Form 1 ENSP Client Outcomes CAPI Specs

Mathematica Reference No.: 4 0298.420

National Evaluation of Title III-C Services

Client Outcomes Survey

CAPI Questionnaire

June 9, 2015

INTRODUCTION

INTERVIEWER: SELECT PARTICIPANT TYPE:

CONGREGATE NUTRITION PARTICIPANT 1 SET PTCPT = CM

HOME-DELIVERED NUTRITION PARTICIPANT 2 SET PTCPT = HDM

CONGREGATE NUTRITION NONPARTICIPANT 3 SET PTCPT = NON;

MATCH = CM

HOME-DELIVERED NUTRITION NONPARTICIPANT 4 SET PTCPT = NON;

MATCH = HDM

INTERVIEWER: WILL INTERVIEW BE CONDUCTED WITH A PROXY?

YES 1 SET PROXY

STATUS = Y

NO 0 SET PROXY

INTERVIEWER: ENTER NAME OF PERSON

INTERVIEWER: ENTER NAME OF PROGRAM

required

IF PTCPT = CM OR HDM AND PROXY = N

INTRO1. My name is [NAME] and I am from Mathematica Policy Research. I am here on behalf of the U.S. Department of Health and Human Services, Administration on Aging. I would like your help with a survey to find out how the Administration on Aging can help meet the needs of older Americans.

This survey has two parts. The first part of the survey is about what you ate and drank yesterday. The second part of the survey is about your participation in the nutrition program at [NAME OF PROGRAM SITE] and your satisfaction with aspects of the nutrition program there. . Your participation is voluntary but we would really like your help. This survey is for research purposes only and will help to improve services for older adults in the future. All of your answers will be kept strictly confidential. Your eligibility for services from this and other programs will not be affected by your decision to participate. The entire survey takes about 75 minutes to complete. We’ll mail you a $50 gift card for completing the survey.

CONTINUE 1 SKIP TO A1

REFUSED r Thank you for your time

required

IF PTCPT = CM OR HDM AND PROXY = Y

INTRO2. My name is [NAME] and I am from Mathematica Policy Research. I am here on behalf of the U.S. Department of Health and Human Services, Administration on Aging. I would like your help with completing a survey on behalf of [NAME OF PARTICIPANT]. The purpose of the survey is to find out how the Administration on Aging can help meet the needs of older Americans.

This survey has two parts. The first part of the survey is about what [NAME OF PARTICIPANT] ate and drank yesterday. The second part of the survey is about [his/her] participation in the nutrition program at [NAME OF PROGRAM SITE] and [his/her] satisfaction with aspects of the nutrition program there. Your participation is voluntary but we would really like your help. This survey is for research purposes only and will help to improve services for older adults in the future. All of your answers will be kept strictly confidential. [NAME OF PARTICIPANT]’s eligibility for services for this and other programs will not be affected by your decision to participate. The entire survey takes about 75 minutes to complete. We’ll mail you a $50 gift card for completing the survey.

For the remainder of the survey I would like you to answer as though you are [NAME OF PARTICIPANT]. All of the following questions pertain to [him/her]. Please provide your best estimate as to [his/her] own response or opinion.

CONTINUE 1 SKIP TO A1

REFUSED r Thank you for your time

required

IF PTCPT = NON AND PROXY = N

INTRO3. My name is [NAME] and I am from Mathematica Policy Research. I am here on behalf of the U.S. Department of Health and Human Services, Administration on Aging. I would like your help with a survey to find out how the Administration on Aging can help meet the needs of Older Americans.

This survey has two parts. The first part is about what you ate and drank yesterday. The second part has some general questions, as well as questions about your general health and dietary habits. Your participation is voluntary but we would really like your help. This survey is for research purposes only and will help to improve services for older adults in the future. All of your answers will be kept strictly confidential. Your eligibility for services from this and other programs will not be affected by your decision to participate. The entire survey takes about 55 minutes to complete. We’ll mail you a $50 gift card for completing the survey.

CONTINUE 1 SKIP TO A1

REFUSED r Thank you for your time

required

IF PTCPT = NON AND PROXY = Y

INTRO4. My name is [NAME] and I am from Mathematica Policy Research. I am here on behalf of the U.S. Department of Health and Human Services, Administration on Aging. I would like your help with completing a survey on behalf of [NAME OF PARTICIPANT]. The purpose of the survey to find out how the Administration on Aging can help meet the needs of older Americans.

This survey has two parts. The first part of the survey is about what [NAME OF PARTICIPANT] ate and drank yesterday. The second part of the survey is about (his/her) general health and dietary habits. . Your participation is voluntary but we would really like your help. This survey is for research purposes only and will help to improve services for older adults in the future. All of your answers will be kept strictly confidential. [NAME OF PARTICIPANT]’s eligibility for services for this and other programs will not be affected by your decision to participate. The entire survey takes about 55 minutes to complete. We’ll mail you a $50 gift card for completing the survey.

For the remainder of the survey I would like you to answer as though you were [NAME OF PARTICIPANT]. All of the following questions pertain to [him/her]. Please provide your best estimate as to [his/her] own response or opinion.

CONTINUE 1 SKIP TO A1

REFUSED r Thank you for your time

24 HOUR DIETARY RECALL

In the first part of the survey, I will ask you questions about what you ate and drank yesterday. . .

A. NUTRITION PROGRAM PARTICIPATION

PROGRAMMER BOX a1

CATI: CONTINUE IF PTCPT = CM OR HDM. IF PTCPT = NON, SKIP TO SECTION B.

required

IF PTCPT = CM

A_Intro: The next part of the survey begins with questions about [your/his/her] participation in the congregate nutrition program at [NAME OF PROGRAM SITE].

A1. During a typical week, how many days [do you/does he/does she] eat at [NAME OF PROGRAM SITE] or another place like it?

| | | days (0-999)

PER WEEK (Range 1-7) 1

PER MONTH (Range 1-31) 2

PER YEAR (Range 1-99) 3

DON’T KNOW d

REFUSED r

HARD CHECK: IF DAYS PER WEEK GT 7; I want to be sure I recorded your answer correctly. Did you say [fill A1] days per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 DAYS PER WEEK.

HARD CHECK: IF DAYS PER MONTH GT 31; I want to be sure I recorded your answer correctly. Did you say [fill A1] days per month? INTERVIEWER: ANSWER CANNOT EXCEED 31 DAYS PER MONTH.

HARD CHECK: IF A1 GT 99; I want to be sure I recorded your answer correctly. Did you say [fill A1] days? INTERVIEWER: ANSWER CANNOT EXCEED 99 DAYS.

HARD CHECK: IF A1 = 0; I want to be sure I recorded your answer correctly. Did you say [fill A1] days? INTERVIEWER: ANSWER CANNOT BE 0.

required

IF PTCPT = HDM

A_Intro: The next part of the survey begins with questions about [your/his/her] participation in the home-delivered nutrition program from [NAME OF PROGRAM SITE]. You may also know this as the meals-on-wheels program from [NAME OF PROGRAM SITE].

A1.1 During a typical week, how many days does [NAME OF PROGRAM SITE] or another program like it deliver meals to [your/his/her] home?

| | | days (0-999)

PER WEEK (Range 1-7) 1

PER MONTH (Range 1-31) 2

PER YEAR (Range 1-99) 3

DON’T KNOW d

REFUSED r

HARD CHECK: IF DAYS PER WEEK GT 7; I want to be sure I recorded your answer correctly. Did you say [fill A1.1] days per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 DAYS PER WEEK.

HARD CHECK: IF DAYS PER MONTH GT 31; I want to be sure I recorded your answer correctly. Did you say [fill A1.1] days per month? INTERVIEWER: ANSWER CANNOT EXCEED 31 DAYS PER MONTH.

HARD CHECK: IF A1.1 GT 99; I want to be sure I recorded your answer correctly. Did you say [fill A1.1] days? INTERVIEWER: ANSWER CANNOT EXCEED 99 DAYS.

HARD CHECK: IF A1.1 = 0; I want to be sure I recorded your answer correctly. Did you say [fill A1.1] days? INTERVIEWER: ANSWER CANNOT BE 0.

required

IF PTCPT = HDM

A2.3. How long ago was the last time [NAME OF PROGRAM SITE] delivered a meal to [your/his/her] home? You can tell me the number of days, weeks, months, or years.

INTERVIEWER: IF RESPONDENT HAD A MEAL DELIVERED TODAY, PLEASE CODE 0 DAYS AGO

| | | (0-999)

DAYS AGO (Range 0-45) 1

WEEKS AGO (Range 1-30) 2

MONTHS AGO (Range 1-13) 3

YEARS AGO (Range 1-40) 4

DON’T KNOW d

REFUSED r

HARD CHECK: IF A2.3 GT 45; I want to be sure I recorded your answer correctly. Did you say [fill A2.3]? INTERVIEWER: ANSWER CANNOT EXCEED 45.

HARD CHECK: IF WEEKS AGO GT 30; I want to be sure I recorded your answer correctly. Did you say [fill A2.3] weeks ago? INTERVIEWER: ANSWER CANNOT EXCEED 30 WEEKS AGO.

HARD CHECK: IF MONTHS AGO GT 13; I want to be sure I recorded your answer correctly. Did you say [fill A2.3] months ago? INTERVIEWER: ANSWER CANNOT EXCEED 13 MONTHS AGO.

HARD CHECK: IF YEARS AGO GT 40; I want to be sure I recorded your answer correctly. Did you say [fill A2.3] years ago? INTERVIEWER: ANSWER CANNOT EXCEED 40 YEARS AGO.

