Form 1 IDEAL telephone screener Part 2

Attachment 5b — IDEAL Telephone Screening Interview Part 2
When the responsibility for administrating the IDEAL telephone screening interview transitioned from
Westat to the NIA, the protocol was also changed. Instead of administering the IDEAL screening
interview in one contact, as Westat did, the NIA conducts the screening interview in two parts, using the
same recruitment and screening instruments administered to all potential BLSA participants. Part 1 is
administered by a BLSA recruiter when a potential IDEAL participant calls in; this contact takes up to 10
minutes and preliminarily establishes the caller’s potential eligibility. Anyone not excluded from
eligibility at this initial contact is called back by a BLSA nurse practitioner to complete Part 2 of the
screening interview. Part 2 revisits the eligibility questions from Part 1, and asks additional questions
pertaining to eligibility. This contact likewise takes up to 10 minutes.
Together, the IDEAL Screening Interview instruments administered by the NIA cover the same questions
previously administered using the Westat instrument with the exception of several new questions.
The following questions from the NIA Screening Interview Part 2 are new:
3. Were you born in the United States?
9a. (If yes to shortness of breath) Do you ever get shortness of breath when walking at your own pace
on a level surface?
9b. (If yes to shortness of breath) Do you ever get shortness of breath when you are lying down flat?
13. Do you wear a hearing aid?
29. Has a doctor (or other health professional) ever said you had peripheral neuropathy or nerve
damage in your lower legs, feet, or hands?
30b. (If yes to High Blood Pressure) Do you still have high blood pressure?
30c. (If yes to High Blood Pressure) Are you currently following lifestyle recommendations (e.g.,
exercise, weight loss, low sodium diet) to treat or manage your high blood pressure?
31b. (If yes to Diabetes) Do you still have diabetes?
31c. (If yes to Diabetes) Are you currently following lifestyle recommendations (e.g., exercise, weight
loss, low sodium diet) to treat or manage your diabetes?
35. Has a doctor (or other health professional) ever said you had arthritis or osteoarthritis?
35a. In which of the following areas have you been told you have arthritis? (See Attachment 5)
Questionnaire —BLSA - Screening for eligibility criteria - LEVEL 1 – (Telephone interview) V2 R
August 24, 2012, page 4 of 4.
35b. Have you had any joint replacement surgery?
35c. Have you had back surgery?
36. Has a doctor (or other health professional) ever said you had osteoporosis or thinning of the
bones? (Do not include osteopenia)
46. Do you have pain in any part of your body?
46a. Where is the pain? (Open-ended question)
48. Does the pain affect your mobility or function?
48a. How? (Open-ended question)
49. Do you have any allergies (food, drug, or environmental)?

IDEAL – Telephone Screening Interview Part 2

OMB No.: 0925-0631
Expiration Date: xx/xx/20xx
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 not 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 kept private to the extent provided
by law. Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study
participants and reported as summaries. You are being interviewed by telephone to complete this instrument so that we can
determine your eligibility for IDEAL.
Public reporting burden for this collection of information is estimated to average 10 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: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0631). Do not return the completed form to this
address.

BLSA - Screening for eligibility criteria LEVEL 1 - (Telephone interview)
Date Completed

Tester ID

Screening Protocol ID:

S C R -

/

/ 2 0

First name:
Last name:

/

1. What is your date of birth?

/

Month
Day
2. What is your current marital status?
Married
Separated
Living with a partner
Divorced

1a. How old are you?
Years

Year
Widowed
Never married

3. Were you born in the United States?

Yes

No

4. Is English your first language?

Yes

No

5. Are you of Spanish, Hispanic, or Latino origin?

Yes

No

6. What race do you consider yourself to be? White
Black or African American
Refused

American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Two or More Races

Asian

9. Do you get shortness of breath when you walk uphill, hurry, or climb a
single flight of stairs?

Yes

No
V

9a. Do you ever get shortness of breath when walking at your Yes
own pace on a level surface?
9b. Do you ever get shortness of breath when you are lying
Yes
down flat?

No
No

11. How would you rate your current eyesight (with glasses or contacts, if you wear them)?
13. Do you wear a hearing aid?

Excellent

Good

Yes

No

Fair

Poor

Very poor

Blind

14. How would you rate your current hearing ability (with a hearing aid, if used)?
Excellent

Good

Fair

Poor

Very poor

Deaf

18. Has a doctor (or other health professional) ever said you had chronic
Yes
bronchitis, emphysema, chronic obstructive pulmonary disease, or COPD?

