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[p. 326]

A
Begin interview by asking: When we conducted the interview several months ago, we recorded (sample person's) age as (age from label). Is this still correct?

1[] Yes (Go to Section A on page 4)
2[] No (Correct age on label, then go to Section A on page 4)
[p. 328]

Section A -- HOUSING AND LONG-TERM CARE SERVICES

ITEM A1
Status of Sample Person (SP).

1[] Institutionalized (Skip to 6 on page 5)
2[] All others (Go to 1)

These first questions are about the place you live.
1. How long have you been living here?

00[] Less than 1 year
____ Years
number
99[] DK

2a. Is it NECESSARY to use any steps or stairs to get into this house from the outside?

1[] Yes
2[] No
9[] DK

b. Counting basements and step down living areas as separate levels, does this home have more than one floor or level?

1[] Yes (Go to 2c)
2[] No (Skip to 3)
9[] DK (Skip to 3)

c. Does this home have a bathroom, bedroom, and kitchen ALL on the SAME floor or level?

1[] Yes
2[] No
9[] DK

3. Because of a physical impairment or health problem, do you have any difficulty --

a. Entering or leaving your home?
1[] Yes
2[] No
9[] DK


b. Opening or closing any of the doors in your home?
1[] Yes
2[] No
9[] DK


c. Reaching or opening cabinets in your home?
1[] Yes
2[] No
9[] DK


d. Using the bathroom in your home?
1[] Yes
2[] No
9[] DK

4. Some residences have special features to assist persons who have physical impairments or health problems. Whether you use them or not, does your residence have any of these features?

a. Widened doorways or hallways
1[] Yes
2[] No
9[] DK


b. Ramps or street level entrances
1[] Yes
2[] No
9[] DK


c. Railings?
1[] Yes
2[] No
9[] DK


d. Automatic or easy to open doors
1[] Yes
2[] No
9[] DK


e. Accessible parking or drop-off site
1[] Yes
2[] No
9[] DK


f. Bathroom modifications
1[] Yes
2[] No
9[] DK


g. Kitchen modifications
1[] Yes
2[] No
9[] DK


h. Elevator, chair lift, or stair glide
1[] Yes
2[] No
9[] DK


i. Alerting devices
1[] Yes
2[] No
9[] DK


j. Any other special features
1[] Yes
2[] No
9[] DK

If all "Yes" in 4, skip to 6 on page 5; otherwise, ask 5 only for those features NOT marked "Yes" in 4.
5. Which special features do you NEED to get around this home, but do not have?

a. Widened doorways or hallways
1[] Yes
2[] No
9[] DK


b. Ramps or street level entrances
1[] Yes
2[] No
9[] DK


c. Railings
1[] Yes
2[] No
9[] DK


d. Automatic or easy to open doors
1[] Yes
2[] No
9[] DK


e. Accessible parking or drop-off site?
1[] Yes
2[] No
9[] DK


f. Bathroom modifications
1[] Yes
2[] No
9[] DK


g. Kitchen modifications
1[] Yes
2[] No
9[] DK


h. Elevator, chair lift, or stair glide
1[] Yes
2[] No
9[] DK


i. Alerting devices
1[] Yes
2[] No
9[] DK


j. Any other special features
1[] Yes
2[] No
9[] DK

[p. 329]

Section A -- HOUSING AND LONG-TERM CARE SERVICES -- Continued

6. DURING THE PAST 12 MONTHS, were you ever refused housing or rental accommodations because of any impairment or health problem that you have, or did you not look for housing in the past 12 months?

0[] Did not look
1[] Yes, refused housing
2[] No, not refused housing
9[] DK

ASK OR VERIFY:
7a. Is this place a -- (Read all categories)
Mark (X) only one.