HARD CHECK: IF WEEKS AGO = 0; I want to be sure I recorded your answer correctly. Did you say [fill A2.3] weeks ago? INTERVIEWER: ANSWER CANNOT BE 0 WEEKS AGO.

HARD CHECK: IF MONTHS AGO = 0; I want to be sure I recorded your answer correctly. Did you say [fill A2.3] months ago? INTERVIEWER: ANSWER CANNOT BE 0 MONTHS AGO.

HARD CHECK: IF YEARS AGO = 0; I want to be sure I recorded your answer correctly. Did you say [fill A2.3] years ago? INTERVIEWER: ANSWER CANNOT BE 0 YEARS AGO.

required

IF PTCPT = CM

A3. Thinking back to 6 months ago (that is, last [CURRENT MONTH – 6 MONTHS]), did [you/he/she] eat meals at the [NAME OF PROGRAM SITE] or other places like this more often, less often, or about as often as [you do/he does/she does] now?

MORE OFTEN 1

LESS OFTEN 2

ABOUT AS OFTEN 3 SKIP TO A5

DON’T KNOW d SKIP TO A5

REFUSED r SKIP TO A5

required

IF A3 = 1

A4. Why [do you/does he/does she] eat at [NAME OF PROGRAM SITE] more often than [you/he/she] did 6 months ago?

PROBE: That is, since last [CURRENT MONTH – 6 MONTHS].

HAVE NO ONE AT HOME TO EAT WITH 1

MADE FRIENDS AT MEAL SITE 2

GOT INVOLVED IN ACTIVITIES AT MEAL SITE 3

COSTS LESS TO EAT AT MEAL SITE THAN ELSEWHERE 4

THE MEAL SITE IS WARM AND INVITING 5

NO LONGER HAVE A PLACE TO PREPARE MEALS 6

PHYSICALLY DIFFICULT TO MAKE OWN MEALS 7

I LIKE THE KINDS OF FOODS THEY SERVE 8

OTHER (PLEASE SPECIFY) 99

(STRING (30))

DON’T KNOW d

REFUSED r

required

IF A3 = 2

A4.1 Why [do you/does he/does she] eat at [NAME OF PROGRAM SITE] less often than [you/he/she] did 6 months ago?

PROBE: That is, since last [CURRENT MONTH – 6 MONTHS].

HAVE FEW OR NO FRIENDS AT MEAL SITE 1

HAVE OTHER PLACES TO EAT 2

HAVEN’T GOTTEN INVOLVED OR NOT INTERESTED IN ACTIVITIES AT MEAL SITE 3

CAN’T AFFORD TO DONATE AT MEAL SITE 4

SOMETIMES DIFFICULT TO GET TO MEAL SITE 5

I FOUND THAT I DON’T ALWAYS LIKE THE KINDS OF FOODS THEY SERVE 6

STILL ABLE TO PREPARE OWN MEALS 7

OTHER (PLEASE SPECIFY) 99

(STRING (30))

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM OR HDM

A13. If the [NAME OF PROGRAM SITE] wasn’t available to provide meals, how often would (INSERT a-h) . . . Would you say most of the time, sometimes, or never?

	MOST OF THE TIME	SOMETIMES	NEVER	DON’T KNOW	REFUSED
a. [You/He/She] cook for [yourself/himself/herself]?	1	2	3	d	r
b. Family or friends provide [you/him/her] with meals?	1	2	3	d	r
c. [You/He/She] eat at restaurants or have food delivered from restaurants?	1	2	3	d	r
d. [You/He/She] eat meals that were easy to fix like sandwiches, microwavable meals, or soups?	1	2	3	d	r
e. [You/He/She] eat meals that were ready to eat right out of the package?	1	2	3	d	r
f. Skip meals or eat less than [you do/he does/she does] now?	1	2	3	d	r
g. Eat foods saved from other meals?	1	2	3	d	r
h. [You/He/She] get food in some other way? (PLEASE SPECIFY)	1	2	3	d	r
(STRING (30))

required

IF PTCPT = CM OR HDM

A11. [Do you/Does he/Does she] currently any emergency meals at home that the [NAME OF PROGRAM SITE] gave [you/him/her]?

YES 1

NO 0

DON’T KNOW d

Refused r

REFUSED r

required

IF PTCPT = CM

A14. Excluding [NAME OF PROGRAM SITE], how many other places like [NAME OF PROGRAM SITE] [do you/does he/does she] usually go for [your/his/her] meals? These could be senior centers, senior lunch programs, or other congregate meals programs.

| | | NUMBER OF PLACES (0-99)

DON’T KNOW d

REFUSED r

HARD CHECK: IF A14 GT 10; I want to be sure I recorded your answer correctly. Did you say [fill A14] places? INTERVIEWER: ANSWER CANNOT EXCEED 10 PLACES.

required

IF PTCPT = HDM

A14.1 Excluding [NAME OF PROGRAM SITE], how many other similar places usually deliver meals to [your/his/her] home?

| | | NUMBER OF PLACES (0-99)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF A14.1 GT 5; I want to be sure I recorded your answer correctly. Did you say [fill A14.1] other places usually deliver meals to [your/his/her] home?

HARD CHECK: IF A14.1 GT 10; I want to be sure I recorded your answer correctly. Did you say [fill A14.1] other places usually deliver meals to [your/his/her] home? INTERVIEWER: ANSWER CANNOT EXCEED 10 OTHER PLACES.

required

IF PTCPT = CM

A15. How long ago did [you/he/she] first begin eating at a congregate meal site, senior center, or senior lunch program for a meal?

PROBE: You may answer in days, weeks, months, or years. Your best estimate is fine.

| | | (0-999)

DAYS AGO (Range 0-45) 1

WEEKS AGO (Range 1-30) 2

MONTHS AGO (Range 1-13) 3

YEARS AGO (Range 1-40) 4

DON’T KNOW d

REFUSED r

HARD CHECK: IF A15 GT 45; I want to be sure I recorded your answer correctly. Did you say [fill A15]? INTERVIEWER: ANSWER CANNOT EXCEED 45.

HARD CHECK: IF WEEKS AGO GT 30; I want to be sure I recorded your answer correctly. Did you say [fill A15] weeks ago? INTERVIEWER: ANSWER CANNOT EXCEED 30 WEEKS AGO.

HARD CHECK: IF MONTHS AGO GT 13; I want to be sure I recorded your answer correctly. Did you say [FILL A15] months ago? INTERVIEWER: ANSWER CANNOT EXCEED 13 MONTHS AGO.

HARD CHECK: IF YEARS AGO GT 40; I want to be sure I recorded your answer correctly. Did you say [fill A15] years ago? INTERVIEWER: ANSWER CANNOT EXCEED 40 YEARS AGO.

HARD CHECK: IF WEEKS AGO = 0; I want to be sure I recorded your answer correctly. Did you say [fill A15] weeks ago? INTERVIEWER: ANSWER CANNOT BE 0 WEEKS AGO.

HARD CHECK: IF MONTHS AGO = 0; I want to be sure I recorded your answer correctly. Did you say [fill A15] months ago? INTERVIEWER: ANSWER CANNOT BE 0 MONTHS AGO.

HARD CHECK: IF YEARS AGO = 0; I want to be sure I recorded your answer correctly. Did you say [fill A15] years ago? INTERVIEWER: ANSWER CANNOT BE 0 YEARS AGO.

required

IF PTCPT = HDM

A15.1 How long ago did [you/he/she] first receive a home-delivered meal?

PROBE: You may answer in days, weeks, months, or years. Your best estimate is fine.

| | | (0-999)

DAYS AGO (Range 0-45) 1

WEEKS AGO (Range 1-30) 2

MONTHS AGO (Range 1-13) 3

YEARS AGO (Range 1-40) 4

DON’T KNOW d

REFUSED r

HARD CHECK: IF A15.1 GT 45; I want to be sure I recorded your answer correctly. Did you say [fill A15.1]? INTERVIEWER: ANSWER CANNOT EXCEED 45.

HARD CHECK: IF WEEKS AGO GT 30; I want to be sure I recorded your answer correctly. Did you say [fill A15.1] weeks ago? INTERVIEWER: ANSWER CANNOT EXCEED 30 WEEKS AGO.

HARD CHECK: IF MONTHS AGO GT 13; I want to be sure I recorded your answer correctly. Did you say [fill A15.1] months ago? INTERVIEWER: ANSWER CANNOT EXCEED 13 MONTHS AGO.

HARD CHECK: IF YEARS AGO GT 40; I want to be sure I recorded your answer correctly. Did you say [fill A15.1] years ago? INTERVIEWER: ANSWER CANNOT EXCEED 40 YEARS AGO.

HARD CHECK: IF WEEKS AGO = 0; I want to be sure I recorded your answer correctly. Did you say [fill A15.1] weeks ago? INTERVIEWER: ANSWER CANNOT BE 0 WEEKS AGO.

HARD CHECK: IF MONTHS AGO = 0; I want to be sure I recorded your answer correctly. Did you say [fill A15.1] months ago? INTERVIEWER: ANSWER CANNOT BE 0 MONTHS AGO.

HARD CHECK: IF YEARS AGO = 0; I want to be sure I recorded your answer correctly. Did you say [fill A15.1] years ago? INTERVIEWER: ANSWER CANNOT BE 0 YEARS AGO.

required

IF PTCPT = CM

A16. How did [you/he/she] first learn about the nutrition program like the one at [NAME OF PROGRAM SITE]?

