Form 0920-17HO Att B-8 Baseline Survey_CATI_09 26 17

Att B-8. Baseline Survey – Telephone

Form Approved

OMB No: 0920-xxxx

Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 30 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-xxxx).

Standard demographic preloads:

Variable Name	Variable Type	Variable Label
AGE	Numeric	Age
GENDER	String	Gender
RACETHNICITY	Numeric	Race/ethnicity
EDUC	Numeric	Education
MARITAL	Numeric	Marital Status
EMPLOY	Numeric	Current employment status
INCOME	Numeric	Household income
STATE	String	State
METRO	Numeric	Metropolitan area flag
INTERNET	Numeric	Household internet access
HOUSING	Numeric	Home ownership
HOME_TYPE	Numeric	Building type of panelist’s residence
PHONE_SERVICE	Numeric	Telephone service for the household
HHSIZE	Numeric	Household size (including children)
HH01	Numeric	Number of HH members age 0-1
HH25	Numeric	Number of HH members age 2-5
HH612	Numeric	Number of HH members age 6-12
HH1317	Numeric	Number of HH members age 13-17
HH18OV	Numeric	Number of HH members age 18+

*These variables are populated as a pre-load when the panelists get sampled into the survey

Standard sample preloads

Variable Name	Variable Type	Variable Label
Username	Numeric	Analogous to Member_PIN
P_Batch	Numeric	Batch Number (if only one assignment, then everyone will be 1)
Dialmode	Numeric	CATI Dialmode (predictive, preview, etc)
P_LCS	Numeric	Life cycle stage, 0=released but not touched
LANG	String	Survey language (EN, ES)
Y_FCELLP	String
S_RES	Numeric
Surveylength	Numeric	Estimated length of survey
SurveyId	Numeric	Survey ID# in A4S
Incentwcomma	String	1,000 or 2,000
P_Hold01	Numeric	Prevents dialing cases without phone numbers

PHONE SCRIPTS

[CATI - OUTBOUND]

INTRO

Hello, my name is $I. I'm calling from AmeriSpeak by NORC. May I please speak with [FIRSTNAME]?

[IF RESPONDENT IS AVAILABLE]

Thank you for your continued participation in AmeriSpeak. I am calling to let you know that your next survey is available. The survey takes approximately [SURVEYLENGTH] minutes to complete. If you complete the survey, you will receive [INCENTWCOMMA] AmeriPoints for your time. We will keep all of your answers confidential. Shall we proceed?

Great. As always, for quality assurance purposes, this call may be recorded or monitored.

[CATI-INBOUND]

INTRO

Thank you for calling AmeriSpeak by NORC.  My name is $I.  How are you today?

And are you calling to take your next survey?

I just need to confirm that I'm speaking with [FIRSTNAME] [LASTNAME]. Is that you?

Great. This survey takes approximately [SURVEYLENGTH] minutes to complete over the phone and you will earn [INCENTPOINTS] AmeriPoints for your time.  We will keep all of your answers confidential. 

As always, for quality assurance purposes, this call may be recorded or monitored.

Shall we proceed?

[CATI-CALLBACK]

CBINTRO

Hello, my name is $I. I'm calling from AmeriSpeak by NORC. We previously spoke with [FIRSTNAME] about completing an AmeriSpeak survey. Is [FIRSTNAME] available?

[IF RESPONDENT IS AVAILABLE]

Hello, my name is $I, calling from AmeriSpeak by NORC. We previously spoke with you about completing an AmeriSpeak survey. Are you available now to continue?

As always, for quality assurance purposes, this call may be recorded or monitored.

[DISPLAY THIS AM LANGUAGE IF SurveyAccessEnd-CALLDATE>1 DAY]

[CATI-MISSED OUTBOUND, ANSWERING MACHINE]

AM1

Hello, this message is [FIRSTNAME] [LASTNAME]. I'm calling from AmeriSpeak from NORC to let you know that you have a survey waiting for you. The survey will take approximately [surveylength] minutes and you will receive [INCENTWCOMMA] AmeriPoints for your time. Call us toll-free at 888-326-9424 and enter your PIN number, [MEMBER_PIN], to complete your survey and earn rewards. Thank you.

