
person 1 ANOTHER PERSON
device 2 SPECIAL DEVICE
both 3 BOTH
--------------------------------------------------------------------------------------
R_C11d
(Does ^R_A.R_A_Name currently need help from another person with:)
Doing light housework, like straightening up his or her room or apartment?
Question Type: TYesNoNot
Yes 1 YES
No 2 NO
Doesnotper 3 DOES NOT PERFORM THIS ACTIVITY
--------------------------------------------------------------------------------------
R_C11e
(Does ^R_A.R_A_Name currently need help from another person with:)
Taking medication -- this includes opening the bottle, remembering to take medication on time, and taking
the prescribed dosage?
Question Type: Tyesnonot
Yes 1 YES
No 2 NO
Doesnotper 3 DOES NOT PERFORM THIS ACTIVITY
Friday, March 07, 2008 Page 32 of 44
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R_C12a
Does ^R_A.R_A_Name now use an amplifier for the telephone, a TDD, TTY or teletype, closed caption TV,
assistive listening or signaling devices, an interpreter, or any other equipment for people with hearing or
speech impairments?
Question Type: TYesNo
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C13
Does ^R_A.R_A_Name have a landline telephone or cellular telephone in ^Fills.HisHer room?
Question Type: TYesNo, dk, rf
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
Logic before:
If R_C10d = yes or R_C10e = yes, skip to R_C12a2
R_C12a1
SHOWCARD R_C12a1- 10
Without assistance and without equipment, how difficult is it for ^R_A.R_A_Name to...
Walk a quarter mile, about three city blocks? Please tell me the numbers that apply from this card.
Question Type: Tdifficult
notdiff 1 NOT AT ALL DIFFICULT
litldiff 2 ONLY A LITTLE DIFFICULT
somewhat 3 SOMEWHAT DIFFICULT
verydiff 4 VERY DIFFICULT
cantdo 5 CAN’T DO AT ALL WITHOUT HELP OR EQUIPMENT
dontdo 6 DOES NOT DO THIS ACTIVITY
--------------------------------------------------------------------------------------
R_C12a2
STAY WITH SHOWCARD R_C12a1 - 10
Without assistance and without equipment, how difficult is it for ^R_A.R_A_Name to...
Walk up 10 steps without resting?
Question Type: Tdifficult
notdiff 1 NOT AT ALL DIFFICULT
litldiff 2 ONLY A LITTLE DIFFICULT
somewhat 3 SOMEWHAT DIFFICULT
verydiff 4 VERY DIFFICULT
cantdo 5 CAN’T DO AT ALL WITHOUT HELP OR EQUIPMENT
dontdo 6 DOES NOT DO THIS ACTIVITY
Friday, March 07, 2008 Page 33 of 44
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R_C12a3
STAY WITH SHOWCARD R_C12a1 - 10
Without assistance and without equipment, how difficult is it for ^R_A.R_A_Name to...
Stand or be on feet for about two hours?
Question Type: Tdifficult
notdiff 1 NOT AT ALL DIFFICULT
litldiff 2 ONLY A LITTLE DIFFICULT
somewhat 3 SOMEWHAT DIFFICULT
verydiff 4 VERY DIFFICULT
cantdo 5 CAN’T DO AT ALL WITHOUT HELP OR EQUIPMENT
dontdo 6 DOES NOT DO THIS ACTIVITY
--------------------------------------------------------------------------------------
R_C12a4
STAY WITH SHOWCARD R_C12a1 - 10
Without assistance and without equipment, how difficult is it for ^R_A.R_A_Name to...
Sit for about two hours?
Question Type: Tdifficult
notdiff 1 NOT AT ALL DIFFICULT
litldiff 2 ONLY A LITTLE DIFFICULT
somewhat 3 SOMEWHAT DIFFICULT
verydiff 4 VERY DIFFICULT
cantdo 5 CAN’T DO AT ALL WITHOUT HELP OR EQUIPMENT
dontdo 6 DOES NOT DO THIS ACTIVITY
--------------------------------------------------------------------------------------
R_C12a5
STAY WITH SHOWCARD R_C12a1 - 10
Without assistance and without equipment, how difficult is it for ^R_A.R_A_Name to...
Stoop, bend, or kneel?