No

Yes

No

19. Has a doctor (or other health professional) ever said you had asthma?

V
19a. Do you need medications to control your asthma?
Yes
No
Bronchodilators
Leukotriene modifiers
19b. What medications:
Oral or inhalerd steroids
None
Draft

Questionnaire #

Page 1 of 4

Version 2 R (August 24, 2012)

BLSA - Screening for eligibility criteria LEVEL 1 - (Telephone interview)
20. Has a doctor (or other health professional) ever said you had cirrhosis or liver disease? Yes

No

21. Has a doctor (or other health professional) ever said you had hepatitis?

Yes

No

22. Has a doctor (or other health professional) ever said you had HIV or AIDS?

Yes

No

24. Many people complain that they accidentally leak urine.
In the past week, did you leak even a small amount of urine?

Yes
No
V
During the past week (7 days), how many times did you leak urine under the following
conditions? 24a. With an activity like coughing, lifting, or exercise?
times
24b. When you had a sense of urgency and could not get to a
toilet fast enough?

times

24c. Unrelated to an activity or urge to urinate?

times

SKIP #25
25. In the past 12 months, did you leak even a small amount of urine?
(SKIP IF 24 WAS YES)

Yes
V

No

25a. In the past 12 months, how often have you leaked urine?
Less than once per month
One or more times per week
One or more times per month
Every day
25b. When did you usually leak urine?
With an activity like coughing, lifting or exercise
When you have the urge to urinate, but can't get to a toilet fast enough
Both with activity and inability to get to toilet fast enough
You leak urine unrelated to an activity or urge

If both mark

29. Has a doctor (or other health professional) ever said you had
peripheral neuropathy or nerve damage in your lower legs, feet or hands?

Yes

No

30. Has a doctor (or other health professional) ever said you had
high blood pressure or hypertension?

Yes

No

V

30a. Are you currently taking prescribed medication(s) to
treat your high blood pressure?
30b. Do you still have high blood pressure? Yes
30c. Are you currently following lifestyle recommendations
(e.g., exercise, weight loss, low sodium diet) to treat or manage
your high blood pressure?

Yes
No

No

V
Don't know
Yes

No

Draft

Questionnaire #

Page 2 of 4

Version 2 R (August 24, 2012)

BLSA - Screening for eligibility criteria LEVEL 1 - (Telephone interview)
31. Has a doctor (or other health professional) ever said you had
diabetes, glucose intolerance or high blood sugar?

Yes
V

31a. Are you currently using prescribed medication(s) or
therapies to treat your diabetes?
31b. Do you still have high blood sugar?

No

Yes

No

V
No

Yes

Don't know

31c. Are you currently following lifestyle recommendations
Yes
No
(e.g., exercise, weight loss, diet) to treat or manage your high blood sugar?
32. Has a doctor (or other health professional) ever said you had
high cholesterol, triglycerides, (dyslipidemia or hypercholesterolemia)?
32a. Are you currently using prescribed medication(s) to
treat your high cholesterol (lipids)?

Yes

No
V

Yes

32b. Do you still have high cholesterol (lipids)? Yes

No
V
No

Don't know

32c. Are you currently following lifestyle recommendations
Yes
No
(e.g., exercise, weight loss, diet) to treat or manage your cholesterol (lipid) levels?
33. Have you ever had any of the following procedures: bypass surgery or (balloon) angioplasty on
your coronary (heart), leg , or femoral arteries , carotid endarterectomy (surgery on neck
arteries) or aortic aneurysm repair ?
Yes
No
34. Has a doctor (or other health professional) ever said you had cancer, a
malignant growth, or malignant tumor? (Exclude uterine "fibroids")
34a. What kind of cancer?
year

None (default)

Yes

No
V

year

year

Bladder

Liver

Skin Basal

Brain

Lung

Skin Squam.

Breast

Lymphoma

Stomach

Cervical

Melanoma

Thyroid

Colon/Rectal

Ovarian

Other:

Endometrial

Pancreatic

Leukemia

Prostate

Draft

Questionnaire #

Page 3 of 4

Version 2 R (August 24, 2012)

BLSA - Screening for eligibility criteria LEVEL 1 - (Telephone interview)
35.Has a doctor (or other health professional) ever said you had
arthritis or osteoarthritis?

Yes

V
35a. In which of the following areas have you been told you have arthritis?
None (default)
Knee(s)
Hip(s)
Feet
Back
Shoulder
35b. Have you had any joint replacement surgery?
No

Knee(s)

Yes (which joint(s)) -->

35c. Have you had back surgery? Yes

\

Hand(s)
Neck
Shoulder

No

36. Has a doctor (or other health professional) ever said you had
osteoporosis or thinning of the bones? (Do not include osteopenia)
46. Do you have pain in any part of your body?

Hip(s)

No

Yes

No

Yes

No

Yes

No

Yes

No

Don't know

46a. Where is the pain?
47. Do you take any medication for pain?
47a. What medicine?
47b. How often do you take the medicine?
48. Does the pain affect your mobility or function?
48a. How?
49. Do you have any allergies (food, drug, or environmental)?

Yes

No

50. How did you find out about the BLSA Study?
52. Are you aware that your participation in the study is for the rest of your
life unless otherwise incapacitated?

Yes

No

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

Yes

No

Draft

Questionnaire #

Page 4 of 4

Version 2 R (August 24, 2012)