Senior Village Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Appendix C.1: Senior Village Survey

Hello. I'm ____________ and I'm calling from the Interviewing Service of America. We are doing a survey of older adults about some health-related issues. This project is funded by the Centers for Disease Control and Prevention, a government agency which promotes best practices for health across the country.

Your participation in this discussion is completely voluntary and we can stop at any point. We will use the information you provide for research purposes only. Your responses will be kept secure and your identity will be protected. We will not link your name to the information that you provide. There are no consequences if you decline to participate.

If you have questions about this study you may contact the Principal Investigator, Joie Acosta, by phone at 703-413-1100 extension 5324. If you have any questions or concerns about your rights as a research participant, please contact the Human Subjects Protection Committee at RAND, 1776 Main Street, Santa Monica, CA 90407, (310) 393-0411, ext. 6369.

Do you have any questions before we begin?

Do you agree to participate in this interview?

No  Okay, thank you for your time and have a nice day.

Yes  Thank you very much. We really appreciate your support.

MODULE 1: HOUSEHOLD SCREENER

ask for those who were identified through senior village member lists:
Q1.1	We have [PERSON’S NAME] listed as a senior village member, is that you?
			yes, speaking with adult 1 not speaking with adult 2		 continue  ask to speak to adult
	if Q1.1 = 1 ask:
	1.1a.	May we continue the interview with you?
				continue 1 not available now 2 refused 7	 continue  arrange callback  terminate
	if Q1.2= 2 ask:
	1.2a.	We would like to speak to [PERSON’S NAME]. May I please speak with that person?
				yes, and comes to phone 1 no, not available now 2 no, refused 7	 continue (Back to consent script)  arrange callback  terminate
	Public reporting burden of this collection of information is estimated to average 20 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
ask for those who were randomly dialed: Q1.2 Do you currently live in what is called a senior village? Yes……..1→ CONTINUE to Q1.2a No…….. 0→ CONTINUE to Q2 if Q1.2 = 1 ask: Q1.2a. What is the name of the senior village? [Free Text Name] Refused………………..7 Don’t know……………..9 Q2. Do you currently live in a skilled nursing facility?
Yes…………………….1→ TERMINATE No………………………0→ CONTINUE Refused………………..7 Don’t know……………..9

MODULE 2: DEMOGRAPHICS I
(All other demographic questions appear at the end of the survey)
Before we begin, I need to tell you that sometimes the calls are monitored by my supervisor to ensure quality and courtesy.
Q3.	What is your age, please?		___________ years old refused 7
	if refused, ask:
	Q2.	We don't need to know exactly, but are you younger than 50, between 50 and 59, 60 and 69, 70 and 79 or 80 or older?	younger than 50 1 50-59 2 60-69 3 70-79 4 80 or older 5 refused 7
Q4.	record gender. (interviewer: i f you have any doubt, say:) Because it is sometimes difficult to determine over the phone, am I speaking to a man or woman?		male 1 female 2

Q5 How long have you been living in your current location?

___________ YEARS
REFUSED…………………………7

if refused, ask:
Q5.	We don't need to know exactly, but have you been living in your current location between 0 and 6 months, 7 months and a year, two to three years, four to five years, six to nine years or ten or more years?	0-6 months 1 7 months to 1 year 2 2 to 3 years 3 4 to 5 years 4 6 to 9 years 5 10 or more years………………………6 refused 7

Q6. Which best describes your current living situation? Are you living alone, with a spouse or partner, with a sibling, with other family member(s), with friends, or with a roommate? You may pick more than one.

Alone…………………………1

With spouse or partner……..2

With sibling…………………..3

With other family member(s).4

With friend(s)………………...5

With roommate(s)………...…6

Refused……………………7

Don’t know…………………9

Q7. What city and county do you live in?

[Free Text City]

[Free Text County]

Refused………………..7

Don’t know……………..9

MODULE 3: DISASTER RESILIENCE

Q8. Now I would like to ask you some questions about ways that you may have prepared for emergencies or disasters. For each one would you say you strongly agree, moderately agree, neither agree nor disagree, moderately disagree, or strongly disagree.