FROM ANOTHER PERSON 1

MEDICAL DOCTOR 2

MEDICAL PERSONNEL OTHER THAN A DOCTOR 3

SOCIAL WORKER 4

FAMILY MEMBER 5

FRIEND 6

NEWSPAPER, TV, RADIO, INTERNET 7

POSTERS, SOMETHING IN THE MAIL 8

ANNOUNCEMENT IN CLUB OR CHURCH 9

REFERRED BY A COMMUNITY-BASED AGENCY (HOSPITAL, SOCIAL SERVICES AGENCY, ETC.) 10

OTHER (PLEASE SPECIFY) 99

(STRING (30))

DON’T KNOW d

REFUSED r

required

IF PTCPT = HDM

A16.1 How did [you/he/she] first learn about the home-delivered nutrition program like the one at [NAME OF PROGRAM SITE]?

FROM ANOTHER PERSON 1

MEDICAL DOCTOR 2

MEDICAL PERSONNEL OTHER THAN A DOCTOR 3

SOCIAL WORKER 4

FAMILY MEMBER 5

FRIEND 6

NEWSPAPER, TV, RADIO, INTERNET 7

POSTERS, SOMETHING IN THE MAIL 8

ANNOUNCEMENT IN CLUB OR CHURCH 9

REFERRED BY A COMMUNITY-BASED AGENCY (HOSPITAL, SOCIAL SERVICES AGENCY, ETC.) 10

OTHER (PLEASE SPECIFY) 99

(STRING (30))

DON’T KNOW d

REFUSED r

B. OTHER SERVICES

PROGRAMMER BOX B1

CATI: CONTINUE IF PTCPT = CM, HDM, OR NON AND FRAIL SKIP HAS NOT BEEN INVOKED. SKIP SECTION B IF FRAIL SKIP HAS BEEN INVOKED.

required

ALL

B_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO B1

required

IF B_FRAIL1 = 1

B_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO B_FRAIL4

required

IF B_FRAIL2 = YES

B_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO B1

NO 0

required

IF B_FRAIL3 = NO

B_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX C1

required

IF B_FRAIL4 = YES

B_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

required

IF PTCPT = CM OR HDM

B1. In the past 6 months, other than meals from [NAME OF PROGRAM SITE], [have you/has he/has she] gotten other types of help or services from either [NAME OF PROGRAM SITE], [NAME OF AREA AGENCY ON AGING], or some other agency or provider?

YES 1

NO 0 SKIP TO B3

DON’T KNOW d SKIP TO B3

REFUSED r SKIP TO B3

required

IF PTCPT = NON

B1.1 In the past 6 months, [have you/has he/has she] gotten any help or received any services from [NAME OF AREA AGENCY ON AGING] or some other agency?

YES 1

NO 0 SKIP TO Programmer Box C1

DON’T KNOW d SKIP TO Programmer Box C1

REFUSED r SKIP TO Programmer Box C1

required

IF B1 OR B1.1 =1

B2. In the past 6 months . . .

	YES	NO	DON’T KNOW	REFUSED
a. [Have you/Has he/Has she] participated in an adult day care program?	1	0	d	r
b. [Have you/Has he/Has she] received personal care services for help with dressing or bathing?	1	0	d	r
c. Did [a visiting nurse or therapist come to [your/his/her] home to provide physical, occupational, or speech therapy?	1	0	d	r
d. Did a nutritional counselor give [you/him/her] individual advice on what [you/he/she] should eat?	1	0	d	r
e. [Have you/Has he/Has she] received case management services in which a case manager set up in-home services for [you/him/her] such as homemaker or personal care services, or called to see how [you are/he is/she is] doing?	1	0	d	r
f. [Have you/Has he/Has she] received free or discounted housing?	1	0	d	r
g. Did [you/he/she] participate in a support group to talk with other people who have the same kind of problems [you have/he has/she has]?	1	0	d	r
h. [Have you/Has he/Has she] received homemaker or housekeeping services to help with light housework, preparing meals, or shopping?	1	0	d	r
i. [Have you/Has he/Has she] received chore services to help with heavier housecleaning or yard work?	1	0	d	r

required

IF PTCPT = CM

B3. In the past 6 months, [have you/has he/has she] attended a class or lecture about any of the following at [NAME OF PROGRAM SITE]?

	YES	NO	DON’T KNOW	REFUSED
a. A specific chronic disease (e.g., Diabetes, heart disease)?	1	0	d	r
b. Nutrition or healthy eating habits?	1	0	d	r
c. Safety issues such as falls prevention?	1	0	d	r
d. Health insurance or Medicare Part D?	1	0	d	r
e. How to manage [your/his/her] medications?	1	0	d	r
f. How to manage [your/his/her] finances?	1	0	d	r

required

IF PTCPT = CM

B3.1 Thinking about other activities at [NAME OF PROGRAM SITE], in the past 6 months [have you/has he/has she] . . .

	YES	NO	DON’T KNOW	REFUSED
a. Participated in an exercise or fitness class there?	1	0	d	r
b. Received assistance in finding employment there?	1	0	d	r
c. Received legal services such as help with making a will or understanding a bill or other legal matter there?	1	0	d	r
d. Received counseling about your housing situation or problems with your housing there?	1	0	d	r

C. SERVICES, ACTIVITIES, AND TRANSPORTATION

PROGRAMMER BOX C1

CATI: CONTINUE IF PTCPT = CM, HDM, or NON AND FRAIL SKIP HAS NOT BEEN INVOKED. SKIP SECTION C IF FRAIL SKIP HAS BEEN INVOKED.

required

IF FRAIL SKIP HAS NOT BEEN INVOKED

C_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO C1

required

IF C_FRAIL1 = 1

C_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO C_FRAIL4

required

IF C_FRAIL2 = YES

C_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO C1

NO 0

required

IF C_FRAIL3 = NO

C_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX D1

required

IF C_FRAIL4 = YES

C_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

required

IF PTCPT = CM

C1. During the past 30 days, [have you/has he/has she] used transportation provided by [NAME OF PROGRAM SITE] to get to and from the meal site?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF C1 = 1

C4. If the transportation provided by [NAME OF PROGRAM SITE] was not available, would [you/he/she] go . . .

About as often as now, 1

Somewhat less often, 2

A lot less often, or 3

Wouldn’t go at all? 4

DON’T KNOW d

REFUSED r

D. RECREATIONAL AND SOCIAL ACTIVITIES

PROGRAMMER BOX d1

CATI: CONTINUE IF PTCPT = CM AND FRAIL SKIP HAS NOT BEEN INVOKED; SKIP SECTION D IF FRAIL SKIP HAS BEEN INVOKED. IF PTCPT = HDM OR NON, SKIP TO SECTION E.

required

IF FRAIL SKIP HAS NOT BEEN INVOKED

D_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO D1

required

IF D_FRAIL1 = 1

D_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO D_FRAIL4

required

IF D_FRAIL2 = YES

D_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO D1

NO 0

required

IF D_FRAIL3 = NO

D_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX E1

required

IF D_FRAIL4 = YES

D_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

D_Intro: The next questions are about recreational and social activities [you/he/she] may participate in at [NAME OF PROGRAM SITE].

required

IF PTCPT = CM

D1. In general, how satisfied [are you/is he/is she] with opportunities [you have/he has/she has] to spend time with other people at [NAME OF PROGRAM SITE]? Would [you/he/she] say [you are/he is/she is] . . .

Very satisfied, 1

Somewhat satisfied, 2

Not too satisfied, or 3

Not at all satisfied? 4

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM

D2. [Do you/Does he/Does she] spend a lot of time, some time, just a little time, or no time participating in other activities or receiving other services at the [NAME OF PROGRAM SITE] meal site?

A LOT OF TIME 1

SOME TIME 2

JUST A LITTLE TIME 3

NO TIME 4

DON’T KNOW d

REFUSED r

E. INFORMATION AND REFERRAL, OTHER SERVICES

PROGRAMMER BOX E1

CATI: CONTINUE IF PTCPT = CM OR HDM. IF PTCPT = NON, CONTINUE IF B1.1 = 1. ELSE, SKIP TO SECTION J. SKIP SECTION E IF FRAIL SKIP HAS BEEN INVOKED

required

IF FRAIL SKIP HAS NOT BEEN INVOKED

E_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO E_INTRO

required

IF E_FRAIL1 = 1

E_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO E_FRAIL4

required

IF E_FRAIL2 = YES

E_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO E_INTRO

NO 0

required

IF E_FRAIL3 = NO

E_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX F1

required

IF E_FRAIL4 = YES

E_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

required

IF PTCPT = CM OR HDM

E_Intro: The next set of questions are about services, help, or information [you/he/she] may receive from [NAME OF PROGRAM SITE].

required

IF PTCPT = NON

E_Intro: The next set of questions are about services, help, or information [you/he/she] may receive from [NAME OF AREA AGENCY ON AGING] or another organization.

required

IF PTCPT = CM OR HDM

E1. During the past year, did someone from the [NAME OF PROGRAM] provide information or refer [you/him/her] to places to learn about financial, social, or health services that are available or tell [you/him/her] how to get the help [you need/he needs/she needs]?

YES 1

NO 0 SKIP TO PROGRAMMER BOX F1

DON’T KNOW d SKIP TO PROGRAMMER BOX F1

REFUSED r SKIP TO PROGRAMMER BOX F1

required

IF PTCPT = NON

E1.1 During the past year, did someone from [NAME OF AREA AGENCY ON AGING] or another organization provide information or refer [you/him/her] to places to learn about financial, social, or health services that are available or tell [you/him/her] how to get the help [you need/he needs/she needs]?

