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Form	Current Question/Item	Requested Change
Attachment D1 Screener and Baseline Interviewer Guide - Pg 3 Section D: Consent - 1st paragraph	As I said before, we expect this interview to take about 10 minutes today. Just to remind you of some of the things I mentioned before, your participation is voluntary. You can decide whether or not to complete the interview, and you may end the interview at any time. Nothing will happen to you if you choose not to participate. You may experience a level of discomfort in answering some questions. You may also choose not to answer any questions you wish.  All the information you share with us will be kept private and secure. Only Battelle project staff will have access to any personally identifiable information about you. Although steps will be in place to protect the security of your responses, there is a small possibility that the information you provide could be connected with your name. Any identifiable information about you will be destroyed at the end of the study.  In addition to today’s survey, we will contact you again in about two weeks for a 10-minute follow-up interview. At the end of the study, we will send you a thank-you gift for participating in both interviews for our study.	As I said before, we expect this interview to take about 10 minutes today. Just to remind you of some of the things I mentioned before, your participation is voluntary. You can decide whether or not to complete the interview, and you may end the interview at any time. Nothing will happen to you if you choose not to participate. You may experience a level of discomfort in answering some questions. You may also choose not to answer any questions you wish. All the information you share with us will be kept private and secure. Only Battelle project staff will have access to any personally identifiable information about you. Although steps will be in place to protect the security of your responses, there is a small possibility that the information you provide could be connected with your name. Any identifiable information about you will be destroyed at the end of the study. CONTROL GROUP ONLY: In addition to today’s survey, we will contact you again in about two weeks for a 10-minute follow-up interview. At the end of the study, we will send you a thank-you gift for participating in both interviews for our study. TREATMENT GROUP ONLY: Within the next few days you will be receiving a brochure in the mail titled “MyMobility”. In addition to today’s survey, we will contact you again in about two weeks for a 10-minute follow-up interview. At the end of the study, we will send you a thank-you gift for participating in both interviews for our study.
Attachment D1 Screener and Baseline Interviewer Guide - Pg 4 Section D: CONSENT - 2nd paragraph	If you have any questions about this research study, you can call Betsy Payn at 206-528-3138. If you have any questions about your rights as a study participant, you can call the Battelle IRB at 1-877-810-9530, ext. 500. I may also be able to address your questions.	If you have any questions about this research study, you can call Jaime Dohack at 1-866-559-0924. If you have any questions about your rights as a study participant, you can call the Battelle IRB at 1-877-810-9530, ext. 500. I may also be able to address your questions.
Attachment D1 Screener and Baseline Interviewer Guide - Pg 5 Section F: DOCTOR VISIT	1. How often do you see a doctor for a regular check-up? Would you say at least once a year, once a year, once every two years, less than once every two years? 2. When is your next appointment to see your doctor? _______ 3. How often do you get your vision checked? Would you say at least once a year, once a year, once every two years, less than once every two years?	1. How often do you see a doctor for a regular check-up? Would you say more than once a year, once a year, once every two years, less than once every two years? 2. When is your next appointment to see your doctor? _______ 3. How often do you get your vision checked? Would you say more than once a year, once a year, once every two years, less than once every two years?