	Strongly Agree	Moderately Agree	Neither Agree or Disagree	Moderately Disagree	Strongly Disagree
a. I am knowledgeable about local emergency plans for my community	1	2	3	4	5
b. I know the evacuation route to take in the event of an emergency	1	2	3	4	5
c. I know how to get information in an emergency	1	2	3	4	5
d. I know what supplies I need to securely seek shelter for up to 72 hours…………………	1	2	3	4	5
e. I could help my neighbor, if he or she needed it, during a disaster…………………	1	2	3	4	5

Q9. In the past 12 months, I have….

	Yes	No	Don’t Know
a. Participated in a neighborhood or community meeting about emergency preparedness	1	0	9
b. Been trained in how to help my neighborhood or my neighbor in responding to an emergency	1	0	9
c. Put together a household preparedness kit	1	0	9
d. Worked with people in my neighborhood to develop a community emergency plan (e.g., call down lists, storing resources)	1	0	9
e. Attended training in Psychological First Aid or other type of training related to dealing with emotional stress of disasters	1	0	9
f. Identified where individuals who need extra help in a disaster may live	1	0	9
g. Put together a 3-day supply of prescription medications to use during an emergency	1	0	9
h. Signed up to be part of a smart 911 program	1	0	9
i. Signed up to receive government alerts during an emergency	1	0	9

Q10. Do you belong to a community organization (e.g., school, church or other faith community, or volunteer organization) that you can depend upon in a disaster?

Yes……………………1

No……………………..0

Don’t know…...……….9

Q11. Could you call upon one of your neighbors to assist you in an emergency such as provide food, transportation, or help with your children?

Yes……………………1

No……………………..0

Don’t know…...……….9

MODULE 3: HEALTH RESILIENCE

Q12. Is there a place you USUALLY go when you are sick or need advice about your health?

Yes……………………………………….…1

There is NO place………………………....2

There is MORE THAN ONE place……….3

Refused………………………………….….7

Don’t know………………………………….9

Q13. What kind of place do you USUALLY go when you are sick or need advice about your health?

Don’t get care anywhere………………….0

Clinic or health center……………………..1

Doctor’s office or HMO…………………….2

Hospital emergency department………….3

Some other place…………………………..4

Doesn’t got to one place most often………5

Refused……………………………………..7

Don’t know…………………………………..9

Q14. Is that [FILL FROM Q5] the same place you USUALLY go when you need routine or preventive care, such as a physical examination or check up?

Yes…………………….1

No………………………2

Refused………………..7

Don’t know……………..9

Q15. About how long has it been since you last saw or talked to a doctor or other health care professional about your own health? Include doctors seen while a patient in a hospital.

Never…………………………………………………..…0

6 months or less………………………………………....1

More than 6 mos, but not more than 1 yr ago…………2

More than 1 yr, but not more than 2 yrs ago…………..3

More than 2 yrs, but not more than 5 yrs ago………….4

More than 5 years ago…………………………………...5

Refused……………………………………………………6

Don't know…………………………………………………7

MODULE 4: EMOTIONAL RESILIENCE

Q16. Now I would like to ask you some questions about what YOU usually do when YOU experience a stressful event. For each one would you say you strongly agree, moderately agree, neither agree nor disagree, moderately disagree, or strongly disagree.