YES 1

NO 0 SKIP TO PROGRAMMER BOX J1

DON’T KNOW d SKIP TO PROGRAMMER BOX J1

REFUSED r SKIP TO PROGRAMMER BOX J1

required

IF E1 OR E1.1 = 1

E3. [Were you/was he/was she] looking for information or a referral to any of the following . . .

	YES	NO	DON’T KNOW	REFUSED
a. An adult day care program?	1	0	d	r
b. Personal care services for help with dressing or bathing?	1	0	d	r
c. A visiting nurse or therapist that would come to your home to provide physical, occupational, or speech therapy?	1	0	d	r
d. A nutritional counselor who would give [you/him/her] individual advice on what [you/he/she] should eat?	1	0	d	r
e. Case management services in which a case manager would set up in-home services for [you/him/her] such as homemaker or personal care services, or calls to see how [you are/he is/she is] doing?	1	0	d	r
f. A support group to talk with other people who have the same kind of problems [you have/he has/she has]?	1	0	d	r
g. Homemaker or housekeeping services to help with light housework, preparing meals, or shopping?	1	0	d	r
h. Chore services to help with heavier housecleaning or yard work?	1	0	d	r
i. Housing assistance?	1	0	d	r
j. Transportation services?	1	0	d	r

F. HELPFULNESS OF PROGRAM

PROGRAMMER BOX F1

CATI: CONTINUE IF PTCPT = CM OR HDM. IF PTCPT = NON, SKIP TO SECTION J. IF FRAIL SKIP HAS BEEN INVOKED, SKIP SECTION F.

required

IF FRAIL SKIP HAS NOT BEEN INVOKED

F_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO F1

required

IF F_FRAIL1 = 1

F_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO F_FRAIL4

required

IF F_FRAIL2 = YES

F_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO F1

NO 0

required

IF F_FRAIL3 = NO

F_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX G1

required

IF F_FRAIL4 = YES

F_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

required

IF PTCPT = CM OR HDM

F1. Overall, how helpful has [NAME OF PROGRAM]’s nutrition program been? Would [you/he/she] say it has. . .

Helped [you/him/her] a lot, 1

Helped [you/him/her] somewhat, 2

Helped [you/him/her] a little, 3

Didn’t help [you/him/her], or 4

Made things worse? 5

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM OR HDM

F2. Has [NAME OF PROGRAM SITE]’s nutrition program . . .

	YES	NO	DON’T KNOW	REFUSED
a. Helped [you/him/her] eat healthier foods?	1	0	d	r
b. Improved [your/his/her] health?	1	0	d	r
c. Helped [you/him/her] follow the special diet that is prescribed by [your/his/her] doctor or dietician?	1	0	d	r
d. Helped [you/him/her] achieve or maintain a healthy weight?	1	0	d	r
e. Helped [you/him/her] to live independently and stay in [your/his/her] home?	1	0	d	r

G. VOLUNTEER WORK FOR [NAME OF PROGRAM SITE] NUTRITION PROGRAM

PROGRAMMER BOX G1

CATI: CONTINUE IF PTCPT = CM. IF FRAIL SKIP HAS BEEN INVOKED, SKIP SECTION G. IF PTCPT = HDM, SKIP TO SECTION H. IF PTCPT = NON, SKIP TO SECTION J.

required

IF FRAIL SKIP HAS NOT BEEN INVOKED

G_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO G_Intro

required

IF G_FRAIL1 = 1

G_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO G_FRAIL4

required

IF G_FRAIL2 = YES

G_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO G_Intro

NO 0

required

IF G_FRAIL3 = NO

G_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX H1

required

IF G_FRAIL4 = YES

G_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

G_Intro: The next set of questions are about volunteer work for [NAME OF PROGRAM SITE]’s nutrition program.

required

IF PTCPT = CM

G1. [Do you/Does he/Does she] do volunteer work for [NAME OF PROGRAM SITE]’s nutrition program?

YES 1

NO 0

DON’T KNOW d

REFUSED r

H. IMPRESSIONS OF THE NUTRITION PROGRAM

PROGRAMMER BOX H1

CATI: CONTINUE IF PTCPT = CM OR HDM. SKIP SECTION H IF FRAIL SKIP HAS BEEN INVOKED. IF PTCPT = NON, SKIP TO SECTION J.

required

IF FRAIL SKIP HAS NOT BEEN INVOKED

H_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO H_INTRO

required

IF H_FRAIL1 = 1

H_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO H_FRAIL4

required

IF H_FRAIL2 = YES

H_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO H_Intro

NO 0

required

IF H_FRAIL3 = NO

H_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX I1

required

IF H_FRAIL4 = YES

H_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

H_Intro: The next questions are about [your/his/her] general impression of the [NAME OF PROGRAM].

required

IF PTCPT = CM

H1. Overall, how would [you/he/she] rate the nutrition program at [NAME OF PROGRAM SITE]? Would [you/he/she] say it is . . .

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

DON’T KNOW d

REFUSED r

required

IF PTCPT = HDM

H1.1 Overall, how would [you/he/she] rate [NAME OF PROGRAM SITE]’s home-delivered nutrition program? Would [you/he/she] say it is . . .

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM OR HDM

H6. How would [you/he/she] rate the [NAME OF PROGRAM SITE]’s staff overall? Would [you/he/she] say they are . . .

Excellent, 1

Very good, 2

Good, 3

Fair, or 4

Poor? 5

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM OR HDM

Next I’m going to read you some statements about [NAME OF PROGRAM SITE]’s nutrition program.

H7. Think about all the foods [you receive/he receives/she receives] from [NAME OF PROGRAM SITE]’s nutrition program. Would [you/he/she] say [you are/he is/she is] always, usually, sometimes, seldom, or never satisfied . . .

	ALWAYS	USUALLY	SOMETIMES	SELDOM	NEVER	DON’T KNOW	REFUSED
a. with the way the food tastes?	1	2	3	4	5	d	r
b. with the way the food smells?	1	2	3	4	5	d	r
c. with the way the food looks?	1	2	3	4	5	d	r
d. with the variety of food?	1	2	3	4	5	d	r
e. that hot foods are hot and cold foods are cold?	1	2	3	4	5	d	r
f. that you get foods that [you like/he likes/she likes]?	1	2	3	4	5	d	r
g. that [your/his/her] special dietary needs or restrictions are met?	1	2	3	4	5	d	r
h. with the amount of food [you receive/he receives/ she receives]?	1	2	3	4	5	d	r
(PTCPT = CM): i. Attractiveness of the dining area?	1	2	3	4	5	d	r

required

IF PTCPT = CM OR HDM

H8. [Do you/Does he/Does she] like the meals that [you get/he gets/she gets] from [NAME OF PROGRAM SITE]?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = HDM

H10. How often does the meal arrive at the scheduled time? Would [you/he/she] say . . .

Always, 1

Usually, 2

Sometimes, 3

Seldom, or 4

Never? 5

DON’T KNOW d

REFUSED r

required

IF PTCPT = HDM

H11. How often does the person who delivers [your/his/her] meals stay and spend some time talking with [you/him/her]? Would [you/he/she] say . . .

Always, 1

Usually, 2

Sometimes, 3

Seldom, or 4

Never? 5

DON’T KNOW d

REFUSED r

required

IF PTCPT = HDM

H12. How often is the person who delivers [your/his/her] meals pleasant? Would [you/he/she] say . . .

Always, 1

Usually, 2

Sometimes, 3

Seldom, or 4

Never? 5

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM OR HDM

H13. Would [you/he/she] recommend [NAME OF PROGRAM SITE]’s nutrition program to [your/his/her] friends or relatives?

YES 1

NO 0

DON’T KNOW d

REFUSED r

I. MEAL CONTRIBUTIONS

PROGRAMMER BOX I1

CATI: CONTINUE IF PTCPT = CM OR HDM. SKIP SECTION I IF FRAIL SKIP HAS BEEN INVOKED. IF PTCPT = NON, SKIP TO SECTION J.

required

IF FRAIL SKIP HAS NOT BEEN INVOKED

I_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO I_Intro

required

IF I_FRAIL1 = 1

I_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO I_FRAIL4

required

IF I_FRAIL2 = YES

I_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO I_Intro

NO 0

required

IF I_FRAIL3 = NO

I_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX J1

required

IF I_FRAIL4 = YES

I_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

I_Intro: The next set of questions are about monetary contributions to the nutrition program at [NAME OF PROGRAM SITE].

required

IF PTCPT = CM OR HDM

I1. [Do you/Does he/Does she] make monetary contributions to [NAME OF PROGRAM SITE]’s nutrition program?

YES 1

NO 0 SKIP TO PROGRAMMER BOX J1

DON’T KNOW d SKIP TO PROGRAMMER BOX J1

REFUSED r SKIP TO PROGRAMMER BOX J1

required

IF I1 = 1

I2. Does the program have a suggested amount that [you/he/she] should contribute for each meal?

YES 1

NO 0 SKIP TO I5

DON’T KNOW d SKIP TO I5

REFUSED r SKIP TO I5

required

IF I1 = 1

I5. [Do you/Does he/Does she] feel pressured to contribute for each meal?

YES 1

NO 0

DON’T KNOW d

REFUSED r

J. EATING BEHAVIOR, DIET AND FOOD PREPARATION

PROGRAMMER BOX J1

CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER QUESTIONS IN SECTION J. SKIP SECTION J IF FRAIL SKIP IS INVOKED.

required

IF FRAIL SKIP HAS NOT BEEN INVOKED

J_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO J_Intro

required

IF J_FRAIL1 = 1

J_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO J_FRAIL4

required

IF J_FRAIL2 = YES

J_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO J_Intro

NO 0

required

IF J_FRAIL3 = NO

J_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO J Intro

required

IF J_FRAIL4 = YES

J_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

J_Intro: The next questions are about the meals [you eat/he eats/she eats] each day.

required

IF PTCPT = CM, HDM OR NON

J1. In total, how many different meals do you usually eat each day? Please include meals you eat at home or away from home.