Question Type: Tdifficult
notdiff 1 NOT AT ALL DIFFICULT
litldiff 2 ONLY A LITTLE DIFFICULT
somewhat 3 SOMEWHAT DIFFICULT
verydiff 4 VERY DIFFICULT
cantdo 5 CAN’T DO AT ALL WITHOUT HELP OR EQUIPMENT
dontdo 6 DOES NOT DO THIS ACTIVITY
Friday, March 07, 2008 Page 34 of 44
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R_C12a6
STAY WITH SHOWCARD R_C12a1 - 10
Without assistance and without equipment, how difficult is it for ^R_A.R_A_Name to...
Reach up over head?
Question Type: Tdifficult
notdiff 1 NOT AT ALL DIFFICULT
litldiff 2 ONLY A LITTLE DIFFICULT
somewhat 3 SOMEWHAT DIFFICULT
verydiff 4 VERY DIFFICULT
cantdo 5 CAN’T DO AT ALL WITHOUT HELP OR EQUIPMENT
dontdo 6 DOES NOT DO THIS ACTIVITY
--------------------------------------------------------------------------------------
R_C12a7
STAY WITH SHOWCARD R_C12a1 - 10
Without assistance and without equipment, how difficult is it for ^R_A.R_A_Name to...
Use fingers to grasp or handle small objects?
Question Type: Tdifficult
notdiff 1 NOT AT ALL DIFFICULT
litldiff 2 ONLY A LITTLE DIFFICULT
somewhat 3 SOMEWHAT DIFFICULT
verydiff 4 VERY DIFFICULT
cantdo 5 CAN’T DO AT ALL WITHOUT HELP OR EQUIPMENT
dontdo 6 DOES NOT DO THIS ACTIVITY
--------------------------------------------------------------------------------------
R_C12a8
STAY WITH SHOWCARD R_C12a1 - 10
Without assistance and without equipment, how difficult is it for ^R_A.R_A_Name to...
Lift or carry something as heavy as 10 pounds, such as a bag of groceries?
Question Type: Tdifficult
notdiff 1 NOT AT ALL DIFFICULT
litldiff 2 ONLY A LITTLE DIFFICULT
somewhat 3 SOMEWHAT DIFFICULT
verydiff 4 VERY DIFFICULT
cantdo 5 CAN’T DO AT ALL WITHOUT HELP OR EQUIPMENT
dontdo 6 DOES NOT DO THIS ACTIVITY
Friday, March 07, 2008 Page 35 of 44
--------------------------------------------------------------------------------------
R_C12a9
STAY WITH SHOWCARD R_C12a1 - 10
Without assistance and without equipment, how difficult is it for ^R_A.R_A_Name to...
Push or pull a large object like a living room chair?
Question Type: Tdifficult
notdiff 1 NOT AT ALL DIFFICULT
litldiff 2 ONLY A LITTLE DIFFICULT
somewhat 3 SOMEWHAT DIFFICULT
verydiff 4 VERY DIFFICULT
cantdo 5 CAN’T DO AT ALL WITHOUT HELP OR EQUIPMENT
dontdo 6 DOES NOT DO THIS ACTIVITY
--------------------------------------------------------------------------------------
R_C12a10
STAY WITH SHOWCARD R_C12a1 - 10
Without assistance and without equipment, how difficult is it for ^R_A.R_A_Name to...
Go out to do things like shopping, movies, or sporting events?
Question Type: Tdifficult
notdiff 1 NOT AT ALL DIFFICULT
litldiff 2 ONLY A LITTLE DIFFICULT
somewhat 3 SOMEWHAT DIFFICULT
verydiff 4 VERY DIFFICULT
cantdo 5 CAN’T DO AT ALL WITHOUT HELP OR EQUIPMENT
dontdo 6 DOES NOT DO THIS ACTIVITY
--------------------------------------------------------------------------------------
R_C12
Over the last 30 days, how often did ^R_A.R_A_Name receive one or more outside visitors? Would you
say...
Question Type: Tvisitor
every 1 every day
atleast 2 at least several times a week
about 3 about once a week
several 4 several times during the past 30 days but less than every week
atleas30 5 at least once in the last 30 days
noneatall 6 none at all in the last 30 days
Friday, March 07, 2008 Page 36 of 44
--------------------------------------------------------------------------------------
R_C14
In the past 30 days, how often has ^R_A.R_A_Name exhibited any of the following behaviors?