	Strongly Agree	Moderately Agree	Neither Agree or Disagree	Moderately Disagree	Strongly Disagree
a. I concentrate my efforts on doing something about ita	1	2	3	4	5
b. I take additional action to try to get rid of the problema	1	2	3	4	5
c. I take direct action to get around the problema	1	2	3	4	5
d. I do what has to be done, one step at a timea	1	2	3	4	5
Q17. Now I would like to ask you some questions about day to day activities and views about life. For each one would you say you strongly agree, moderately agree, neither agree nor disagree, moderately disagree, or strongly disagree.
	Strongly Agree	Moderately Agree	Neither Agree or Disagree	Moderately Disagree	Strongly Disagree
a. I lead a purposeful and meaningful lifeb………	1	2	3	4	5
b. My social relationships are supportive and rewardingb…………………………………	1	2	3	4	5
c. I am engaged and interested in my daily activitiesb…………………………………….....	1	2	3	4	5
d. I actively contribute to the happiness and well-being of othersb………………………….	1	2	3	4	5
e. I am competent and capable in the activities that are important to meb…………………….	1	2	3	4	5
f. I am a good person and live a good lifeb……	1	2	3	4	5
g. My material life (income, housing, etc.) is sufficient for my needsb………………………	1	2	3	4	5
h. I generally trust others and feel part of my communityb…………………………………	1	2	3	4	5
i. I am satisfied with my religious or spiritual lifeb…………………………………………	1	2	3	4	5
j. I am optimistic about the futureb…………….	1	2	3	4	5
k. I have no addictions, such as to alcohol, illicit drugs, or gamblingb…………………………..	1	2	3	4	5
l. People respect meb…………….…………….	1	2	3	4	5

^aActive coping subscale

^bEmotional wellbeing subscale

MODULE 6: SOCIAL RESILIENCE

Next we are going to ask you about the activities you do and the people you see.

Q18. Approximately how many people do you know with whom you can discuss important matters? ⁱ

None……………0

One or two……...1

Three to five…….2

Six to ten………..3

More than ten…..4

Don’t know……...9

Q19. In the past two months, about how often did you talk with one or more of these individuals (by phone, email, or in person)? ⁱⁱ

Once a day………………………………………….1

Several times a week……………………………………….2

Once a week………………………………………….3

Less than once a week……………………………………..4

Less than once a month…………………………………….5

Never (Did not get together socially in the past month)…..0

Q20. Approximately how many friends would you say you have? ⁱⁱⁱ

None…………….0

One or two………1

Three to five……..2

Six to ten…………3

More than ten…....4

Don’t know……...9

Q21. In the past two months, about how often did you get together socially with friends or neighbors? ^iv

Several times a week………………………………………………....1

About once a week……………………………………………………2

About once a month…………………………………………………..3

Less than once a month………………………………………………4

Never (Did not get together socially in the past two months)………5

Q22. In the past two months, how often did you attend meetings of any organized group? (such as: a choir, a committee or board, a support group, a sports or exercise group, a hobby group, or a professional society) ^v

Several times a week………………………………………………....1

About once a week……………………………………………………2

About once a month…………………………………………………..3

Less than once a month………………………………………………4

Never (Did not attend group meetings in the past two months)…...5

Q23. In the past two months, how often did you do volunteer work for religious, charitable, political, health-related, or other organizations? ^vi

Several times a week………………………………………………....1

About once a week……………………………………………………2

About once a month…………………………………………………..3

Less than once a month………………………………………………4

Never (Did not do volunteer work in the past two months)………...5

Q24. In the past two months, how often did you feel that you lacked companionship?^vii

Hardly ever (or never)…..1

Some of the time………..2

Often……………………..3

Q25. In the past two months, how often did you feel left out? ^viii

Hardly ever (or never)…..1

Some of the time………..2

Often……………………..3

Q26. In the past two months, how often did you feel isolated from others? ^ix

Hardly ever (or never)…..1

Some of the time………..2

Often……………………..3

Q27. How often do you feel that you can open up to other people about personal concerns? ^x

Hardly ever (or never)…..1

Some of the time………..2

Often……………………..3

Q28. How often do you feel that you can rely on other people to provide help when you need it? ^xi

Hardly ever (or never)…..1

Some of the time………..2

Often……………………..3

MODULE 7: EXPOSURE TO AGE FRIENDLY INITIATIVES

Q29. Next, we will ask you questions about whether you have been exposed to any of the age friendly initiatives in your community. For each one would you say you strongly agree, moderately agree, neither agree nor disagree, moderately disagree, or strongly disagree.