ENTER MEALS PER DAY 0

NOT REGULAR, EAT WHEN HUNGRY 99

DON’T KNOW d

REFUSED r

required

IF J1 = 0

J1_Meals. ENTER NUMBER OF MEALS PER DAY

| | MEALS PER DAY (0-99)

DON’T KNOW d

REFUSED r

HARD CHECK: IF J1_Meals = 0; I want to be sure I recorded your answer correctly. Did you say [fill J1_Meals] meals per day? INTERVIEWER: ANSWER CANNOT BE 0

HARD CHECK: IF J1_Meals GT 7; I want to be sure I recorded your answer correctly. Did you say [fill J1_Meals] meals per day? INTERVIEWER: ANSWER CANNOT EXCEED 7 MEALS PER DAY

required

IF PTCPT = CM, HDM OR NON

J2. When at home, [do you/does he/does she] usually prepare [your/his/her] own meals, help someone else cook, or don’t cook at all?

PREPARE OWN MEALS 1

HELP SOMEONE ELSE COOK 2

DON’T COOK 3

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

J3. Can [you/he/she] prepare hot meals for [yourself/himself/herself] if [you need/he needs/she needs] to?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

J4. [Are you/Is he/Is she] currently on any special diet for health, medication, religious, or cultural reasons?

YES 1

NO 0 SKIP TO J7

DON’T KNOW d SKIP TO J7

REFUSED r SKIP TO J7

required

IF J4 = 1

J5. What kind of special diet [are you/is he/is she] on?

DIABETIC 1

LOW SODIUM/SALT 2

LOW CHOLESTEROL 3

LOW CALORIE 4

LOW SUGAR 5

LOW FAT 6

LOW FIBER 7

HIGH FIBER 8

GROUND OR PUREED 9

VEGETARIAN 10

NON-DAIRY/ LACTOSE-FREE 11

KOSHER 12

HALAL 13

OTHER (PLEASE SPECIFY) 99

(STRING (30))

DON’T KNOW d

REFUSED r

J7. How is [your/his/her] appetite? Would [you/he/she] say it is usually excellent, good, fair, or poor?

EXCELLENT 1

GOOD 2

FAIR 3

POOR 4

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

J8. [Do you/Does he/Does she] eat alone most of the time?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required IF FRAIL SKIP HAS NOT BEEN INVOKED

IF PTCPT = CM, HDM OR NON

J9. [Do you/Does he/Does she] have a refrigerator that works?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required IF FRAIL SKIP HAS NOT BEEN INVOKED

IF PTCPT = CM, HDM OR NON

J10. [Do you/Does he/Does she] have a freezer that works?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required IF FRAIL SKIP HAS NOT BEEN INVOKED

IF PTCPT = CM, HDM OR NON

J11. [Do you/Does he/Does she] have a stove or toaster oven that works?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required IF FRAIL SKIP HAS NOT BEEN INVOKED

IF PTCPT = CM, HDM OR NON

J12. [Do you/Does he/Does she] have a microwave that works?

YES 1

NO 0

DON’T KNOW d

REFUSED r

K. FOOD SECURITY

PROGRAMMER BOX K1

CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER QUESTIONS IN SECTION K.

K_Intro: These next questions are about the food eaten in [your/his/her] household in the last 30 days and whether [you were/he was/she was] able to afford the food [you need/he needs/she needs].

required

IF PTCPT = CM, HDM OR NON

K1. I'm going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was OFTEN, SOMETIMES, or NEVER true for [your/his/her] household in the last 30 days.

The first statement is, “The food that [I/he/she] bought just didn’t last, and [I/he/she] didn't have money to get more.” Was that often, sometimes, or never true for [your/his/her] household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

K2. “[I/he/she] couldn't afford to eat balanced meals.” Was that often, sometimes, or never true for [your/his/her] household in the last 30 days?

OFTEN TRUE 1

SOMETIMES TRUE 2

NEVER TRUE 3

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

K3. In the last 30 days, did anyone in [your/his/her] household ever cut the size of [your/his/her] meals or skip meals because there wasn't enough money for food?

YES 1

NO 0 SKIP TO K5

DON’T KNOW d SKIP TO K5

REFUSED r SKIP TO K5

required

IF K3 = 1

K4. In the last 30 days, how many days did this happen?

| | | DAYS (1-99)

DON’T KNOW d

REFUSED r

HARD CHECK: IF K4 = 0; In a previous question you answered that in the last 30 days, someone in your household cut the size of [your/his/her] meals because there wasn’t enough money for food. However, in K4 you answered that this happened on 0 days. Have I entered something incorrectly? INTERVIEWER: ANSWER MUST BE GREATER THAN 0 DAYS.

HARD CHECK: IF K4 GT 30; I want to be sure I recorded your answer correctly. Did you say [fill K4] days? INTERVIEWER: ANSWER CANNOT EXCEED 30 DAYS.

required

IF PTCPT = CM, HDM OR NON

K5. In the last 30 days, did [you/he/she] ever eat less than [you/he/she] felt [you/he/she] should because there wasn't enough money to buy food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

K6. In the last 30 days, [were you/was he/was she] ever hungry but didn't eat because [you/he/she] couldn't afford enough food?

YES 1

NO 0

DON’T KNOW d

REFUSED r

L. HEALTH STATUS

PROGRAMMER BOX L1

CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER QUESTIONS IN SECTION L.

L_Intro: The next questions are about [your/his/her] health.

required

IF PTCPT = CM, HDM OR NON

L1. In general, would [you/he/she] say [your/his/her] health is excellent, very good, good, fair, or poor?

EXCELLENT 1

VERY GOOD 2

GOOD 3

FAIR 4

POOR 5

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

L7. Has a doctor ever told [you/he/she] that [you have/he has/she has]:

	YES	NO	DON’T KNOW	REFUSED
a. Arthritis or rheumatism?	1	0	d	r
b. High blood pressure or hypertension?	1	0	d	r
c. A heart attack, coronary heart disease, angina, congestive heart failure, or any other heart problems?	1	0	d	r
d. High cholesterol?	1	0	d	r
e. Diabetes or high blood sugar?	1	0	d	r
f. Allergies, asthma, emphysema, chronic bronchitis, or other breathing and lung problems?	1	0	d	r
g. Cancer or malignant tumor, excluding minor skin cancer?	1	0	d	r
h. A hearing impairment?	1	0	d	r
i. Stroke?	1	0	d	r
j. Anemia?	1	0	d	r
k. Osteoporosis?	1	0	d	r
l. Kidney disease?	1	0	d	r
m. Eye or vision conditions such as glaucoma, cataracts, macular degeneration or other medical conditions of the eye?	1	0	d	r
[INTERVIEWER NOTE: THIS DOES NOT INCLUDE JUST WEARING GLASSES OR CONTACTS.]
n. Dementia or Alzheimer’s Disease	1	0	d	r

required

IF PTCPT = CM, HDM OR NON

L8. [Do you/Does he/Does she] currently have trouble eating due to the condition of your teeth, gums or another dental issue?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

L9. In the past 3 months, how many times have you fallen?

_| | | TIMES (0-30)

DON’T KNOW d

REFUSED r

required

IF L9 GE 1

L10. How many of these falls caused an injury? By an injury we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor.

__| | | NUMBER OF FALLS CAUSING AN INJURY (0-30)

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

L11. How fearful are you of falling? Would you say…

Not at all, 1

A little, 2

Somewhat, or 3

A lot? 4

DON’T KNOW d

REFUSED r

O. MEDICAL INSURANCE

PROGRAMMER BOX O1

CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON). SKIP SECTION O IF FRAIL SKIP IS INVOKED.

required

IF FRAIL SKIP HAS NOT BEEN INVOKED

O_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO O_Intro

required

IF O_FRAIL1 = 1

O_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO O_FRAIL4

required

IF O_FRAIL2 = YES

O_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO O_Intro

NO 0

required

IF O_FRAIL3 = NO

O_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX P1

required

IF O_FRAIL4 = YES

O_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

O_Intro: The next questions are about health insurance and health care coverage.

PROGRAMMER NOTE: IF STATE IS CALIFORNIA, FILL STATE NAME FOR MEDICAID WITH MEDIC-CAL; IF MASSACHUSETTS, FILL WITH MASS-HEALTH; IF OREGON, FILL WITH OREGON HEALTH PLAN; IF TENNESSEE, FILL WITH TENNCARE; IF ARIZONA, FILL WITH AHCCCS/ACCESS; IF MAINE, FILL WITH MAINECARE.

required

IF PTCPT = CM, HDM OR NON

O1. What kind of health insurance plan or health care coverage [do you/does he/does she] have right now? If [you have/he has/she has] more than one kind of health insurance, tell me all plans that [you have/he has/she has]. Please exclude private plans that only provide extra cash while hospitalized.

CAPI INSTRUCTION: DO NOT ALLOW MORE THAN ONE ANSWER WHEN 10 (NO COVERAGE OF ANY TYPE) IS CODED.