[DISPLAY THIS AM LANGUAGE IF SurveyAccessEnd-CALLDATE>1 DAY]

[CATI-ANSWERING MACHINE MISSED APPOINTMENT CALLBACK]

AMHARD

Hello, this message is for [FIRSTNAME] and I'm calling from AmeriSpeak from NORC. When we spoke previously, you requested that we call you back <at this time>. I'm sorry that we've missed you. We'll try to contact you again soon but please feel free to return our call any time at 888-326-9424 and enter your PIN number, [MEMBER_PIN], to complete your survey and earn rewards. Thank you.

[DISPLAY THIS AM LANGUAGE IF SurveyAccessEnd-CALLDATE>1 DAY]

[CATI-ANSWERING MACHINE MISSED CALLBACK]

AMSOFT

Hello, this message is for [FIRSTNAME]. I am calling from AmeriSpeak from NORC. We are calling you back to complete your AmeriSpeak survey. Remember, you will earn rewards for completing this survey. I'm sorry that we've missed you. We'll try to contact you again soon but please feel free to return our call any time at 888-326-9424 and enter your PIN number, [MEMBER_PIN], to complete this survey. Thank you.

[DISPLAY THIS AM LANGUAGE IF SurveyAccessEnd-CALLDATE=1 DAY]

[CATI-NEARING END OF FIELD, ANSWERING MACHINE]

AMEND

Hello, this message is for [FIRSTNAME]. I'm calling from AmeriSpeak from NORC to let you know that a survey will be ending tomorrow. We’d love to hear from you so please call us toll-free at 888-326-9424 and enter your PIN number, [MEMBER_PIN], to complete your survey and earn rewards. Thank you.

Please include the following options for all questions:

77 DON’T KNOW

99 REFUSED

Text shown includes programming language, interviewer script and interview instructions.

Text shown in boxes includes researcher notes and should not be included in the programming.

[START OF SURVEY]

CREATE DATA-ONLY VARIABLE: QUAL

1=Qualified Complete

2=Not Qualified

3=In progress

AT START OF SURVEY COMPUTE QUAL=3 “IN PROGRESS”

[DISPLAY – WINTRO_1]

Thank you for agreeing to participate in our new AmeriSpeak survey! To thank you for sharing your opinions, we will give you a reward of [INCENTWCOMMA] AmeriPoints after completing the survey. If you complete all of the Health and Stability Surveys including this survey, each monthly survey, and the final survey you will earn a bonus of [INCENTWCOMMA] AmeriPoints. As always, your answers are confidential.

DISPLAY – FALLS

For purposes of this survey, you will be asked a series of questions about your health with a particular focus on falls.  A fall is being defined as an event that resulted in a person unintentionally coming to rest on the ground, floor, or other lower level.  Please keep this definition in mind as you complete the survey.

Domain	Instrument/Source	Question as written in instrument
Cognitive status	Brief Screen for Cognitive Impairment (BSCI)	Please remember these three words, you will be asked to recall them later: dog, apple, house. Please share the three words shared earlier.

DISPLAY – THREE

Please remember these three words, you will be asked to recall them later: dog, apple, house.

Domain	Instrument/Source	Question as written in instrument
Disability status	HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status https://aspe.hhs.gov/basic-report/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-and-disability-status	Are you deaf or do you have serious difficulty hearing? a. ____ Yes b. ____No

[SP]

D4.

Are you deaf or do you have serious difficulty hearing?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Disability status	HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status https://aspe.hhs.gov/basic-report/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-and-disability-status	Are you blind or do you have serious difficulty seeing, even when wearing glasses? a. ____ Yes b. ____No

[SP]

D5.