PRESS "1" AND ENTER TO CONTINUE.
Question Type: TContinue
CONTINUE 1 CONTINUE
--------------------------------------------------------------------------------------
R_C14a
(In the past 30 days, how often has ^R_A.R_A_Name exhibited any of the following behaviors?)
Refusing to take prescribed medicines at the appropriate time or in the prescribed dosage? Would you
say…
Question Type: TBehaveMeds
often 1 Often
sometimes 2 Sometimes
never 3 Never
noMedications 4 RESIDENT DOES NOT TAKE ANY PRESCRIBED MEDICATIONS
notFacility 5 FACILITY DOES NOT HANDLE RESIDENTS' MEDICATIONS
--------------------------------------------------------------------------------------
R_C14c
(In the past 30 days, how often has ^R_A.R_A_Name exhibited any of the following behaviors?)
Creating disturbances or being excessively noisy by knocking on doors, getting lost, or moving aimlessly
in the building or grounds? Would you say…
Question Type: Tbehave
often 1 Often
sometimes 2 Sometimes
never 3 Never
--------------------------------------------------------------------------------------
R_C14d
(In the past 30 days, how often has ^R_A.R_A_Name exhibited any of the following behaviors?)
Refusing to bathe or clean oneself? Would you say…
Question Type: Tbehave
often 1 Often
sometimes 2 Sometimes
never 3 Never
Friday, March 07, 2008 Page 37 of 44
--------------------------------------------------------------------------------------
R_C14e
(In the past 30 days, how often has ^R_A.R_A_Name exhibited any of the following behaviors?)
Rummaging through or taking other people's belongings? Would say…
Question Type: Tbehave
often 1 Often
sometimes 2 Sometimes
never 3 Never
--------------------------------------------------------------------------------------
R_C14f
(In the past 30 days, how often has ^R_A.R_A_Name exhibited any of the following behaviors?)
Damaging or destroying property? Would you say…
Question Type: Tbehave
often 1 Often
sometimes 2 Sometimes
never 3 Never
--------------------------------------------------------------------------------------
R_C14g
(In the past 30 days, how often has ^R_A.R_A_Name exhibited any of the following behaviors?)
Verbally threatening other persons including staff or other residents? Would you say…
Question Type: Tbehave
often 1 Often
sometimes 2 Sometimes
never 3 Never
--------------------------------------------------------------------------------------
R_C14h
(In the past 30 days, how often has ^R_A.R_A_Name exhibited any of the following behaviors?)
Being physically aggressive towards other persons including staff or other residents? Would you say…
Question Type: Tbehave
often 1 Often
sometimes 2 Sometimes
never 3 Never
Friday, March 07, 2008 Page 38 of 44
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R_C14i
(In the past 30 days, how often has ^R_A.R_A_Name exhibited any of the following behaviors?)
Removing clothing in public? Would you say…
Question Type: Tbehave
often 1 Often
sometimes 2 Sometimes
never 3 Never
--------------------------------------------------------------------------------------
R_C14j
(In the past 30 days, how often has ^R_A.R_A_Name exhibited any of the following behaviors?)
Making unwanted sexual advances towards staff or other residents? Would you say…
Question Type: Tbehave
often 1 Often
sometimes 2 Sometimes
never 3 Never
--------------------------------------------------------------------------------------
Logic before:
IF R_C14a or R_C14c or R_C14d or R_C14e or R_C14f or R_C14g or R_C14h or R_C14i or RCC14j =
"Often" or "Sometimes" then C15, else C16
R_C15
Does a physician ever prescribe medications to help control ^R_A.R_A_Name's behavior or to reduce
agitation?
Question Type: TYesNo
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C16a
Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the facility
by non-facility staff?
Special diets
Question Type: Tyesno
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 39 of 44
--------------------------------------------------------------------------------------
R_C16b
(Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the
facility by non-facility staff?)
Assistance with activities of daily living
Question Type: Tyesno
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C16c
(Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the
facility by non-facility staff?)
Assistance with a bath or shower at least once a week
Question Type: Tyesno
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C16d
(Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the
facility by non-facility staff?)