01[] Single family house or townhouse that is not part of a retirement community, (Skip to 10 on page 6)
02[] Single family house, townhouse, or apartment that is part of a retirement community, (Skip to 8)
03[] Regular apartment, (Skip to 10 on page 6)
04[] Supervised apartment, (Go to 7b)
05[] Group home, (Go to 7b)
06[] Halfway house, (Go to 7b)
07[] Personal care or board and care home, (Go to 7b)
08[] Developmental center, (Go to 7b)
09[] Some other type of supervised group residence or facility, (Go to 7b)
10[] Assisted living facility, (Go to 7b)
11[] Nursing or convalescent home, (Go to 7b)
12[] Retirement home, (Go to 7b)
13[] Center for Independent Living, or (Go to 7b)
14[] Something else? (Go to 7b)
99[] DK (Go to 7b)

ASK OR VERIFY:
b. Does this place primarily or exclusively serve people who are elderly?

1[] Yes (Skip to Item A2)
2[] No (Go to 7c)
9[] DK (Go to 7c)

ASK OR VERIFY:
c. Does this place primarily or exclusively serve persons with hearing or vision impairments, mental illness, mental retardation, or developmental disabilities?

1[] Yes (Go to 7d)
2[] No (Skip to Item A2)
9[] DK (Skip to Item A2)

ASK OR VERIFY:
d. Which?
Mark (X) all that apply.

1[] Hearing impairments
2[] Vision impairments
3[] Mental retardation/developmental disabilities
9[] DK

ITEM A2
Status of SP.

1[] Institutionalized (Skip to 11 on page 6)
2[] All others (Go to 8)
8. Whether you use them or not, does this place routinely provide services such as meals, help with housework or personal care, transportation, or recreation?

1[] Yes (Go to 9 on page 6)
2[] No (Skip to 10 on page 6)
9[] DK (Skip to 10 on page 6)

[p. 330]

Section A -- HOUSING AND LONG-TERM CARE SERVICES -- Continued

9. Whether you use them or not, does this place routinely provide --

a. Group meals for residents?
1[] Yes
2[] No
9[] DK


b. Housekeeping or maid service?
1[] Yes
2[] No
9[] DK


c. Nursing or medical care?
1[] Yes
2[] No
9[] DK


d. Supervision of residents who give themselves their own medication?
1[] Yes
2[] No
9[] DK


e. Help with bathing, eating, or dressing?
1[] Yes
2[] No
9[] DK


f. Help with walking or getting about?
1[] Yes
2[] No
9[] DK


g. Help with shopping?
1[] Yes
2[] No
9[] DK


h. Planned social activities or trips?
[] 1 Yes
[] 2 No
[] 9 DK


i. Educational or training programs?
1[] Yes
2[] No
9[] DK


j. Help with laundry?
1[] Yes
2[] No
9[] DK


k. Help with money management?
[] 1 Yes
[] 2 No
[] 9 DK


l. Transportation?
1[] Yes
2[] No
9[] DK


m. Protective oversight?
1[] Yes
2[] No
9[] DK

10. Are you planning a move in order to receive any (additional) personal help, assistance or services?

1[] Yes
2[] No
9[] DK

Mark "Yes" if SP is currently living in a nursing home; otherwise ask:
11a. Have you EVER been a resident or patient in a nursing home?

1[] Yes (Go to 11b)
2[] No (Skip to 13 on page 8)
9[] DK (Skip to 13 on page 8)

b. How many DIFFERENT TIMES have you been a resident or patient in a nursing home (including the current time)?

____ Times (Number)
99[] D

c. On what date were you admitted (the FIRST time)?
If date not known, ask: Was it within the past 12 months?

Month ____
Year 19____

0001[] In past 12 months
0002[] Not in past 12 months
9999[] DK

Mark box if "Now in nursing home"; otherwise ask:
d. On what date were you discharged (the LAST time)?
If date not known, ask: Was it within the past 12 months?

0000[] Now in nursing home

Month ____
Year 19____

0001[] In past 12 months
0002[] Not in past 12 months
9999[] DK

e. How long (were you/have you been) in the nursing home (the LAST time/THIS time)?