Attachment D1 Screener and Baseline Interviewer Guide - Pg 6 & 7 Section H: BACKGROUND	Now I’d like to ask you some general questions about your background. 1. How long have you lived in your current residence? [RECORD NUMBER OF YEARS/ MONTHS] 2. How many adults, age 18 years or older, live in your home with you? [RECORD NUMBER] 3. Are you of Hispanic or Latino/Latina origin or descent? a. Yes b. No 4. Which of the following best describes your race? [READ LIST:] a. White, b. Black or African American, c. Asian, d. Native Hawaiian or Other Pacific Islander, or e. American Indian or Alaska Native. 5. What is your current marital status? Are you currently married, widowed, divorced, separated, or never married? [CURRENTLY MARRIED, WIDOWED, DIVORCED, SEPARATED, OR NEVER MARRIED] 6. ASK IF NOT OBVIOUS: Are you male or female? [MALE/FEMALE] 7. What is the highest grade or year of school that you completed? RECORD RESPONSE: ___ Less than High School Degree or GED ___ High School Degree or GED only ___ Some college (no degree) ___ Completed associate or other technical 2-year degree ___ Completed Bachelor’s degree (but not graduate or professional degree) ___ Completed graduate or professional degree (Master’s degree or higher) 8. Last week were you working full time at least 35 hours, working part time less than 35 hours, retired, volunteering, going to school, keeping house, or doing something else? [CHECK ALL THAT APPLY]	Now I’d like to ask you some general questions about your background. 1. How long have you lived in your current residence? [RECORD NUMBER OF YEARS/ MONTHS] 2. How many adults, age 18 years or older, live in your home with you? Do not include yourself in this count. [RECORD NUMBER] 3. Are you of Hispanic or Latino/Latina origin or descent? a. Yes b. No 4. Which of the following best describes your race? [READ LIST:] a. White, b. Black or African American, c. Asian, d. Native Hawaiian or Other Pacific Islander, or e. American Indian or Alaska Native. 5. What is your current marital status? Are you currently married, widowed, divorced, separated, or never married? [CURRENTLY MARRIED, WIDOWED, DIVORCED, SEPARATED, OR NEVER MARRIED] 6. ASK IF NOT OBVIOUS: Are you male or female? [MALE/FEMALE] 7. What is the highest grade or year of school that you completed? RECORD RESPONSE: ___ Less than High School Degree or GED ___ High School Degree or GED only ___ Some college (no degree) ___ Completed associate or other technical 2-year degree ___ Completed Bachelor’s degree (but not graduate or professional degree) ___ Completed graduate or professional degree (Master’s degree or higher) 8. Last week were you working full time at least 35 hours, working part time less than 35 hours, retired, volunteering, going to school, keeping house, or doing something else?
Attachment D2 Screener and Baseline Interviewer Guide - Pg 2 SECTION B: CONSENT 2nd paragraph	If you have any questions about this research study, you can call Betsy Payn at 206-528-3138. If you have any questions about your rights as a study participant, you can call the Battelle IRB at 1-877-810-9530, ext. 500. I may also be able to address your questions.	If you have any questions about this research study, you can call Jaime Dohack at 1-866-559-0924. If you have any questions about your rights as a study participant, you can call the Battelle IRB at 1-877-810-9530, ext. 500. I may also be able to address your questions.
Attachment D2 Screener and Baseline Interviewer Guide - Pg 4 SECTION D: BEHAVIORS IN THE PAST 2 WEEKS 2nd paragraph	[ASK FOR EACH OF THE FOLLOWING ACTIVITIES:] 1. Scheduled an appointment to see your doctor? Would you say you did not think about doing it, you thought about doing it, you made plans to do it, or you did it? 2. Scheduled a vision check? 3. Participated in a physical activity program to increase your physical strength? [The next activity is…] Participated in a physical activity program to increase your balance? 4. [The next activity is…] Checked your home for tripping hazards? 5. [The next activity is…] Made any changes for safety in your home, such as putting handrails on the stairs, grab bars in your bathroom, a lamp within reach of your bed, or any other changes for safety? 6. [The next activity is…] Took a driving refresher course? 7. [The next activity is…] Got your car checked to see how well it fits you? 8. [The next activity is…] Gathered information on transportation options other than driving yourself?	[ASK FOR EACH OF THE FOLLOWING ACTIVITIES:] 1. Scheduled an appointment to see your doctor? Would you say you did not think about doing it, you thought about doing it, you made plans to do it, or you did it? 2. Scheduled a vision check? 3. Participated in a physical activity program to increase your physical strength? 4. [The next activity is…] Participated in a physical activity program to increase your balance? 5. [The next activity is…] Checked your home for tripping hazards? 6.[The next activity is…] Made any changes for safety in your home, such as putting handrails on the stairs, grab bars in your bathroom, a lamp within reach of your bed, or any other changes for safety? 7. [The next activity is…] Took a driving refresher course? 8. [The next activity is…] Got your car checked to see how well it fits you? 9. [The next activity is…] Gathered information on transportation options other than driving yourself? 10. [The next activity is…] Looked up your medications to see how they may affect safe driving?
