[p. 98]
HOME CARE PAGE
Some people are limited in what they can do because of physical or mental condition; that is, they cannot do some of the daily activities that other people do.
1 a. Because of a disability or health problem, does anyone in the family, (that is you, your --, etc.), receive or need help from another person, or use special equipment in -
If "Yes," ask 1b and c
[] N
[] N
[] N
[] N
[] N
[] N
[] N
c. Does anyone else receive or need help or use special equipment in - ?
[MK Note: The following is a table to enter responses in for question 1. There are four rows to enter responses in]
Activity (b)
Doesn't do (c)
If "doesn't do," go to next line.
Does -- use any special equipment in (activity)? (d)
2 [] N
Does -- receive or need the help of another person in (activity)? (e)
2 [] N (Next line)
Does -- need help from another person in (activity) most of the time, some of the time, or once in a while? (f)
2 [] Some (Mark H box)
3 [] Once (Mark H box)
4 [] Never (Mark H box)
8 [] Other - Specify ____ (Mark H box)
2 a. Because of a disability or health problem, does anyone in the family receive or need help from another person in -
If "Yes," ask 2b and c.
[] N
[] N
[] N
[] N
b. Who is this?
c. Does anyone else receive or need help in - ?
1 [] Meals (Mark H box)
2 [] Shopping (Mark H box)
3 [] Chores (Mark H box)
4 [] Handling money (Mark H box)
3 a. Because of disability or health problem does anyone in the family usually stay in bed all or most of the time?
[] N (4)
b. Who is this? Mark box in person's column.
1 [] Stays in bed (H box THEN 3c)
c. Anyone else?
[] N
Mark box or ask:
4 a. What (other) condition causes -- to (need help in activities in 1 and 2/ (or) stay in bed)?
[] No H box (NP)
b. Does any other condition cause -- to (need help in activities in 1 and 2/ (or) stay in bed)?
2 [] N
Mark box or ask:
c. Which of these conditions would you say is the main condition that causes -- to (need help in activities in 1 and 2/ (or) stay in bed)?
[] Only one condition
Main condition ____
HC1
Refer to item C2 to determine if a condition page was completed for the main condition in 4. Enter condition number, or mark box.
[] No condition page
5. When did -- first notice his (main condition in 4)?
2 [] Week before
3 [] Past 2 weeks, DK which
4 [] 2 weeks - 3 months
5 [] Over 3-12 months
6 [] More than 12 months ago
[p. 99]
HOME CARE PAGE - Continued
[MK Note: The following is a table to enter responses in for question 1 on page 98. There are four rows to enter responses in]
Activity (b)
Doesn't do (c)
If "doesn't do," go to next line.
Does -- use any special equipment in (activity)? (d)
2 [] N
Does -- receive or need the help of another person in (activity)? (e)
2 [] N (Next line)
Does -- need help from another person in (activity) most of the time, some of the time, or once in a while? (f)
2 [] Some (Mark H box)
3 [] Once (Mark H box)
4 [] Never (Mark H box)
8 [] Other - Specify ____ (Mark H box)
[MK Note: The following is a response sheet for questions asked on page 98. There are five columns to enter responses in; only one is represented here since they each contain the same information.]
2 [] Shopping (Mark H box)
3 [] Chores (Mark H box)
4 [] Handling money (Mark H box)
____
b.
2 [] N
Mark box or ask:
c.
[] Only one condition
Main condition ____
[] No condition page
2 [] Week before
3 [] Past 2 weeks, DK which
4 [] 2 weeks - 3 months
5 [] Over 3-12 months
6 [] More than 12 months ago
[p. 100]
HOME CARE PAGE - Continued
6 a. Does anyone in the family have a colostomy, a urinary catheter, or any other device to help control bowel movements or urination?
[] N (7)
b. Who is this? Mark "Device" box in person's column.
c. Anyone else?
[] N
If "Device," ask 6d and e
d. Which does -- have - a colostomy, a catheter, or another type of device?
2 [] Catheter
8 [] Other - Specify ____
e. Does -- receive or need help from another person in taking care of his (device in 6d)?
2 [] N
7 a. (Besides --) Does anyone (else) in the family have any accidents or any trouble controlling their bowel movements or urination?
[] N (8)
b. Who is this? Mark "Trouble controlling" box in person's column.
c. Anyone else?
[] N
8 a. Does anyone in the family (that is you, your --, etc.) now use (any of the following special aids)-
If "Yes," ask 8b and c
[] N
[] N
[] N
[] N
[] N
b. Who is this? Mark box in person's column.
2 [] Artificial leg
3 [] Brace - Part of body ____
4 [] Crutches
5 [] Cane or walking stick
6 [] Special shoes
7 [] Wheel chair
8 [] Walker
9 [] Guide dog
10 [] Other - Specify ____
c. Anyone else?
9 a. Does anyone in the family use -
[] N
[] N
[] N
b. Who is this? Mark box in person's column
2 [] Contact lenses
3 [] Hearing aid
c. Anyone else?
10 a. Does anyone in the family receive help here at home with -
[] N
[] N
[] N
b. Who is this? Mark box in person's column
2 [] Physical therapy
3 [] Bandages
8 [] Other - Specify ____
c. Anyone else?
[p. 101]
[MK Note: The following is a response sheet for questions asked on page 100. The response sheet contains five columns to enter responses in; only one is represented here since each column contains the same information.]
d.
2 [] Catheter
8 [] Other - Specify ____
e.