00[] Less than 1 month
____ Months (Number)
99[] D

Ask if date in 11d is within the past 12 months, including "Now in". If not within the past 12 months, skip to 13 on page 8.

f. How many weeks in the past 12 months (were you/have you been) in a nursing home?

00[] Less than 1 week
____ Weeks (Number)
99[] DK

[p. 331]

Section A -- HOUSING AND LONG-TERM CARE SERVICES -- Continued

HAND CARD A1. Read categories if telephone interview.

(Correct card not found)

12a. Who paid or will pay for your nursing home stays in the past 12 months?
(Anyone else?)
Mark (X) all that apply.

01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 13 on page 8)
99[] DK (Skip to 13 on page 8)

Ask if more than one source in 12a. If only one source in 12a, transcribe the number of the box marked without asking.
b. Who paid or will pay the most for your nursing home stays in the past 12 months?
Record number of the main source.

_ _ Paid most [number]
99[] DK

Ask only if box 01 marked in 12a; otherwise, skip to 13 on page 8.
c. During the past 12 months, about how much did you or your family pay for your nursing home stays? Do not count any money that has been or will be reimbursed by insurance or any other source.

000000[] None
$____.00
999999[] DK

[p. 332-333]

Section A -- HOUSING AND LONG-TERM CARE SERVICES -- Continued

Ask 13 for places A-F before going to 14.
13. Have you EVER lived in --

A (01) A convalescent home?
1[] Yes
2[] No
9[] DK
B (02) A facility or group home for persons with mental illness?
1[] Yes
2[] No
9[] DK
C (03) A board and care home?
1[] Yes
2[] No
9[] DK
D (04) A facility for persons with mental retardation?
1[] Yes
2[] No
9[] DK
E (05) An assisted living facility?
1[] Yes
2[] No
9[] DK
F (06) Any other long-term care facility?
1[] Yes
2[] No
9[] DK

Ask 14a-e for each "Yes" in 13.
If more than one stay, these questions refer to the most recent.

14a. When did you last leave (place)?
If DK, probe: Was it within the past 12 months?

A (01) A convalescent home
0000[] Now in
Month ____
Year 19____

0001[] In past 12 months
0002[] Not in past 12 months
9999[] DK
B (02) A facility or group home for persons with mental illness
0000[] Now in
Month ____
Year 19____

0001[] In past 12 months
0002[] Not in past 12 months
9999[] DK
C (03) A board and care home
0000[] Now in
Month ____
Year 19____

0001[] In past 12 months
0002[] Not in past 12 months
9999[] DK
D (04) A facility for persons with mental retardation
0000[] Now in
Month ____
Year 19____

0001[] In past 12 months
0002[] Not in past 12 months
9999[] DK
E (05) An assisted living facility
0000[] Now in
Month ____
Year 19____

0001[] In past 12 months
0002[] Not in past 12 months
9999[] DK
F (06) Any other long term care facility
0000[] Now in
Month ____
Year 19____

0001[] In past 12 months
0002[] Not in past 12 months
9999[] DK

b. How long did you stay at (place)?

A (01) A convenient home
000[] Less than 1 month
____ number
01[] Months
02[] Years

999[] DK
B (02) A facility or group home for persons with mental illness
000[] Less than 1 month
____ number
01[] Months
02[] Years

999[] DK
C (03) A board and care home
000[] Less than 1 month
____ number
01[] Months
02[] Years

999[] DK
D (04) A facility for persons with mental retardation
000[] Less than 1 month
____ number
01[] Months
02[] Years

999[] DK
E (05) An assisted living facility
000[] Less than 1 month
____ number
01[] Months
02[] Years

999[] DK
F (06) Any other long-term care facility
000[] Less than 1 month
____ number
01[] Months
02[] Years

999[] DK

HAND CARD A1. Read categories if telephone interview.

(Correct card not found)

c. Who paid or will pay for your stay at (place)?
(Anyone else?)
Mark (X) all that apply.