Are you blind or do you have serious difficulty seeing, even when wearing glasses?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Disability status	HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status https://aspe.hhs.gov/basic-report/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-and-disability-status	Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (5 years old or older) a. ____Yes b. ____No

[SP]

D6.

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Disability status	HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status https://aspe.hhs.gov/basic-report/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-and-disability-status	Do you have serious difficulty walking or climbing stairs? (5 years old or older) a. ____Yes b. ____No

[SP]

D7.

Do you have serious difficulty walking or climbing stairs?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Disability status	HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status https://aspe.hhs.gov/basic-report/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-and-disability-status	Do you have difficulty dressing or bathing? (5 years old or older) a. ____Yes b. ____ No

[SP]

D8.

Do you have difficulty dressing or bathing?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Disability status	HHS Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status https://aspe.hhs.gov/basic-report/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-and-disability-status	Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping? (15 years old or older) a. ____Yes b. ____ No

[SP]

D9.

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Cognitive status	Brief Screen for Cognitive Impairment (BSCI)	Frequency of help with planning everyday activities such as errands

[SP]

D10.

Do you ever need help with planning trips for errands?

RESPONSE OPTIONS:

1. Never

2. Rarely

3. Sometimes

4. Frequently

5. Always

Domain	Instrument/Source	Question as written in instrument
Cognitive status	Brief Screen for Cognitive Impairment (BSCI)	Frequency of help remembering to take medications

[SP]

D11.

Do you ever need help remembering to take medications?

RESPONSE OPTIONS:

1. Never

2. Rarely

3. Sometimes

4. Frequently

5. Always

6. Not applicable, no medications taken regularly

STEADI Stay Independent Brochure

Domain	Instrument/Source	Question as written in instrument
Falls screener	STEADI Stay Independent Brochure https://www.cdc.gov/steadi/pdf/stay_independent_brochure-a.pdf	Please circle “Yes” or “No” for each statement below. Add up the number of points for each “yes” answer. If you scored 4 points or more, you may be at risk for falling. Discuss this brochure with your doctor.

[GRID; SP]

Q1.

For each of the following statements, please indicate yes or no.

GRID ITEMS:

1. I have fallen in the past year.

2. I use or have been advised to use a cane or walker to get around safely.

3. Sometimes I feel unsteady when I am walking.

4. I steady myself by holding onto furniture when walking at home.

5. I am worried about falling.

6. I need to push with my hands to stand up from a chair.

7. I have some trouble stepping up onto a curb.

8. I often have to rush to the toilet.

9. I have lost some feeling in my feet.

10. I take medicine that sometimes make me feel light-headed or more tired than usual.

11. I take medicine to help me sleep or improve my mood.

12. I often feel sad or depressed.

RESPONSE OPTIONS:

1. Yes

2. No

CREATE RISK

CALCULATE RISK AS SUM OF:

IF Q1_1=1 THEN ADD 2 POINTS

IF Q1_2=1 THEN ADD 2 POINTS

IF Q1_3=1 THEN ADD 1 POINT

IF Q1_4=1 THEN ADD 1 POINT

IF Q1_5=1 THEN ADD 1 POINT

IF Q1_6=1 THEN ADD 1 POINT

IF Q1_7=1 THEN ADD 1 POINT

IF Q1_8=1 THEN ADD 1 POINT

IF Q1_9=1 THEN ADD 1 POINT

IF Q1_10=1 THEN ADD 1 POINT

IF Q1_11=1 THEN ADD 1 POINT

IF Q1_12=1 THEN ADD 1 POINT

IF Q1=0 FOR ALL GRID ITEMS THEN RISK=0

Domain	Instrument/Source	Question as written in instrument
Cognitive status	Brief Screen for Cognitive Impairment (BSCI)	Please remember these three words, you will be asked to recall them later: dog, apple, house. Please share the three words shared earlier.