[Note to interviewer: Ask a, b if they live in an age-friendly city/county. Ask c, d if they live in a senior village.]

	Strongly Agree	Moderately Agree	Neither Agree or Disagree	Moderately Disagree	Strongly Disagree
ask for those Living in a Age-friendly City: a. I am aware of the Age Friendly Initiative in my community	1	2	3	4	5
b. I actively participate in the Age Friendly initiative in my community	1	2	3	4	5
ask for those Living in senior villages: c. I am aware of the services offered by the senior village in my community	1	2	3	4	5
d. I actively participate in the services offered by the senior village in my community	1	2	3	4	5
ask to everyone: e. I am aware of community forums or meetings where the local government talks about issues related to seniors	1	2	3	4	5
f. I actively participate in community forums or meetings where the local government talks about issues related to seniors	1	2	3	4	5
g. I feel like I can live independently in my current location	1	2	3	4	5
h. I feel like I would have to move into a nursing home if I did not have the supports I have today	1	2	3	4	5

MODULE 7: DEMOGRAPHICS II

(Other demographic questions appear at the beginning of the survey)

Q30. Are you Hispanic or Latino?

Yes………………1

No………………..0

Don’t know……...9

Q31. Which best describes your race? You may pick more than one.

White………………………………………..1

Black or African American………………...2

American Indian or Alaska Native………3

Asian Indian…………….………………….4

Japanese…………………………………..5

Native Hawaiian……………………….…..6

Chinese…………………………………….7

Japanese…………………………………..8

Korean……………………………………..9

Guamanian or Chamorro………………..10

Filipino…………………………………….11

Vietnamese……………………………….12

Samoan……………………………………13

Other Asian………………………………..14

Other Pacific Islander…………………….15

Other race…………………………………16

Refused……………………………………..17

Don’t know………………………………….18

Q32. In the last year, did a doctor tell you that you have any of the following conditions or illnesses? You may pick more than one. [Interviewer walk through each condition allowing the respondent to state yes or no to having any of the conditions/illnesses.]

Asthma……………………1

Diabetes…………………..2

Heart Problems…………..3

Cancer…………………….4

Other physical condition…5

Mental health condition…..6

None……………………….0

Refused……………………7

Don’t know…………………9

Q33. Before taxes and other deductions, was your total personal income from all sources less than $20,000 a year?

Yes…………………………1

No…………………………..0

Refused……………………7

Don’t know…………………9

if Q33=0, ask:
Q33.	We don't need to know exactly, but is your total personal income between $20,000 and $24,9999, $25,000 and $29,999, $30,000 and $34,999, $40,000 and $44,999, $50,000 and $74,999, $75,000 and $99,999 or more than $100,000?	$20,000 - $24,999…………………..1 $25,000 - $29,999……………….…2 $30,000 - $34,999………………….3 $35,000 - $39,999………………….4 $40,000 - $44,999………………….5 $45,000 - $49,999………………….6 $50,000 - $74,999………………….7 $75,000 - $99,999………………….8 $100,000 OR MORE…………….…9

Thank you for your time today!

i National Social Life, Health and Aging Project (NSHAP) Social Network subscale (Social Disconnectedness Scale)

ii NSHAP Social Network subscale (Social Disconnectedness Scale)

iii NSHAP Social Network subscale (Social Disconnectedness Scale)

iv NSHAP Social Activity subscale (Social Disconnectedness Scale)

v NSHAP Social Activity subscale (Social Disconnectedness Scale)

vi NSHAP Social Activity subscale (Social Disconnectedness Scale)

vii NSHAP Loneliness subscale (Social Isolation Scale)

viii NSHAP Loneliness subscale (Social Isolation Scale)

ix NSHAP Loneliness subscale (Social Isolation Scale)

x NSHAP Social Support subscale (Social Isolation Scale)

xi NSHAP Social Support subscale (Social Isolation Scale)