A (01) A convalescent home
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 14a for next "Yes" in 13)
99[] DK (Skip to 14a for next "Yes" in 13)
B (02) A facility or group home for persons with mental illness
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 14a for next "Yes" in 13)
99[] DK (Skip to 14a for next "Yes" in 13)
C (03) A board and care home
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 14a for next "Yes" in 13)
99[] DK (Skip to 14a for next "Yes" in 13)
D (04) A facility for persons with mental retardation
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 14a for next "Yes" in 13)
99[] DK (Skip to 14a for next "Yes" in 13)
E (05) An assisted living facility
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 14a for next "Yes" in 13)
99[] DK (Skip to 14a for next "Yes" in 13)
F (06) Any other long-term care facility
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 14a for next "Yes" in 13)
99[] DK (Skip to 14a for next "Yes" in 13)

Ask if more than one source in 14c. If only one source in 14c, transcribe number of the box marked without asking.
d. Who paid or will pay for most of the cost of your stay at (place)?
Record number of the main source.

A (01) A convalescent home
_ _ Paid most [number]
99[] DK
B (02) A facility or group home for persons with mental illness
_ _ Paid most [number]
99[] DK
C (03) A board and care home
_ _ Paid most [number]
99[] DK
D (04) A facility for persons with mental retardation
_ _ Paid most [number]
99[] DK
E (05) An assisted living facility
_ _ Paid most [number]
99[] DK
F (06) Any other long term care facility
_ _ Paid most [number]
99[] DK

Ask only if box 01 marked in 14c AND any part of the stay was in the past 12 months; otherwise, ask 14a for next "yes" in 13.
e. During the past 12 months, about how much did you or your family pay for your stay at (place)? Do not count any money that has been or will be reimbursed by insurance or any other source.

A (01) A convalescent home
000000[] None
$____.00
999999[] DK
B (02) A facility or group home for persons with mental illness
000000[] None
$____.00
999999[] DK
C (03) A board and care home
000000[] None
$____.00
999999[] DK
D (04) A facility for persons with mental retardation
000000[] None
$____.00
999999[] DK
E (05) An assisted living facility
000000[] None
$____.00
999999[] DK
F (06) Any other long term care facility
000000[] None
$____.00
999999[] DK

[p. 334]

Section A -- HOUSING AND LONG-TERM CARE SERVICES -- Continued

HAND CARD A2.

(Correct card not found)

15a. Are you currently on a waiting list for any of these facilities?
Read categories in 15b if telephone interview.

1[] Yes (Go to 15b)
2[] No (Skip to 16)
9[] DK (Skip to 16)

b. For which facilities are you on a waiting list?
Anywhere else?
Read categories if necessary.
Mark (X) all that apply.

1[] Nursing home
2[] Convalescent home
3[] Facility or group home for persons with mental illness
4[] Board and care home
5[] Facility for persons with mental retardation
6[] Assisted living facility
7[] Any other long-term care facility
9[] DK

16. Are you on a waiting list for publicly funded home care or community-based care?

1[] Yes
2[] No
9[] DK

[p. 335]

Section B -- TRANSPORTATION

These next questions are about getting around outside your home.

1. How frequently do you drive a car or other motor vehicle? Would you say -- (Read all categories)
Mark (X) only one.

1[] Everyday or almost everyday, (Skip to 3)
2[] Occasionally, (Skip to 3)
3[] Seldom, or (Skip to 3)
4[] Never? (Go to 2)
9[] DK (Skip to 3)

2. Is this because of an impairment or health problem?

1[] Yes (Skip to 4)
2[] No (Skip to 4)
9[] DK (Skip to 4)

3a. Because of an impairment or health problem, do you have any special equipment on your car or other motor vehicle?

1[] Yes (Go to 3b)
2[] No (Skip to 3c)
3[] Don't have a car (Skip to 3c)
9[] DK (Skip to 3c)

b. What special equipment do you have?
Anything else?
Mark (X) all that apply.