[TEXTBOXES]

RETHREE.

Please share the three words shared earlier.

[SMALL TEXTBOX1]

[SMALL TEXTBOX2]

[SMALL TEXTBOX3]

AGS/BGS Recommendations

Domain	Instrument/Source	Question as written in instrument
Falls screener	AGS/BGS Recommendations http://www.americangeriatrics.org/health_care_ professionals/clinical_practice/clinical_guidelines_recommendations/prevention_of_falls_summary_of_recommendations	Older individuals should be asked if they experience difficulties with walking or balance.

[SP]

Q2.

Do you experience any difficulties with walking?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Falls screener	AGS/BGS Recommendations http://www.americangeriatrics.org/health_care_ professionals/clinical_practice/clinical_guidelines_recommendations/prevention_of_falls_summary_of_recommendations	Older individuals should be asked if they experience difficulties with walking or balance.

[SP]

Q3.

Do you experience any difficulties with balance?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Fear of Falling	Short FES-I Gertrudis 2008 article	See below for original question instructions (slight change indicated in attached comment bubble), items, and response options. SCORING: To obtain a total score for the Short FES-I add the scores on all items together, to give a total that will range from 7 (no concern about falling) to 28 (severe concern about falling). If data is missing on more than one item then the Short FES-I question cannot be scored. If data is missing on no more than one of the 7 items, then calculate the sum score of the 6 items (i.e. add together the responses to each item on the scale), divide by 6, and multiply by 7. The new sum score should be rounded up to the nearest whole number.

[SP]

Q4. Now we would like to ask some questions about how concerned you are about the possibility of falling. Please reply thinking about how you usually do the activity. If you currently do not do the activity, please answer to show whether you think you would be concerned about falling <u>if</u> you did the activity.

For each of the following activities, please choose the response which is closest to your own opinion to show how concerned you are that you might fall if you did this activity: Not at all concerned, Somewhat concerned, Fairly concerned, or Very concerned.

1. Getting dressed or undressed

2. Taking a bath or shower

3. Getting in or out of a chair

4. Going up or down stairs

5. Reaching for something above your head or on the ground

6. Walking up or down a slope

7. Going out to a social event (e.g. religious service, family gathering or club meeting)

RESPONSE OPTIONS:

1. NOT AT ALL CONCERNED

2. SOMEWHAT CONCERNED

3. FAIRLY CONCERNED

4. VERY CONCERNED

Domain	Instrument/Source	Question as written in instrument
Falls screener – falls history	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Number of falls in the past 12 months? • No falls • 1 fall • 2 falls • 3 or more

[SP]

Q5.

How many falls have you had in the past 12 months?

RESPONSE OPTIONS:

1. No falls

2. One fall

3. Two falls

4. If 3 or more falls, please specify: [DROP DOWN NUMBER BOX]

CREATE RISK3

CALCULATE RISK3 AS:

IF Q4_1=1 THEN RISK3=0

IF Q4_2=1 THEN RISK3=1

IF Q4_3=1 THEN RISK3=2

IF Q4_4=1 THEN RISK3=3

Domain	Instrument/Source	Question as written in instrument
Falls screener – falls history	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Was an injury sustained in any of the fall/s in the past 12 months? (rate most severe injury due to a fall in the past 12 months) • No • Minor injury, did not require medical attention • Minor injury, did require medical attention • Severe injury (fracture, etc.)

[SHOW IF Q5=2,3,4]

[SP]

Q6.

Were you hurt or injured in any of the falls in the past 12 months?

RESPONSE OPTIONS:

1. No

2. Minor injury, did not require medical attention

3. Minor injury, did require medical attention

4. Severe injury (fracture, etc.)

Domain	Instrument/Source	Question as written in instrument
Falls history	Designed for survey	What is the date of your most recent fall in the past 12 months?

[SHOW IF Q5=2,3,4]

[DROPDOWNS]

Q7.