MEDICARE 1

MEDI-GAP 2

OTHER PRIVATE HEALTH INSURANCE 3

MEDICAID ({DISPLAY STATE PLAN NAME}). 4

MILITARY HEALTH CARE (TRICARE/VA/CHAMP-VA) 5

INDIAN HEALTH SERVICE 6

STATE-SPONSORED HEALTH PLAN ({DISPLAY STATE PLAN NAME}) 7

OTHER GOVERNMENT PROGRAM 8

NO COVERAGE OF ANY TYPE 10 SKIP TO O3

DON’T KNOW d SKIP TO O3

REFUSED r SKIP TO O3

O2: Do you have insurance to cover…

	YES	NO	DON’T KNOW	REFUSED
a. dental care?	1	0	d	r
b. vision care?	1	0	d	r
c. prescription drugs?	1	0	d	r
d. long term care or nursing home care?	1	0	d	r

P. MOBILITY

required

ALL

P_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO P_Intro

required

IF P_FRAIL1 = 1

P_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO P_FRAIL4

required

IF P_FRAIL2 = YES

P_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO P_Intro

NO 0

required

IF P_FRAIL3 = NO

P_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX P1

required

IF P_FRAIL4 = YES

P_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

PROGRAMMER BOX P1

CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER QUESTIONS IN SECTION P.

P_Intro: The next set of questions are about [your/his/her] physical and mental health.

required

IF PTCPT = CM, HDM OR NON

P1. (ASK IF NOT APPARENT) Is [respondent/he/she] . . .

Able to walk, 1 SKIP TO P5

Bed bound, 2 SKIP TO P6

Chair bound or in a wheelchair? 3 SKIP TO P6

required

IF P1 = 1 AND FRAIL SKIP HAS NOT BEEN INVOKED

P5. [Do you/Does he/Does she] have serious difficulty walking or climbing stairs?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

P6. Because of a physical, mental, or emotional condition, [do you/does he/does she] have serious difficulty concentrating, remembering, or making decisions?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON AND FRAIL SKIP HAS NOT BEEN INVOKED

P7. The next questions ask about difficulties [you/he/she] may have doing certain activities. [Do you/Does he/Does she] have difficulty . . .

	YES	NO	NOT APPLICABLE	DON’T KNOW	REFUSED
a. shopping for groceries or personal items, such as toilet items or medicine?	1	0	99	d	r
b. getting to a store to buy groceries or personal items?	1	0	99	d	r
e. using the telephone?	1	0	99	d	r
f. doing light housework?	1	0	99	d	r
h. using public transportation or riding in a private automobile?	1	0	99	d	r
i. taking medications?	1	0	99	d	r
j. managing money or balancing a checkbook?	1	0	99	d	r
k. taking a bath or shower?	1	0	99	d	r
l. dressing?	1	0	99	d	r
[ASK ONLY IF P1=1] m. getting in or out of a bed or chair?	1	0	99	d	r
n. eating?	1	0	99	d	r
o. using the toilet?	1	0	99	d	r

R. HEIGHT AND WEIGHT

PROGRAMMER BOX R1

CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER QUESTIONS IN SECTION R.

R_Intro: The next questions are about [your/his/her] height and weight.

required

IF PTCPT = CM, HDM OR NON

R1. How tall [are you/is he/is she] without shoes?

| | FEET (0-99)

| | | INCHES (0-99)

DON’T KNOW d

REFUSED r

HARD CHECK: IF FEET LT 4; I want to be sure I recorded your answer correctly. Did you say [fill R1] feet? INTERVIEWER: ANSWER CANNOT BE LESS THAN 4 FEET.

HARD CHECK: IF FEET GT 7; I want to be sure I recorded your answer correctly. Did you say [fill R1] feet? INTERVIEWER: ANSWER CANNOT EXCEED 7 FEET.

HARD CHECK: IF INCHES GT 11; I want to be sure I recorded your answer correctly. Did you say [fill R1] inches? INTERVIEWER: ANSWER CANNOT EXCEED 11 INCHES.

required

IF PTCPT = CM, HDM OR NON

R2. How much [do you/does he/does she] weigh without clothes or shoes?

| | | | POUNDS (0-999)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF POUNDS GT 300; I want to be sure I recorded your answer correctly. Did you say [fill R2] pounds?

HARD CHECK: IF POUNDS LT 50 I want to be sure I recorded your answer correctly. Did you say [fill R2] pounds? INTERVIEWER: ANSWER CANNOT BE LESS THAN 50 POUNDS.

HARD CHECK: IF POUNDS GT 500; I want to be sure I recorded your answer correctly. Did you say [fillR2] pounds? INTERVIEWER: ANSWER CANNOT EXCEED 500 POUNDS.

required

IF PTCPT = CM, HDM OR NON

R3. Without trying to, [have you/has he/has she] gained or lost ten pounds in the last six months?

YES 1

NO 0

DON’T KNOW d

REFUSED r

S. PRESCRIPTIONS

PROGRAMMER BOX S1

CATI: ALL RESPONDENTS (PTCPT = CM, HDM, OR NON) ANSWER QUESTIONS IN SECTION S. SKIP SECTION S IF FRAIL SKIP IS INVOKED.

required

IF FRAIL SKIP HAS NOT BEEN INVOKED

S_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO S_Intro

required

IF S_FRAIL1 = 1

S_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO S_FRAIL4

required

IF S_FRAIL2 = YES

S_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO S_Intro

NO 0

required

IF S_FRAIL3 = NO

S_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX U1

required

IF S_FRAIL4 = YES

S_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

S_Intro: The next set of questions are about prescription medications, excluding vitamins and minerals.

required

IF PTCPT = CM, HDM OR NON

S1. How many different prescription medications [do you/does he/does she] take or use every day?

| | | NUMBER (0-99)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF S1 GT 10; I want to be sure I recorded your answer correctly. Did you say [fill S1] prescriptions?

HARD CHECK: IF S1 GT 30; I want to be sure I recorded your answer correctly. Did you say [fill S1] prescriptions? INTERVIEWER: ANSWER CANNOT EXCEED 30.

required

IF S1 = d, r

S2. Would you say [you take/he takes/she takes]. . .

Zero, 1

One or two, 2

three to five, 3

six to nine, 4

or 10 or more prescription medications every day? 5

DON’T KNOW d

REFUSED r

U. DEPRESSION, LONELINESS, SOCIAL ISOLATION

PROGRAMMER BOX U1

CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER QUESTION IN SECTION U.

U_Intro: The next set of questions are about [your/his/her] social life.

required

IF PTCPT = CM, HDM OR NON

U1. Overall, how satisfied [are you/is he/is she] with the opportunities [you have/he has/she has] to spend time with other people? Would [you/he/she] say [you are/he is/she is] . . .

Very satisfied, 1

Somewhat satisfied, 2

Not too satisfied, or 3

Not at all satisfied? 4

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

U2. [Do you/Does he/Does she] belong to any religious or social groups, book clubs, special interest groups, or other organizations?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

U3. How often [do you/does he/does she] feel that you lack companionship?

Hardly ever, 1

Some of the time, or 2

Often? 3

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

U4. How often [do you/does he/does she] feel left out?

Hardly ever, 1

Some of the time, or 2

Often? 3

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

U5. How often [do you/does he/does she] feel isolated from others?

Hardly ever, 1

Some of the time, or 2

Often? 3

DON’T KNOW d

REFUSED r

For the next three questions, please think about the past two weeks.

required

IF PTCPT = CM, HDM OR NON AND FRAIL SKIP HAS NOT BEEN INVOKED

U6. [During the past two weeks], how often [have you/has he/has she] been bothered by any of the following problems? Little interest or pleasure in doing things. Would [you/he/she] say . . .

Not at all, 1

Several days, 2

More than half of the days, or 3

Nearly every day? 4

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON AND FRAIL SKIP HAS NOT BEEN INVOKED

U7. [During the past two weeks], how often [have you/has he/has she] felt down, depressed or hopeless. Would [you/he/she] say . . .

Not at all, 1

Several days, 2

More than half of the days, or 3

Nearly every day? 4

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON AND FRAIL SKIP HAS NOT BEEN INVOKED

U8. [During the past two weeks], how often was it difficult to get in touch with others when [you/he/she] wanted to. Would [you/he/she] say . . .

Almost always, 1

Most of the time, 2

About half the time, 3

Occasionally, or 4

Not at all? 5

DON’T KNOW d

REFUSED r

V. DEMOGRAPHICS

PROGRAMMER BOX V1

CATI: ALL RESPONDENTS (PTCPT = CM, HDM, OR NON) ANSWER QUESTIONS IN SECTION V.

V_Intro: The following questions are about [your/his/her] background and education.

required

IF PTCPT = CM, HDM OR NON

V1. INTERVIEWER: ASK IF NOT OBVIOUS: What is [your/his/her] gender?

MALE 1

FEMALE 2

required

IF PTCPT = CM, HDM OR NON

V2. In what year [were you/was he/was she] born?

| | | | | YEAR (Range 1800-2012)

DON’T KNOW d

REFUSED r

HARD CHECK: IF V2 LT 1900; I want to be sure I recorded your answer correctly. Did you say you were born in [fill V2]? INTERVIEWER: YEAR OF BIRTH MUST BE GREATER THAN 1900.

HARD CHECK: IF V2 GT 1965; I want to be sure I recorded your answer correctly. Did you say you were born in [fill V2]? INTERVIEWER: YEAR OF BIRTH MUST BE PRIOR TO 1965.

required

IF PTCPT = CM, HDM OR NON

V3. Are you a veteran of the U.S. Armed Forces?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

V4. What is the highest grade or level of school [you have/he has/she has] completed or the highest degree [you have/he has/she has] received?