1[] Hand controls
2[] Hand rails, straps, specialized handles, ramps, or lifts
3[] Power controls for windows, mirrors, seat, or steering
4[] Automatic transmission
5[] Air conditioning
6[] A button that opens the door
7[] A large trunk or storage area
8[] Other special features
9[] DK

c. Do you need any (other) special equipment or features on a car or other motor vehicle because of an impairment or health problem?

1[] Yes (Go to 3d)
2[] No (Skip to 4)
9[] DK (Skip to 4)

d. What (other) equipment or features do you need?
Anything else?
Mark (X) all that apply.

1[] Hand controls
2[] Hand rails, straps, specialized handles, ramps, or lifts
3[] Power controls for windows, mirrors, seat, or steering
4[] Automatic transmission
5[] Air conditioning
6[] A button that opens the door
7[] A large trunk or storage area
8[] Other special features
9[] DK

4a. Some communities have special bus, cab or van services for people who have difficulty using the regular public transportation service. When using this special service, people can call ahead and ask to be picked up. Is such a service available in your area?

1[] Yes (Go to 4b)
2[] No (Skip to 6 on page 12)
9[] DK (Skip to 6 on page 12)

b. Is this special service operated by a transit authority, government program or some other private source?
Mark (X) all that apply.

1[] Transit authority
2[] Government program
3[] Other private source
9[] DK

[p. 336]

Section B -- TRANSPORTATION -- Continued

5a. Have you used this special service in the past 12 months?

1[] Yes (Skip to 5c)
2[] No (Go to 5b)
9[] DK (Skip to 6)

b. Why haven't you used this service in the past 12 months?
Anything else?
Mark (X) all that apply.

01[] Don't know how to use (Skip to 6)
02[] Need help from another person (Skip to 6)
03[] Can't use alone (Skip to 6)
04[] Can't use phone (Skip to 6)
05[] Don't have phone (Skip to 6)
06[] Can't read (Skip to 6)
07[] Illness (Skip to 6)
08[] Can't get reservation for service (Skip to 6)
09[] Hours of service inadequate (Skip to 6)
10[] Pickup unreliable/inconvenient (Skip to 6)
11[] Cost (Skip to 6)
12[] Denied use of service (Skip to 6)
13[] Service not needed/wanted (Skip to 6)
14[] Other reason (Skip to 6)
99[] DK (Skip to 6)

c. About how many times have you used this service in the PAST 12 MONTHS?

____ Times in past 12 months [number]
999[] DK

d. About how many times have you used this service in the PAST WEEK?

____ Times in past week [number]
999[] DK

6a. During the past 12 months, have you used local public transportation, such as a regular bus line, rapid transit, subway, or street car?
Mark (X) only one.

0[] No public system available (Skip to 8 on page 13)
1[] Yes (Skip to 6c)
2[] No (Go to 6b)
9[] DK (Go to 6b)

b. Does an impairment or health problem prevent or limit your use of the public transportation service?
Mark (X) only one.

0[] No public system available (Skip to 8 on page 13)
1[] Yes (Skip to 6e)
2[] No (Skip to 7 on page 13)
9[] DK (Skip to 7 on page 13)

c. During the past 12 months, how often did you use the local public transportation service? Would you say -- (Read all categories)
Mark (X) only one.

1[] Everyday or almost everyday,
2[] Occasionally, or
3[] Seldom?
9[] DK

d. Because of an impairment or health problem, during the past 12 months, did you have any difficulty using the local public transportation service?

1[] Yes (Go to 6e)
2[] No (Skip to 7 on page 13)
9[] DK (Skip to 7 on page 13)

e. What types of difficulties (did/would) you have using the public transportation service?
Anything else?
Mark (X) all that apply.

01[] Cognitive/mental problems (remembering where to go/knowing how to avoid trouble)
02[] Fear
03[] Vision
04[] Hearing
05[] Weather
06[] Difficulty walking/can't walk
07[] Wheelchair/scooter/access problems
08[] Problems with other medical/assistive devices
09[] Need help from another person
10[] Hours inadequate
11[] Cost
12[] Other
99[] DK

Ask 6f only if box 01 marked in 6e; otherwise, skip to 7 on page 13.
f. If you were given mobility training about how to use the public transportation service, such as what stop to get off, how to transfer or how to pay the fare, would you use the service?