What is the year, month, and day of your most recent fall in the past 12 months?

[DROPDOWN LIST YEAR – 2016 or 2017 and don’t know] [DROPDOWN LIST 12 MONTHS and don’t know] [DROPDOWN LIST DATE and don’t know]

[SHOW IF Q5=2,3,4]

DISPLAY – RECENT

Let’s discuss the circumstances of your most recent fall in the past 12 months.

Domain	Instrument/Source	Question as written in instrument
Falls screener – falls history (circumstances)	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Describe the circumstances of the most recent fall in the past 12 months. Time of fall: AM / PM

[SHOW IF Q5=2,3,4]

[DROPDOWNS]

Q8.

What was the time of your most recent fall in the past 12 months?

IF NEEDED: If you are unsure of the time please give your best guess.

[DROPDOWN LIST HOUR]:[DROPDOWN LIST MINUTES] [DROPDOWN LIST AM or PM]

Domain	Instrument/Source	Question as written in instrument
Falls screener – falls history (circumstances)	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Location of fall: inside home / outside home / community

[SHOW IF Q5=2,3,4]

[SP]

Q9.

What was the location of your most recent fall in the past 12 months?

RESPONSE OPTIONS:

1. Inside home, please specify: [TEXTBOX]

2. Outside home, please specify: [TEXTBOX]

3. In community, please specify: [TEXTBOX]

Domain	Instrument/Source	Question as written in instrument
Falls screener – falls history (circumstances)	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Direction of fall: left / right / forward / backward / down / can't remember / other

[SHOW IF Q5=2,3,4]

[MP]

Q10.

What was the direction of your most recent fall in the past 12 months?

RESPONSE OPTIONS:

1. Left

2. Right

3. Forward

4. Backward

5. Down

6. Can’t remember

Domain	Instrument/Source	Question as written in instrument
Falls screener – falls history (circumstances)	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Cause of fall: trip / slip / loss of balance / knees gave way / fainted / feeling dizzy or giddy / alcohol or meds / fell out of bed / unknown

[SHOW IF Q5=2,3,4]

[MP]

Q11.

What was the cause of your most recent fall in the past 12 months?

RESPONSE OPTIONS:

1. Trip

2. Slip

3. Loss of balance

4. Knees gave way

5. Fainted

6. Feeling dizzy

7. Feeling giddy

8. Alcohol

9. Medications

10. Fell out of bed

11. Pets

12. Stairs

13. Other, please specify: [TEXTBOX]

77. Unknown

Domain	Instrument/Source	Question as written in instrument
ADLs	Adapted from Katz Index of Independence in Activities of Daily Living (ADL) https://consultgeri.org/try-this/general-assessment/issue-2.pdf	From FROP-Com: Prior to this fall, how much assistance was the individual requiring for personal care activities of daily living (e.g., dressing, grooming, toileting)? (NOTE: If no fall in last 12 months, rate current function) • None (completely independent) • Supervision • Some assistance required • Completely dependent

[GRID; SP]

D2.

Are you able to do the following activities without help?

GRID ITEMS:

1. Bathing or showering

2. Dressing

3. Eating

4. Getting in or out of bed or chairs

5. Walking

6. Using the toilet

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
ADLs	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Has this changed since the most recent fall? (leave blank if no falls in 12 months) • No • Yes (specify)

[SHOW IF Q5=2,3,4]

[GRID; SP]

D3.

Has your need for assistance with bathing or showering, dressing, eating, getting in or out of bed or chairs, walking, or using the toilet, changed since your most recent fall?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
IADLs	Adapted from Lawton & Brody Instrumental Activities of Daily Living (IADL) Scale http://www.healthcare.uiowa.edu/igec/tools/function/lawtonbrody.pdf	From FROP-Com: Prior to this fall, how much assistance was the individual requiring for instrumental activities of daily living (e.g., shopping, housework, laundry)? (NOTE: If no fall in last 12 months, rate current function) • None (completely independent) • Supervision • Some assistance required • Completely dependent

[GRID; SP]

D12.

