Form 1 Telephone Interview

Recruitment and Screening for the Insight into Determination of Exceptional Aging and Longevity (IDEAL) Study (NIA)

Attachment 5 Telephone Interview v5 (2578 - Activated Traditional)

Individuals

OMB: 0925-0631

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OMB # 0925‐XXXX 
Expiration Date: XX/XXXX 

IDEAL-Screening for Eligibility
Level 1-Telephone Interview

STATEMENT OF CONFIDENTIALITY
Collection of this information is authorized by Public Law 93-296. Rights of study participants are protected
by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for participating or
withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The
information collected in this study will be held in professional confidence. Names and other identifiers will
be separated from information provided and will not appear in any report of the study. Information provided
will be combined for all study participants and reported as statistical summaries.

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 10 minutes per response,
including the time for reviewing instructions, searching exiting 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 burden to: NIH, Project Clearance Branch,
6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974 ATTN:PRA (0925-xxxx). Do not return the
completed form to this address.

IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:

Tester ID:

Date Completed:

/

S C R -

/ 2 0

First name:
Last name:

INTRODUCTION: "The following questions cover basic demographic information."
1.

ASK OR CONFIRM: are you [male/female]?
Male

2.

Female

Don't know

Refused

/

What is your date of birth?
Month

3.

How old are you today?

4.

What is your current marital status?

5.

/ 1 9
Day

Year

Years

Married

Separated

Widowed

Don't know

Living with a partner

Divorced

Never married

Refused

Is English your first language?
Yes

No

Don't know

Refused

If 'Yes,' go to question 7.
6.

Are you fluent in English?
Yes

7.

No

Don't know

Are you of Spanish, Hispanic, or Latino origin?
Yes, of Hispanic origin

8.

Refused

No, not of Hispanic origin

Don't know

Refused

What race do you consider yourself to be?
White

American Indian or Alaskan Native

Black or African American

Don't know

Asian or Pacific Islander

Refused

2578

1

IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:

Tester ID:

Date Completed:

/

S C R 9.

What is the highest grade in school that you completed?

/ 2 0
Years of school

Examiner Note: use 00 for no formal schooling, 12 for high school (or
GED equivalent), 14 for two year college / Associate's degree, 16 for
four year college, 18 for Master's degree, 19 for Law degree, 20 for
MD or PhD, 21 for multiple graduate degrees, 77 for refused and 88
for unknown).

INTRODUCTION: "The next several questions concern how well (you) function in
(your) usual environment, without the use of special equipment or help from another
person."
10. Because of a health or physical problem, do you have any difficulty walking a quarter
of a mile, that is about 2 or 3 blocks, without stopping?
Yes

No

11. Do you need to use a cane, a walker, or a wheelchair?
Yes

No

Don't know

Refused

12. Because of a health or physical problem, do you have any difficulty walking up 10
steps, that is about 1 flight, without resting?
Yes

No

13. Because of a health or physical problem, do you have any difficulty lifting or carrying
something weighing 10 pounds, for example a small bag of groceries or an infant?
Yes

No

14. Because of a health or physical problem, do you have any difficulty getting in and out
of bed or chairs?
Yes

No

Don't know

Refused

15. Because of a health or physical problem, do you have any difficulty bathing or
showering?
Yes

No

Don't know

Refused

16. Because of a health or physical problem, do you have any difficulty dressing?
Yes

No

Don't know

Refused

2578

2

IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:

Tester ID:

Date Completed:

/

S C R -

/ 2 0

17. Because of a health or physical problem, do you have any difficulty using the toilet,
including getting to the toilet?
Yes

No

Don't know

Refused

INTRODUCTION: "Now I would like to ask you some questions about your eyesight
and hearing."
18. Can you see well enough to read an ordinary print newspaper (with glasses or
contacts, if you wear them)?
Yes

No

Don't know

Refused

19. Can you hear well enough to maintain a conversation in a crowded place such as a
restaurant or train station (wearing a hearing aid, if used)?
Yes

No

Don't know

Refused

lbs.