Attachment D2 Screener and Baseline Interviewer Guide - Pg 5 SECTION F: DISSEMINATION AND FEEDBACK ON USE OF MPT - Tittle	SECTION F: DISSEMINATION AND FEEDBACK ON USE OF MPT	[TREATMENT GROUP ONLY; CONTROL GROUP – SKIP TO SECTION G] SECTION F: DISSEMINATION AND FEEDBACK ON USE OF MPT
Attachment D2 Screener and Baseline Interviewer Guide - Pg 5 SECTION F: DISSEMINATION AND FEEDBACK ON USE OF MPT - 1st paragraph	Finally, I would like to ask you some questions about the brochure that was sent to your home 2 weeks ago. [INSERT DESCRIPTION OF BROCHURE AFTER TOOL IS FINALIZED.]	Finally, I would like to ask you some questions about the brochure that was sent to your home 2 weeks ago. The brochure is called “MyMobility” and has different sections about planning for your continued good mobility in regard to your physical body, your home and in your community.
Attachment D2 Screener and Baseline Interviewer Guide - Pg 5 SECTION F: DISSEMINATION AND FEEDBACK ON USE OF MPT - 3rd paragraph	1. Using a scale from 1 to 5, where 1 is not at all likely and 5 is very likely, how likely are you to download the brochure if it is on the Web or Internet? [RECORD RESPONSE] 2. How likely are you to use the brochure if it is given to you by your medical provider? [RESTATE RESPONSE SCALE IF NECESSARY. RECORD RESPONSE.] 3. How likely are you to read the rest of the brochure if you only saw the first page? [RESTATE RESPONSE SCALE IF NECESSARY. RECORD RESPONSE.] 4. Did you use the list on the second page of the brochure, named Mobility Plan for Myself, to develop a plan for yourself? [yes/no] 5. Which parts of that page about keeping yourself healthy did you find most helpful? 6. Which parts did you find least helpful? 7. Did you use the list on the third page of the brochure named Mobility Plan for Inside My Home, to develop a plan to reduce the risk of trips and falls in your home? [yes/no] 8. Which parts of that page about keeping you safe inside your home did you find most helpful? 9. Which parts did you find least helpful? 10. Did you use the chart on the fourth page of the brochure, named Mobility Plan for Outside My Home, to develop a plan for how you would get around if you could not do what you usually do? [yes/no] 11. Which parts of that page about planning to stay mobile in your community did you find most helpful? 12. Which parts did you find least helpful?	1. Using a scale from 1 to 5, where 1 is not at all likely and 5 is very likely, how likely are you to download the brochure if it is on the Web or Internet? [RECORD RESPONSE] 2. How likely are you to use the brochure if it is given to you by your medical provider? [RESTATE RESPONSE SCALE IF NECESSARY. RECORD RESPONSE.] 3. How likely are you to read the rest of the brochure if you only saw the first page? [RESTATE RESPONSE SCALE IF NECESSARY. RECORD RESPONSE.] 4. Did you use the list on the second page of the brochure, named Myself- A Plan to Keep Me Healthy, to develop a plan for yourself? [yes/no] 5. Which parts of that page about keeping yourself healthy did you find most helpful? 6. Which parts did you find least helpful? 7. Did you use the list on the third page of the brochure named My House – A Plan to Keep Me Safe Inside My Home, to develop a plan to reduce the risk of trips and falls in your home? [yes/no] 8. Which parts of that page about keeping you safe inside your home did you find most helpful? 9. Which parts did you find least helpful? 10. Did you use the chart on the fourth page of the brochure (the page titled My Community – A Plan to Stay Mobile in My Community, to develop a plan for how you would get around if you could not do what you usually do? [yes/no] 11. Which parts of that page about planning to stay mobile in your community did you find most helpful? 12. Which parts did you find least helpful?
Attachment D2 Screener and Baseline Interviewer Guide - Pg 5 SECTION G: END	Those are all the questions I have for you. Thank you very much for answering our survey. Goodbye	Those are all the questions I have for you. Thank you very much for answering our survey. Over the next few weeks you will be receiving a small gift in the mail in appreciation for the time you spent participating in this study. Thank you again. Goodbye