NEVER ATTENDED/KINDERGARTEN ONLY 0

1ST GRADE 1

2ND GRADE 2

3RD GRADE 3

4TH GRADE 4

5TH GRADE 5

6TH GRADE 6

7TH GRADE 7

8TH GRADE 8

9TH GRADE 9

10TH GRADE 10

11TH GRADE 11

12TH GRADE, NO DIPLOMA 12

HIGH SCHOOL GRADUATE 13

GED OR EQUIVALENT 14

SOME COLLEGE, NO DEGREE 15

ASSOCIATE DEGREE; OCCUPATIONAL, TECHNICAL, OR VOCATIONAL PROGRAM 16

ASSOCIATE DEGREE: ACADEMIC PROGRAM 17

BACHELOR’S DEGREE(EXAMPLE: BA, AB, BS, BBA) 18

MASTER’S DEGREE (EXAMPLE: MA, MS, MEng, MEd, MBA) 19

PROFESSIONAL SCHOOL DEGREE (EXAMPLE: MD, DDS, DVM, JD) 20

DOCTORAL DEGREE (EXAMPLE: PhD, EdD) 21

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

V5. [Are you/Is he/Is she] of Hispanic or Latino origin?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

V6. I am going to read a list of five race categories. Please choose one or more races that [you consider yourself/he considers himself/she considers herself] to be. American Indian or Alaska Native; Asian; Black or African American; Native Hawaiian or other Pacific Islander or White.

AMERICAN INDIAN OR ALASKA NATIVE 1

ASIAN 2

AFRICAN AMERICAN OR BLACK 3

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 4

WHITE 5

OTHER (PLEASE SPECIFY) 99

(STRING (30))

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

V7. [Are you/Is he/Is she] now married, widowed, divorced, separated, never married or living with a partner?

MARRIED 1

WIDOWED 2

DIVORCED 3

SEPARATED 4

NEVER MARRIED 5

LIVING WITH A PARTNER 6

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

V8. What is [your/his/her] home zip code?

ZIP

DON’T KNOW d

REFUSED r

HARD CHECK: IF NUMBER OF DIGITS ENTER GT 5; I want to be sure I entered your answer correctly. Did you say zip code [fill V8]? INTERVIEWER: ZIP CODE MUST HAVE 5 DIGITS.

HARD CHECK: IF NUMBER OF DIGITS ENTER LT 5; I want to be sure I entered your answer correctly. Did you say zip code [fill V8]? INTERVIEWER: ZIP CODE MUST HAVE 5 DIGITS.

required

IF PTCPT = CM, HDM OR NON

V9. Including [yourself/himself/herself], how many people live in [your/his/her] household? By “live in [your/his/her] household” I mean all people who usually stay in the household. Please do include people who are away, such as students, people on vacation, or traveling for business, or people who are in the hospital for a brief stay. Do not include people in institutions, serving in the military, or people who are temporary visitors.

| | | NUMBER OF PEOPLE IN HOUSEHOLD (0 – 99)

DON’T KNOW d

REFUSED r

SOFT CHECK: IF V9 GT 10; I want to be sure I recorded your answer correctly. Did you say [fill V9] people live in your household?

HARD CHECK: IF V9 = 0; I want to be sure I recorded your answer correctly. Did you say [fill V9] people live in your household? INTERVIEWER: NUMBER OF PEOPLE IN HOUSEHOLD CANNOT BE 0.

HARD CHECK: IF V9 GT 20; I want to be sure I recorded your answer correctly. Did you say [fill V9] people live in your household? INTERVIEWER: NUMBER OF PEOPLE IN HOUSEHOLD CANNOT EXCEED 20.

required

IF V9 = 1, GO TO V11

IF V9 NE 1

V10. Who are all the people who live in [your/his/her] household?

HUSBAND/WIFE/PARTNER 1

CHILD OR CHILDREN 2

BROTHER(S) OR SISTER(S) 3

GRANDCHILD OR GRANDCHILDREN 4

SON-IN-LAW OR DAUGHTER-IN-LAW 5

OTHER RELATIVE (PLEASE SPECIFY) 6

(STRING (30))

NON RELATIVE OR FRIEND 7

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

V11. Now I’d like to ask you some questions about income and financial assistance [you/he/she] [IF V9 NE 1 fill (or others) in [your/his/her] household] may be receiving. During the past 30 days, did [you/he/she] (or anyone in [your/his/her] household) receive money from any of the following . . .

	YES	NO	DON’T KNOW	REFUSED
a. Full- or part-time work?	1	0	d	r
b. Social Security?	1	0	d	r
c. Unemployment Compensation?	1	0	d	r
d. Disability (SSDI) or Worker’s Compensation?	1	0	d	r
e. Supplemental Security Income or SSI?	1	0	d	r
f. Pension or retirement fund?	1	0	d	r
g. General Assistance?	1	0	d	r
h. Money from relatives? or	1	0	d	r
i. Other sources? (PLEASE SPECIFY)	1	0	d	r
(STRING (30))

required

IF PTCPT = CM, HDM OR NON

V12. What was ([your/his/her] household’s) total income last month before taxes? Please include all types of income received by all household members last month, including all earnings, pensions, Social Security, cash welfare benefits and SSI. Do not include the value of SNAP benefits or food stamps, Medicaid, or public housing.

$ | | | , | | | | (0-99,999)

NO INCOME 0

DON’T KNOW d

REFUSED r

SOFT CHECK: IF V12 GT 5,000; I want to be sure I recorded your answer correctly. Did you say [your/his/her] household’s) total income last month before taxes was $[fill V12]?

HARD CHECK: IF V12 GT 15,000; I want to be sure I recorded your answer correctly. Did you say [your/his/her] household’s) total income last month before taxes was $[fill V12]? INTERVIEWER: ANSWER CANNOT EXCEED $15,000.

required

IF V12 = d, r

V13. Please stop me when I reach [your/his/her] household’s total income for last month. Was It . . .

Less than $900, 1

$901 - $1,200, 2

$1,201 - $1,500, 3

$1,501 - $1,800, 4

$1,801 - $2,100, 5

$2,101 - $2,400, 6

$2,401 or more? 7

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

V14. What was ([your /his/her] household’s) total income before taxes last year from all sources, including Social Security and other government programs but excluding the value of SNAP benefits or food stamps, Medicaid, or public housing. Your best estimate is fine.

$ | | | | , | | | | (0-999,999)

NO INCOME 0

DON’T KNOW d

REFUSED r

SOFT CHECK: IF V14 LT 1,000; I want to be sure I recorded your answer correctly. Did you say [your/his/her] household’s) total income last year before taxes was$[fill V14]?

SOFT CHECK: IF V14 GT 100,000; I want to be sure I recorded your answer correctly. Did you say [your/his/her] household’s) total income last year before taxes was $[fill V14]?

HARD CHECK: IF V14 GT 250,000; I want to be sure I recorded your answer correctly. Did you say [your/his/her] household’s) total income last year before taxes was $[fill V14]? INTERVIEWER: ANSWER CANNOT EXCEED $250,000.

required

IF V14 = d, r

V15. Please stop me when I reach [your/his/her] household’s total income for last year. Was It . . .

Less than $10,000, 1

$10,001 - $14,000, 2

$14,001 - $18,000, 3

$18,001 - $22,000, 4

$22,001 - $26,000, 5

$26,001 - $30,000, 6

$30,001 or more? 7

DON’T KNOW d

REFUSED r

W. ADEQUACY OF MONEY

PROGRAMMER BOX W1

CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER QUESTIONS IN SECTION W. IF FRAIL SKIP HAS BEEN INVOKED, SKIP SECTION W.

required

IF FRAIL SKIP HAS NOT BEEN INVOKED

W_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO W_Intro

required

IF W_FRAIL1 = 1

W_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO W_FRAIL4

required

IF W_FRAIL2 = YES

W_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO W_Intro

NO 0

required

IF W_FRAIL3 = NO

W_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX Y1

required

IF W_FRAIL4 = YES

W_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

required

IF PTCPT = CM, HDM OR NON

W1. How well does the amount of money [you have/he has/she has] take care of [your/his/her] needs? Would you say very well, fairly well, or poorly?

VERY WELL 1

FAIRLY WELL 2

POORLY 3

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

W2. In the past month, did [you/he/she] ever have to choose between buying food and buying medications?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

W3. In the past month, did [you/he/she] ever have to choose between buying food and paying [your/his/her] utility bills?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

W4. In the past month, did [you/he/she] ever have to choose between buying food and paying [your/his/her] rent?

YES 1

NO 0

DON’T KNOW d

REFUSED r

X. PROGRAM PARTICIPATION

PROGRAMMER BOX X1

CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER QUESTIONS IN SECTION X. IF FRAIL SKIP HAS BEEN INVOKED, SKIP SECTION X.

required

IF FRAIL SKIP HAS NOT BEEN INVOKED

X_FRAIL1. INTERVIEWER: Did the respondent have trouble answering questions in the previous section of the survey due to fatigue or a physical or cognitive barrier?

YES 1

NO 0 SKIP TO X_Intro

required

IF X_FRAIL1 = 1

X_FRAIL2. Would you like to take a short break now?

YES 1

NO 0 SKIP TO X_FRAIL4

required

IF X_FRAIL2 = YES

X_FRAIL3. INTERVIEWER: Does the respondent appear less fatigued after the break?

YES 1 SKIP TO X_Intro

NO 0

required

IF X_FRAIL3 = NO

X_FRAIL4. INTERVIEWER: Is there a proxy available who can complete the remainder of the survey on behalf of the respondent now?