Are you able to do the following activities without help?

GRID ITEMS:

1. Use the telephone

2. Go shopping

3. Prepare meals

4. Light housework

5. Heavy housework

6. Manage money

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
IADLs	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Has this changed since the most recent fall? (leave blank if no falls in 12 months) • No • Yes (specify)

[SHOW IF Q5=2,3,4]

[GRID; SP]

D13.

Has your need for assistance with using the telephone, going shopping, preparing meals, housework, or managing money changed since your most recent fall?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Depression	Patient Health Questionnaire 2 (PHQ-2) http://www.cqaimh.org/pdf/tool_phq2.pdf	Over the past two weeks, how often have you been bothered by any of the following problems? A. Little interest or pleasure in doing things B. Feeling down, depressed, or hopeless Rate on scale of 0 to 3, where 0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day. PHQ-2 scores can therefore range from 0 to 6.

[SP]

D14.

Over the past 2 weeks, how often have you been bothered by any of the following problems?

GRID ITEMS:

1. Little interest or pleasure in doing things

2. Feeling down, depressed or hopeless

RESPONSE OPTIONS:

1. Not at all

2. Several days

3. More than half the days

4. Every day

Domain	Instrument/Source	Question as written in instrument
Falls screener – medications	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Does the individual take any of the following type of medication? • Sedative • Antidepressant • Anti-epileptics • Central acting analgesic • Digoxin • Diuretics • Type 1a antiarrhythmic • Vestibular suppressant • None apply • 1-2 apply • 3 apply • 4 or more apply

Q12.

[GRID; SP]

Do you take either prescription or over-the-counter medicine to help you sleep?

Do you take over the counter medicine to help with pain?

Do you take prescription medicine to help with pain?

Do you take prescription medicine to help your mood or for sadness?

Do you take prescription medicine to help with anxiety or nervousness?

Do you take prescription medicine to help with seizures?

RESPONSE OPTIONS:

1. Yes

2. No

[DROPDOWNS]

Q13.

How many prescription medications are you currently taking? [DROP DOWN NUMBER BOX]

Domain	Instrument/Source	Question as written in instrument
Falls screener – medical condition	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Does the individual have a chronic medical condition(s) affecting their balance and mobility? • Arthritis • Respiratory condition • Parkinson's disease • Diabetes • Dementia • Peripheral neuropathy • Cardiac condition • Stroke • Other neurological conditions • Lower limb amputation • Osteoporosis • Vestibular disorder • Other dizziness • Back pain • Lower limb joint replacement • None apply • 1-2 apply • 3-4 apply • 5 or more apply Osteoporosis: • Unknown • Does not have

[GRID; SP]

D15.

Do you have any of the following chronic conditions?

GRID ITEMS:

1. Arthritis

2. A respiratory condition

3. Parkinson's disease

4. Diabetes

5. Dementia

6. Peripheral neuropathy

IF NEEDED: OR loss of feeling in your feet

7. A cardiac condition

IF NEEDED: OR heart disease

8. A chronic condition resulting from stroke

9. Other neurological conditions

IF NEEDED: OR a disease of the brain, spinal cord and nerves throughout the body

10. Lower limb amputation

IF NEEDED: OR an operation to remove a leg or foot

11. Osteoporosis

12. Vestibular disorder

IF NEEDED: OR a balance disorder or condition that makes you feel unsteady or dizzy

13. Other dizziness

14. Chronic musculoskeletal pain (e.g., back pain)

15. Lower limb joint replacement

16. Other, please specify: [TEXTBOX]

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Falls screener – sensory loss	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Does the client have an uncorrected sensory deficit(s) that limits their functional ability? Vision: • No • Yes Somato sensory: • No • Yes

[SP]

D16.

Do you have an uncorrected problem with your vision?

