phc
[p. 72]

HOME CARE PAGE

Some people are limited in what they can do because of physical or mental condition; that is, the cannot do some of the daily activities that other people do.

1a. 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

b. Who is this?

c. Does anyone else receive or need help or use special equipment in -- ?

The following represents the table that collects info from 1a-c. The series is repeated 4 times

(c) Doesn't do

[] Doesn't do (Mark H box, then 1c)

2a. 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.

b. Who is this?

c. Does anyone else receive or need help in --?

2b.

3a. Because of a disability or health problem does anyone in the family usually stay in bed all or most of the time?

b. Who is this?
Mark box in person's column.

c. Anyone else?

Mark box or ask:
4a. What (other) condition causes -- to (need help in activities in 1 and 2/(or) stay in bed)?

b. Does any other conditions cause -- to (need help in activities in 1 and 2/ (or) stay in bed)?

Mark box or ask:
c. Which of these conditions would you say ins the main condition that causes -- to (need help in activities in 1 and 2/ (or) stay in bed)?

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.

5. When did -- first notice his (main condition in 4)?

[p. 73]

Home Care Page -- Continued

6a. Does anyone in the family have a colostomy, a urinary catheter, or any other device to help control bowel movements or urination?

b. Who is this? Mark "Device" box in person's column.

c. Anyone else

If "Device," ask 6d and e
d. Which does -- have - a colostomy, a catheter, or another type of device?

e. Does -- receive or need help from another person in taking care of his (device in 6d)?

7a. (Besides --) Does anyone (else) in the family have any accidents or any trouble controlling their bowel movements or urinations?

b. Who is this? (Mark "Trouble Controlling" box in person's column.)

c. Anyone else?

8a. Does anyone in the family (this is you, your, -- etc.) now use (any of the following special aids) -
If "Yes, " ask 8b and c

b. Who is this? Mark box in person's column.

c. Anyone else?

9a. Does anyone in the family use -
If "Yes," ask 9b and c

b. Who is this? Mark box in person's column

c. Anyone else?

10a. Does anyone in the family receive help here at home with -
If "Yes," ask 10b and c

b. Who is this? Mark box in person's column

c. Anyone else?

[p. 74]

Home Care Page - Continued

11a. 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?

b. Who received the meals? Mark "Meals" box in person's column.

c. Anyone else?

If "Meals in 11b, ask 11d-e

d. Does -- now regularly receive meals that are prepared outside the home and brought in?

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.

b. Who received the care? Mark "nurse" box in person's column.

c. Anyone else?

[p. 75]

Individual Home Care Page

Complete for each person with H box

2a. 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 else?)

1 [] Related HH members
2 [] Nurse
3 [] Other Health worker -- Specify ____
4 [] Other relatives or friends
8 [] Other - Specify ____

b. Does anyone else help --?

[] Y (Reask 2a and b)
[] N

If "Nurse" in 2a, ask:

3a. 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 --?

c. Does anyone in the family, that is you, your --, etc. pay any part of the cost for the nurse?

d. Does any government agency or program help pay for the nurse?

e. What agency or program helps pay?

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 --?

c. Does anyone in the family, that is you, your --, etc. pay any part of the cost for the (other health worker)?

d. Does any government agency or program help pay for the (other health worker)?

e. What agency or program helps pay?

f. During the past 2 weeks, how many times was -- visited by the (other health worker)?

HC2

5a. Does -- receive or need help from others in using public transportation, such as buses, trains, subways, or planes?

[] 1 Y (6)
[] 2 N
[] 4 Doesn't use (5c)

b. Does -- use public transportation?

c. If -- had to use public transportation, would [he/she] need the help of other persons?

6a. Does -- drive a car?

b. Does -- not drive a car because of a disability or health problem or because of some other reason?

7a. Does -- use the telephone without the help of another person?

b. Would -- be able to use the telephone in an emergency?

8a. During the 2 weeks outlined in red on the calendar, did -- have any visits from a friend, relative or neighbor?

b. How many times during that period was -- visited by 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?)

c. During these 2 weeks, did -- go out to visit a friend, relative or neighbors?

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?)

9. During the past 12 months, did -- go on a vacation?

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?