Skilled nursing services
Question Type: Tyesno
Yes 1 YES
No 2 NO
--------------------------------------------------------------------------------------
R_C16e
(Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the
facility by non-facility staff?)
Basic health monitoring (e.g. blood pressure and weight checks)
Question Type: Tyesno
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 40 of 44
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R_C16f
(Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the
facility by non-facility staff?)
Social and recreational activities within the facility
Question Type: Tyesno
Yes 1 YES
No 2 NO
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R_C16g
(Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the
facility by non-facility staff?)
Social and recreational activities outside the facility
Question Type: Tyesno
Yes 1 YES
No 2 NO
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R_C16h
(Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the
facility by non-facility staff?)
Incontinence care
Question Type: Tyesno
Yes 1 YES
No 2 NO
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R_C16i
(Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the
facility by non-facility staff?)
Transportation to medical appointments
Question Type: Tyesno
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 41 of 44
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R_C16j
(Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the
facility by non-facility staff?)
Transportation to stores and elsewhere
Question Type: Tyesno
Yes 1 YES
No 2 NO
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R_C16k
(Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the
facility by non-facility staff?)
Personal laundry
Question Type: Tyesno
Yes 1 YES
No 2 NO
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R_C16L
(Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the
facility by non-facility staff?)
Linen laundry services
Question Type: Tyesno
Yes 1 YES
No 2 NO
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R_C16m
(Does ^R_A.R_A_Name use any of the following services offered by facility staff or provided at the
facility by non-facility staff?)
Social services counseling
Question Type: Tyesno
Yes 1 YES
No 2 NO
Friday, March 07, 2008 Page 42 of 44
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R_C17
The next few questions are about you.
How long have you worked at this facility?
Question Type: TC17
lessthan6 1 6 MONTHS OR LESS
lessthanyr 2 MORE THAN 6 MONTHS BUT LESS THAN ONE YEAR
lessthantwo 3 AT LEAST ONE YEAR TO LESS THAN TWO YEARS
morethantwo 4 TWO YEARS OR MORE
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R_C18
SHOWCARD R_C18
Please look at this showcard and tell me which best describes your position at this facility:
Question Type: TFacilityPosition
RN 1 RN
LPN 2 LPN
Certaide 3 CERTIFIED MEDICATION AIDE OR SUPERVISOR
Persaide 4 PERSONAL CARE AIDE
Staff 5 ACTIVITY DIRECTOR OR STAFF
OwnAdmin 6 OWNER, ADMINISTRATOR, DIRECTOR, OR MANAGER
Other 7 SOME OTHER POSITION
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Logic before:
IF C_18 = other then continue, else skip to R_CEND
R_C18SPEC
What is that position?
Question Type: STRING[50]
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R_CEND
Thank you. These are all the questions I have for you regarding this resident. Now I need to check my
records if there are any other selected residents for whom you were identified as a caregiver.
INTERVIEWER: CHECK YOUR 'RESIDENT SELECTION FORM' FOR OTHER RESIDENTS FOR WHOM THIS
CAREGIVER WAS A DESIGNATED RESPONDENT.
TO EXIT THIS SCREEN, PRESS "1" AND ENTER.
Question Type: TContinue
CONTINUE 1 CONTINUE
Friday, March 07, 2008 Page 43 of 44
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R_C_DR
@rINTERVIEWER: ARE YOU READY TO FINALIZE THIS RESIDENT INTERVIEW?
HAVE YOU ANSWERED ALL QUESTIONS TO THE BEST OF YOUR ABILITY AND THAT OF YOUR
RESPONDENT(S)?
IF THERE ARE QUESTIONS ANSWERED DON'T KNOW @b(?)@b OR REFUSED @b(!)@b FOR WHICH YOU
CAN STILL DO DATA RETRIEVAL, ANSWER NO ON THIS SCREEN.@r
Question Type: TYesNo, NoDK, NoRF
Yes 1 YES
No 2 NO
Logic after:
IF R_C_D7=NO, THEN SAVE CMS CODE 391. IF F_D7=YES, THEN SAVE CMS CODE 491.
Friday, March 07, 2008 Page 44 of 44
| File Type | application/msword |
| File Title | Question by Question Specific Comments |
| Author | tsf |
| Last Modified By | Christine Caffrey |
| File Modified | 2008-06-11 |
| File Created | 2008-06-11 |