1[] Yes
2[] No
9[] DK

[p. 337]

Section B -- TRANSPORTATION -- Continued

7. In general, how difficult is it for you to get to and use public transportation? Would you say it is -- (Read all categories)
Mark (X) only one.

0[] No public system available
1[] Very difficult,
2[] Somewhat difficult,
3[] A little difficult, or
4[] Not at all difficult?
9[] DK

8a. Do you have any (other) problems getting around outside your home due to an impairment or health problem?

1[] Yes (Go to 8b)
2[] No (Skip to 9)
9[] DK (Skip to 9)

b. What (other) problem do you have getting around outside your home?
Anything else?
Mark (X) all that apply.

01[] Cognitive or mental problems (remembering where to go, knowing how to avoid trouble)
02[] Fear
03[] Vision
04[] Hearing
05[] Weather
06[] Difficulty walking/can't walk
07[] Wheelchair/scooter/access problems
08[] Problems with other medical/assistive devices
09[] Need help from another person
10[] Other
99[] DK

9. DURING THE PAST 6 MONTHS, have you traveled by car, airplane, bus, train, or boat?

1[] Yes (Go to 10)
2[] No (Skip to Section C on page 15)
9[] DK (Skip to Section C on page 15)

10. IN THE PAST WEEK, about how many times did you --

a. Drive a car?
____ Times
number

00[] None
99[] DK


b. Ride as a passenger in a car?
____ Times
number

00[] None
99[] DK

IN THE PAST WEEK, about how many times did you ride --

c. A regular bus?
____ Times
number

00[] None
99[] DK


d. An accessible bus?
____ Times
number

00[] None
99[] DK


e. A subway?
____ Times
number

00[] None
99[] DK


f. Some other rail system?
____ Times
number

00[] None
99[] DK


g. A ferry boat?
____ Times
number

00[] None
99[] DK

IN THE PAST WEEK, about how many times did you ride in a --

h. Social service agency van?
____ Times
number

00[] None
99[] DK


i. Regular taxi, in which you paid the fare?
____ Times
number

00[] None
99[] DK

[p. 338]

Section B -- TRANSPORTATION -- Continued

11a. IN THE PAST 6 MONTHS, about how many times did you fly in an airplane?

[] 01 One (Skip to 11f)

____ Times (Go to 11b)
number

00[] None (Skip to 12)
99[] DK (Skip to 12)

b. About how many of these times were on a large airplane with 200 or more seats?

____ Times
number

00[] None
99[] DK

c. (About how many of these times were) on a medium sized airplane with 100 to 199 seats?

____ Times
number

00[] None
99[] DK

d. (About how many of these times were) on a small airplane with 19 to 99 seats?

____ Times
number

00[] None
99[] DK

e. (About how many of these times were) on an airplane with fewer than 19 seats?

____ Times (Skip to 12)
number

00[] None (Skip to 12)
99[] DK (Skip to 12)

f. Was that flight in -- (Read all categories)

1[] A large airplane with 200 or more seats,
2[] A medium sized airplane with 100-199 seats,
3[] A small airplane with 19-99 seats, or
4[] An airplane with fewer than 19 seats?
9[] DK

12a. IN THE PAST 6 MONTHS, about how many times did you ride a long-distance bus, such as Greyhound or Trailways?

____ Times
number

00[] None
99[] DK

b. (IN THE PAST 6 MONTHS, about how many times did you) take a trip on a train such as Amtrak?

____ Times
number

00[] None
99[] DK

c. (IN THE PAST 6 MONTHS, about how many times did you) take a trip on a cruise ship or boat?

____ Times
number

00[] None
99[] DK

[p. 339]

Section C -- SOCIAL ACTIVITY

ITEM C1
Status of SP.