2 [] N
2 [] Artificial leg
3 [] Brace - Part of body ____
4 [] Crutches
5 [] Cane or walking stick
6 [] Special shoes
7 [] Wheel chair
8 [] Walker
9 [] Guide dog
10 [] Other - specify ____
2 [] Contact lenses
3 [] Hearing aid
c. Anyone else?
2 [] Physical therapy
3 [] Bandages
8 [] Other - Specify ____
[p. 102]
HOME CARE PAGE - Continued
11 a. During the past 12 months, (that is since (date) a year ago) has anyone in the family received meals that were prepared outside the home and brought on a fairly regular basis?
[] N (12)
b. Who received the meals? Mark "Meals" box in person's column.
c. Anyone else?
[] N
If "Meals" in 11b, ask 11d-e
d. Does -- now regularly receive meals that are prepared outside the home and brought in?
2 [] N (NP)
e. What agency, organization or program provides these meals for --?
12a. During the past 12 months, has anyone in the family received any care at home from a nurse? Exclude related HH members.
[] N (IHCP)
b. Who received this care? Mark "Nurse" box in person's column.
c. Anyone else?
[] N
[p. 103]
[MK Note: Page 103 contains a response sheet for questions asked on page 102. The response sheet has five columns to enter information in; only one is represented here since each column contains the same information.]
d.
2 [] N (NP)
e.
[p. 104]
INDIVIDUAL HOME CARE PAGE
Complete for each person with H box
2 a. Earlier you said that -- receives or needs the help of another person. Who helps --?
(Is -- helped by anyone who lives here, by any other friends or relatives, a nurse, or any other health care professionals who come into the home, or is -- helped by someone eles?)
2 [] Nurse
3 [] Other health worker - specify ____
4 [] Other relatives or friends
8 [] Other - Specify ____
b. Does anyone else help --?
[] N
If "Nurse" in 2a, ask:
3 a. On the average, how many days per week does the nurse visit --?
b. When the nurse visits, how many hours per day does he or she usually spend helping --?
Hours ____
c. Does anyone in the family, that is you, your --, etc. pay any part of the cost for the nurse?
2 [] N
d. Does any government agency or program help pay for the nurse?
2 [] N (3f)
e. What agency or program helps pay?
2 [] Medicare
3 [] Health insurance
[] Other - Specify ____
f. During the past 2 weeks, how many times was -- visited by the nurse?
If "Other health worker" in 2a, ask:
4 a. On the average, how many days per week does the (other health worker) visit --?
b. When the (other health worker) visits, how many hours per day does he or she usually spend helping --?
Hours ____
c. Does anyone in the family, that is you, your --, etc. pay any part of the cost for the (other health worker)?
2 [] N
d. Does any government agency or program help pay for the (other health worker)?
2 [] N (4f)
e. What agency or program helps pay?
2 [] Medicare
3 [] Health insurance
[] Other - specify ____
f. During the past 2 weeks, how many times was -- visited by the (other health worker)?
5 a. Does -- receive or need help from others in using public transportation, such as buses, trains, subways, or planes?
HC2
2 [] 17+
2 [] N
4 [] Doesn't use (5c)
b. Does -- use public transportation?
2 [] N
c. If -- had to use public transportation, would -- need the help of other persons?
2 [] N
2 [] N
b. Does -- not drive a car because of a disability or health problem or because of some other reason?
2 [] Disability
8 [] Other
7 a. Does -- use the telephone without the help of another person?
2 [] N
b. Would -- be able to use the telephone in an emergency?
2 [] N
8 a. During the 2 weeks outlined in red on the calendar, did -- have any visits from a friend, relative or neighbor?
2 [] N (8c)
b. How many times during that period was -- visited by friends, relatives, or neighbors?
(Was it 3 times or more or less than 3 times?)
(Was it 12 or more times or less than 12 times?)
2 [] 4-12 times
3 [] 13+ times
c. During these 2 weeks, did -- go out to visit a friend, relative or neighbor?
2 [] N (9)
d. How many times during that period did -- go out to visit friends, relatives or neighbors?
(Was it 3 or more times or less than 3 times?
(Was it 12 or more times or less than 12 times?)
2 [] 4-12 times
3 [] 13+ times
9. During the past 12 months, did -- go on a vacation?
2 [] N
10. Because of a disability or health problem, how often must someone be here with --, most of the time, some of the time, once in a while or never?
2 [] Some
3 [] Once
4 [] Never
8 [] Other - Specify ____
[p. 105]
[MK Note: Page 105 contains a response sheet for questions asked on page 104. The response sheet has 3 columns to enter responses in; only one is represented here since each column contains the same information]
2 [] Nurse
3 [] Other health worker - Specify ____
4 [] Other relatives or friends
8 [] Other - Specify ____
b.
[] N
b.
Hours ____
c.
2 [] N
d.
2 [] N (3f)
e.
2 [] Medicare
3 [] Health insurance
[] Other - Specify ____
f.
4a.
b.
Hours ____
c.
2 [] N
d.
2 [] N (4f)
e.
2 [] Medicare
3 [] Health insurance
[] Other - Specify ____
f.
HC2
2 [] 17+
2 [] N
4 [] Doesn't use (5c)
b.
2 [] N
c.
2 [] N
6a.
2 [] N
b.
2 [] Disability
8 [] Other
2 [] N
b.
2 [] N
2 [] N (8c)
b.
2 [] 4-12 times
3 [] 13+ times
c.
2 [] N (9)
d.
2 [] 4-12 times
3 [] 13+ times
2 [] N
2 [] Some
3 [] Once
4 [] Never
8 [] Other - Specify ____