RESPONSE OPTIONS:

1. Yes

2. No

[SP]

D17.

Do you have an uncorrected problem with your ability to feel pressure, pain, or warmth?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Falls screener – feet & footwear	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Does the client have foot problems, e.g. corns, bunions, swelling etc.? • No • Yes (specify)

[SP]

D19.

Do you have foot problems, such as corns, bunions, or swelling?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Falls screener – continence	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Does the individual regularly have to go to the toilet in the night (3 or more times)? • No • Yes (If uses a bottle, rate as 0)

[SP]

D21.

Do you often have to go to the bathroom 3 or more times at night?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Falls screener – nutritional status	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Has the individual’s food intake declined in the past three months due to a loss of appetite, digestive problems, chewing or swallowing difficulties? • No • Small change, but intake remains good • Moderate loss of appetite • Severe loss of appetite / poor oral intake

[SP]

D22.

In the past three months are you eating less?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Falls screener – nutritional status	FROP-Com http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Falls-risk-for-older-people-community-setting-09.pdf	Weight loss during the last 3-12 months • Nil • Minimal (<1kg) or unsure • Moderate (1-3kg) • Marked (>3kg)

[SP]

D23.

Have you had weight loss in the last 3 to 12 months?

RESPONSE OPTIONS:

1. None

2. Minimal (<3 pounds)

3. Moderate (3-7 pounds)

4. Severe (>7 pounds)

Domain	Instrument/Source	Question as written in instrument
Falls screener -- nutritional status	Adapted from FROP-Com; NIAA Recommended Questions https://www.niaaa.nih.gov/research/guidelines-and-resources/recommended-alcohol-questions	FROP-Com: Number of alcoholic drinks consumed in the past week • Nil • 1-3 • 4-10 • 11+ During the last 12 months, how often did you usually have any kind of drink containing alcohol? By a drink we mean half an ounce of absolute alcohol (e.g. a 12 ounce can or glass of beer or cooler, a 5 ounce glass of wine, or a drink containing 1 shot of liquor). Choose only one. Every day 5 to 6 times a week 3 to 4 times a week twice a week once a week 2 to 3 times a month once a month 3 to 11 times in the past year 1 or 2 times in the past year

[SP]

D24.

During the last 12 months, how often did you usually have any kind of drink containing alcohol?

NOTE: One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. A 40-ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.

RESPONSE OPTIONS:

1.  Every day
2.  2 to 3 times a week
3.  Once a week
4.  2 to 3 times a month
5.  Once a month
6.  3 or 4 times in the past year

7. I did not drink any alcohol in the past year, but I did drink in the past
8. I never drank any alcohol in my life

Domain	Instrument/Source	Question as written in instrument
Falls screener -- nutritional status	Adapted from FROP-Com; NIAA Recommended Questions https://www.niaaa.nih.gov/research/guidelines-and-resources/recommended-alcohol-questions	During the last 12 months, how many alcoholic drinks did you have on a typical day when you drank alcohol? 25 or more drinks 19 to 24 drinks 16 to 18 drinks 12 to 15 drinks 9 to 11 drinks 7 to 8 drinks 5 to 6 drinks 3 to 4 drinks 2 drinks 1 drink

[SHOW IF D16L=1,2,3,4,5,6,77,98,99]

[SP]

D25.

During the past 12 months, on the days when you drank, about how many drinks did you drink on average?

NOTE: One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. A 40-ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.

RESPONSE OPTIONS:

1. 1

2. 2 to 3

3. 4 to 7

4. 8 to 11

5. 12 to 15

6. 16 or more

Domain	Instrument/Source	Question as written in instrument
Self-rated health status	Behavioral Risk Factor Surveillance System (BRFSS)	Would you say that in general your health is — Excellent, Very good, Good, Fair, or Poor?

[SP]

D26.