20. What is your weight?

Don't Know

Refused

INTRODUCTION: "The following questions concern your past medical and
health-related history as well as diagnoses and treatments received."
21. Has a doctor or other health professional ever said you had a heart attack or
myocardial infarction?
Yes

No

Don't know

Refused

22. Has a doctor or other health professional ever said you had heart failure or congestive
heart failure?
Yes

No

Don't know

Refused

23. Has a doctor or other health professional ever said you had angina (pectoris), chest
pain due to heart disease or coronary artery disease?
Yes

No

Don't know

Refused

24. Has a doctor or other health professional ever said you had a stroke?
Yes

No

Don't know

Refused

2578

3

IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:

Tester ID:

Date Completed:

/

S C R -

/ 2 0

25. Has a doctor or other health professional ever said you had high blood pressure or
hypertension?
Yes

No

If 'No,' go to question 26.
25a. Do you know your average blood pressure?
Yes

No

Don't know

Refused

25b. What is your average blood pressure?
Systolic
Diastolic

26. Do you have diabetes?
Yes

No

Don't know

Refused

27. In the last two years, have you had symptoms of or have you been treated for asthma,
chronic bronchitis or emphysema?
Yes

No

Don't know

Refused

28. Has a doctor or other health professional ever said you had cirrhosis or liver disease?
Yes

No

Don't know

Refused

29. Has a doctor or other health professional ever said you had HIV or AIDS?
Yes

No

Don't know

Refused

30. Have you leaked urine (even a small amount) more than three times in the last month?
Yes

No

Don't know

Refused

2578

4

IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:

Tester ID:

Date Completed:

/

S C R -

/ 2 0

31. During the last 3 months, did you leak urine:
(Check all that apply)
When you were performing some physical activity, such as coughing, sneezing, lifting,
or exercising?
When you had the urge or the feeling that you needed to empty your bladder, but you
could not get to the toilet fast enough?
Without physical activity and without sense of urgency
32. Have you ever had any of the following procedures: bypass surgery or (balloon)
angioplasty on your coronary (heart), arteries, or aortic aneurysm repair?
Yes

No

Don't know

Refused

33. Has a doctor or other health professional ever said you had cancer, a malignant
growth, or malignant tumor? (Examiner note: Exclude uterine "fibroids")
Yes

No

q
33a. Was it a cancer of the skin?
Yes
No
If 'No,' go to question 33c.
33b. Was it a melanoma?
Yes
No
If 'No,' go to question 34.
33c. Has there been any activity or recurrence
(of any cancers) in the last 10 years?
Yes
No

2578

5

IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:

Tester ID:

Date Completed:

/

S C R -

/ 2 0

34. Have you had any joint replacement surgery?
Yes

No

Don't know

Refused

35. Has a doctor (or other health professional) ever said you had a connective tissue
disease, such as rheumatoid arthritis, gout, lupus, ulcerative colitis, Crohn's disease, or
scleroderma?
Yes

No

Don't know

Refused

36. Has a doctor (or other health professional) ever said you had Parkinson's disease,
multiple sclerosis, or ASL (Lou Gehrig's disease)?"
Yes

No

Don't know

Refused

37. Have you had a seizure in the last 10 years or are you currently receiving chronic
treatment for seizures?"
Yes

No

Don't know

Refused

38. Has a doctor or other health professional ever said you have any psychological or
psychiatric conditions like manic depressive disorder or bipolar disorder, obsessive
compulsive disorder, or schizophrenia?
Yes

No

Don't know

Refused

39. Do you regularly take any medication for pain?
Yes

No

If 'No,' go to question 41.
40. Have you been taking this medication regularly for at least a month?
Yes

No

Don't know

Refused

41. Do you regularly take any other medications?
Yes

No

If 'Yes,' complete Medication List.

2578

6

IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:

Tester ID:

Date Completed:

/

S C R -

/ 2 0

IDEAL MEDICATIONS LIST
Interviewer Instructions: As per questionnaire item 41, please record all
medications taken by the respondent (other than pain medications) in the following
table. Include the name of the medication and length of time used.

Example:

Medication Name

Length of time used

Lasix

4 mo

2578

7

IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:

Tester ID:

Date Completed:

/

S C R -

/ 2 0

ADDITIONAL INFORMATION
INTRODUCTION: "Now I would like to ask you some general questions."
42. How did you find out about the IDEAL Study?

43. Please tell me why you became interested in joining the study?

44. Are you aware that your participation in the BLSA Study as an IDEAL participant is for
the rest of your life unless otherwise incapacitated?
Yes

No

Don't know

Refused

45. If you become unable to come into the unit for participation in the study, are you
willing to have a home visit?
Yes

No

Don't know

Refused

46. If you are not eligible for this study, are you willing to learn about additional studies?
Yes

No

Don't know

Refused

2578

8


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