YES 1

NO 0 INVOKE FRAIL SKIP AND SKIP TO PROGRAMMER BOX Y1

required

IF X_FRAIL4 = YES

X_FRAIL5. INTERVIEWER: CONTINUE THE INTERVIEW WITH THE RESPONDENT’S PROXY.

ENTER 1 TO CONTINUE 1

X_Intro: The next questions are about [your/his/her] participation in different types of programs.

required

IF PTCPT = CM, HDM OR NON

X1. Are [you/he/she] or anyone else in [your/his/her] household currently receiving SNAP benefits or food stamps?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

X2. During the past 30 days, did [you/he/she] or anyone else in [your/his/her] household get food from a food pantry or food bank?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

X3. Excluding meals you got from NAME OF PROGRAM SITE, during the past 30 days, did [you/he/she] receive any meals provided by churches or meals at a soup kitchen or emergency kitchen?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = CM, HDM OR NON

X4. During the past 30 days, did [you/he/she] receive assistance to pay for heating and cooling your home, such as LIHEAP?

INTERVIEWER: LIHEAP IS PRONOUNCED [li-heep] AND STANDS FOR LOW INCOME HOME ENERGY ASSISTANCE PROGRAM.

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = NON AND MATCH = CM

X5. [Are you/Is he/Is she] aware that the Administration on Aging’s Nutrition Program provides meals and related nutrition services for individuals aged 60 years and older in group settings such as senior centers, faith-based settings, and schools? [You/He/She] may know of this as a congregate nutrition program.

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = NON AND MATCH = HDM

X5.1 Are you aware that the Administration on Aging’s Nutrition Program provides meals and related nutrition services for individuals aged 60 years and older who are homebound due to illness, disability, or geographic isolation? You may know of this as a home-delivered nutrition program.

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = NON AND MATCH = CM

X6. [Have you/Has he/Has she] ever received information about going to a congregate nutrition program?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = NON AND MATCH = HDM

X6.1 [Have you/Has he/Has she] ever received information about getting meals from a home-delivered nutrition program?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = NON AND MATCH = CM

X7. What are the reasons that [you do/he does/she does] not participate in a congregate nutrition program?

DON’T KNOW ABOUT THE PROGRAM/DON’T KNOW WHERE MEAL SITES ARE LOCATED 1

DON’T NEED THIS PROGRAM/NOT OLD ENOUGH/TOO HEALTHY 2

TRANSPORTATION PROBLEMS/BARRIERS 3

DO NOT NEED/WANT ASSISTANCE FROM THE GOVERNMENT 4

HEALTH IS TOO POOR/PHYSICAL IMPAIRMENT/MEAL SITE IS NOT ACCESSIBLE BASED ON PHYSICAL HEALTH 5

MEALS OFFERED DO NOT MEET NEEDS/TASTES/ETHNIC VALUES/NOT ENOUGH VARIETY IN MEALS 6

LANGUAGE BARRIER/DO NOT SPEAK ENGLISH WELL 7

MEAL SITE IS NOT IN A SAFE LOCATION/ DON’T FEEL SAFE AT MEAL SITE/DON’T FEEL SAFE LEAVING HOME TO GO TO MEAL SITE 8

HOURS THAT MEALS ARE OFFERED ARE TOO LIMITED 9

WANTED TO PARTICIPATE BUT WAS PLACED ON WAITING LIST 10

COST OF MEAL IS TOO HIGH 11

OTHER (PLEASE SPECIFY) 99

(STRING (30))

DON’T KNOW d

REFUSED r

required

IF PTCPT = NON AND MATCH = HDM

X7.1 What are the reasons that [you do/he does/she does] not participate in a home-delivered nutrition program?

DON’T KNOW ABOUT THE PROGRAM 1

DON’T NEED THIS PROGRAM/NOT OLD ENOUGH/TOO HEALTHY 2

DO NOT NEED/WANT ASSISTANCE FROM THE GOVERNMENT 3

MEALS OFFERED DO NOT MEET NEEDS/ TASTES/ETHNIC VALUES/NOT ENOUGH VARIETY IN MEALS 4

LANGUAGE BARRIER/DO NOT SPEAK ENGLISH WELL 5

COST OF MEAL IS TOO HIGH 6

WANTED TO PARTICIPATE BUT WAS PLACED ON WAITING LIST 7

APPLIED BUT WAS NOT ELIGIBLE TO RECEIVE MEALS 8

DO NOT LIKE OTHER PEOPLE COMING INTO HOME 9

OTHER (PLEASE SPECIFY) 99

(STRING (30))

DON’T KNOW d

REFUSED r

required

IF PTCPT = NON AND MATCH = CM

X8. [Do you/Does he/Does she] think [you/he/she] will be interested in going to a congregate nutrition program in the future?

YES 1

NO 0

DON’T KNOW d

REFUSED r

required

IF PTCPT = NON AND MATCH = HDM

X8.1 [Do you/Does he/Does she] think [you/he/she] will be interested in getting meals from a home-delivered nutrition program in the future?

YES 1

NO 0

DON’T KNOW d

REFUSED r

Y. RELEASE OF SOCIAL SECURITY NUMBER

PROGRAMMER BOX Y1

CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER QUESTIONS IN SECTION Y.

required

IF PTCPT = CM, HDM OR NON

Y1. Mathematica Policy Research will combine your survey data with health and other related records to determine if people who receive nutrition services are more or less healthy than similar people who do not. To obtain these records, we need your social security number. We will not release it to anyone, including any government agency, for any other reason. Providing this information is voluntary. There will be no effect on your benefits if you do not provide it.

| | | |-| | |-| | | | | ENTER SOCIAL SECURITY NUMBER

DON’T KNOW/DOES NOT HAVE SOCIAL SECURITY NUMBER d SKIP TO SECTION Z

REFUSED r SKIP TO SECTION Z

INTERVIEWER: IF RESPONDENT CANNOT RECALL FROM MEMORY ASK {HIM/HER} TO GET CARD AT THIS TIME.

IF SOCIAL SECURITY NUMBER IS ENTERED AT Y1, A NEW SCREEN SHOULD APPEAR FOR THE INTERVIEWER TO VERIFY THE NUMBER THAT WAS ENTERED:

INTERVIEWER: READ THE NUMBER BACK TO THE RESPONDENT TO MAKE SURE IT WAS RECORDED CORRECTLY.

IF RESPONDENT REFUSES, DISPLAY THESE INTERVIEWER NOTES:

IF RESPONDENT IS RELUCTANT TO GIVE NUMBER OR IF RESPONDENTS ASK IF THEY MUST GIVE NUMBER: It is extremely useful to have this information to be able to link to health records such as Medicare records. Many years in the future, the information you gave me can be used to see how health habits and diet at one point in your life influence how healthy you are in the future. If you prefer, you can give us only the last four digits of your social security number, and we can use this number to access your records.

IF RESPONDENT CITES PRIVACY CONCERNS: I understand your concern. Mathematica has never had a breach of confidentiality in the more than 40 years we have been conducting research studies. I do not have access to this information after I type it. Once I complete the interview all the information is sent to a secure facility. Only one or two people have access to the file to use it for our health research. If you prefer, you can give us only the last four digits of your social security number, and we can use this number to access your records.

required

IF Y1 = d

Y1_dk. INTERVIEWER: CODE PREVIOUS RESPONSE.

DOES NOT HAVE SOCIAL SECURITY NUMBER 1

DON’T KNOW 2

required

IF Y1 NE d, r

Y2. INTERVIEWER: SELECT CATEGORY FOR REPORTING OF SOCIAL SECURITY NUMBER.

SELF REPORTED FROM MEMORY 1

SELF REPORTED FROM RECORDS 2

Z. RESPONDENT PAYMENT

Confirm1. Thank you very much for your time. You have really helped us with this study. I’d like to make sure the contact information we have on file for you is correct so that we can send you a $25 gift card within the next few weeks. According to our records we have . . .

[FILL NAME, ADDRESS, CITY, STATE, ZIP, PHONE NUMBER]

YES 1

NO 2

FIX THIS NAME/ADDRESS 3

NEW NAME/ADDRESS 4

(STRING (30))

FIRST NAME

(STRING (30))

MIDDLE INITIAL/NAME

(STRING (30))

LAST NAME

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

Z1_PhonNum1. According to our records your phone number is . . .

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

Z2. In about 6 months, we will be contacting you again to see how you are doing. The interview will take no more than 5 minutes to complete. You will get a $10 gift card for participating in that interview. In case we can’t reach you at the phone number we just discussed, is there another number we should try?

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d GO TO THANK YOU

REFUSED r GO TO THANK YOU

Z3. In case we have trouble reaching you in 6 months, please give me the name and telephone number of a relative or friend who would know where you could be reached. Please give me the name of someone not currently living in your household.

(STRING (30))

FIRST NAME

(STRING (30))

MIDDLE INITIAL/NAME

(STRING (30))

LAST NAME

STREET 1

STREET 2

STREET 3

CITY

STATE

ZIP

| | | | - | | | | - | | | | |

(RANGE) (RANGE) (RANGE)

DON’T KNOW d GO TO THANK YOU

REFUSED r GO TO THANK YOU

Z4. How is this person related to you?

HUSBAND/WIFE/PARTNER 1

CHILD 2

BROTHER OR SISTER 3

GRANDCHILD 4

SON-IN-LAW OR DAUGHTER-IN-LAW 5

OTHER RELATIVE 6

NON RELATIVE OR FRIEND 7

DON’T KNOW d

REFUSED r

THANK YOU. Thank you very much for your help with this important study. We look forward to speaking with you again in about 6 months.