Would you say that in general your health is –

RESPONSE OPTIONS:

1. Excellent

2. Very Good

3. Good

4. Fair

5. Poor

Domain	Instrument/Source	Question as written in instrument
Prior exposure to fall prevention programs	Designed for survey (by Sarah Ruiz based on AGEid ACL database and survey for the national evaluation for Aging and Disability Resource Centers.)	Have you taken any classes offered by your doctor or community center that focus on physical activity or falls prevention? 1) Yes 2) No

[SP]

D27.

Have you taken any classes offered by your doctor or community center that focus on physical activity or preventing falls?

RESPONSE OPTIONS:

1. Yes

2. No

Domain	Instrument/Source	Question as written in instrument
Prior exposure to fall prevention programs	Designed for survey (by Sarah Ruiz based on AGEid ACL database and survey for the national evaluation for Aging and Disability Resource Centers.)	What was the name of the class?

[IF D27=1]

[TEXTBOX]

D28.

What was the name of the class?

[MEDIUM TEXTBOX]

Domain	Instrument/Source	Question as written in instrument
Prior exposure to fall prevention programs	Designed for survey (by Sarah Ruiz based on AGEid ACL database and survey for the national evaluation for Aging and Disability Resource Centers.)	When did you take the class? 1) In the last month 2) In the last year 3) More than one year ago

[IF D27=1]

[SP]

D29.

When did you take the class?

RESPONSE OPTIONS:

1. In the last month

2. In the last year

3. More than one year ago

Domain	Instrument/Source	Question as written in instrument
Prior exposure to fall prevention programs	Designed for survey (by Sarah Ruiz based on AGEid ACL database and survey for the national evaluation for Aging and Disability Resource Centers.)	Where was the class held? 1) In my doctor's office 2) A senior center 3) A community center 4) A religious center 5) Other, please specify:

[IF D27=1]

[MP]

D30.

Where was the class held?

RESPONSE OPTIONS:

1. In my doctor’s office

2. A senior center

3. A religious center

4. Other community center

5. Other, please specify: [TEXTBOX]

[TEXTBOXES]

D31.

We will be following up with you monthly to ask you a similar but shorter series of questions about your health with a particular focus on falls over the next year. In the event we are unable to reach you, we would like to speak with someone who can answer on your behalf. Please list the names and contact information of two individuals, either of which you are comfortable with acting on your behalf.

[NAME1]

[ADDRESS1]

[CITY1][STATE1][ZIP1]

[NAME2]

[ADDRESS2]

[CITY2][STATE2][ZIP2]

We will be sending you a [PROJECT NAME] calendar and log to help you keep track of any falls you experience and to help you respond to the upcoming monthly surveys. If for any reason you do not receive the calendar and log, you can email us at support@AmeriSpeak.org or call us toll-free at 888-326-9424.

SCRIPTING NOTES: PUT QFINAL1, QFINAL2, QFINAL3 in the same screen.

[SINGLE CHOICE]

QFINAL1. Thank you for your time today. To help us improve the experience of AmeriSpeak members like yourself, please give us feedback on this survey.

Please rate this survey overall from 1 to 7 where 1 is Poor and 7 is Excellent.

Poor						Excellent
1	2	3	4	5	6	7

[TEXT BOX] [“no” option]

QFINAL3. Do you have any general comments or feedback on this survey you would like to share? If you would like a response from us, please email support@AmeriSpeak.org or call (888) 326-9424.

RE-COMPUTE QUAL=1 “COMPLETE”

SET CO_DATE, CO_TIME, CO_TIMER VALUES HERE

[DISPLAY]

END.

Those are all the questions we have. You have earned a reward of [INCENTWCOMMA] AmeriPoints for completing the survey. If you have any questions at all for us, you can email us at support@AmeriSpeak.org or call us toll-free at 888-326-9424. Let me repeat that again: email us at support@AmeriSpeak.org or call us at 888-326-9424. Thank you for participating in our new AmeriSpeak survey! 

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