1[] Institutionalized (Skip to Section D on page 16)
2[] All others (Go to 1)

These next questions are about various activities you may have participated in.

Ask 1a-g before going to question 2.
1. DURING THE PAST 2 WEEKS, did you --

a. Get together socially with friends or neighbors?
1[] Yes
2[] No
9[] DK


b. Talk with friends or neighbors on the telephone?
1[] Yes
2[] No
9[] DK


c. Get together with ANY relatives not including those living with you?
1[] Yes
2[] No
9[] DK


d. Talk with ANY relatives on the telephone not including those living with you?
1[] Yes
2[] No
9[] DK


e. Go to church, temple, or another place of worship for services or other activities?
[] 1 Yes
[] 2 No
[] 9 DK


f. Go to a show or movie, sports event, club meeting, class, or other group event?
1[] Yes
2[] No
9[] DK


g. Go out to eat at a restaurant?
1[] Yes
2[] No
9[] DK

Ask 2 for each "Yes" in 1.

2. DURING THE PAST 2 WEEKS, how many times did you do (activity)?

a. Get together socially with friends or neighbors?
____ Times
number

99[] DK


b. Talk with friends or neighbors on the telephone?
____ Times
number

99[] DK


c. Get together with ANY relative snot including those living with you?
____ Times
number

99[] DK


d. Talk with ANY relatives on the telephone not including those living with you?
____ Times
number

[] 99 DK


e. Go to church, temple, or another place of worship for services or other activities?
____ Times
number

99[] DK


f. Go to a show or movie, sports event, club meeting, class, or other group event?
____ Times
number

99[] DK


g. Go out to eat at a restaurant?
____ Times
number

99[] DK

3. How many days in the past two weeks did you leave your home for any reason?

[] 14 Every day
[] 00 None

____ Days
number

99[] DK

If proxy respondent, skip to Section D on page 16; otherwise, ask:
4. Regarding your present social activities, do you feel that you are doing about enough, too much, or would you like to be doing more?
Mark (X) only one.

1[] About enough
2[] Too much
3[] Would like to be doing more
9[] DK

[p. 340]

Section D -- WORK HISTORY/EMPLOYMENT

These next questions are about working for pay or profit, and about unpaid volunteer work.

1. Have you EVER worked at a job or business?

1[] Yes (Skip to 16 on page 18)
2[] No (Go to 2)
9[] DK (Go to 2)

2. Does an ongoing health problem, impairment or disability ENTIRELY prevent you from working?

1[] Yes (Go to 3)
2[] No (Skip to 8)
9[] DK (Skip to 8)

3. If enough accommodations were made in transportation and at the work place, would you be able to work?

1[] Yes (Go to 4)
2[] No (Skip to 6)
9[] DK (Skip to 6)

4. IN ORDER TO WORK, would you NEED any of these special features at your work site --

a. Handrails or ramps?
1[] Yes
2[] No
9[] DK


b. Accessible parking or an accessible transportation stop close to the building?
1[] Yes
2[] No
9[] DK


c. An elevator?
1[] Yes
2[] No
9[] DK


d. An elevator designed for persons with special needs?
1[] Yes
2[] No
9[] DK


e. A work station specially adapted for your use?
1[] Yes
2[] No
9[] DK


f. A restroom designed for persons with special needs?
1[] Yes
2[] No
9[] DK


g. An automatic door?
1[] Yes
2[] No
9[] DK

5. Because of an ongoing health problem, impairment, or disability, would you NEED any other special equipment, assistance or work arrangement in order to work?

1[] Yes (Skip to 13b on page 18)
2[] No (Go to 6)
9[] DK (Go to 6)

6. DURING THE PAST 12 MONTHS, were you involved in unpaid volunteer work such as teaching or coaching, office work, or providing care?

1[] Yes (Go to 7)
2[] No (Skip to Section E on page 31)
9[] DK (Skip to Section E on page 31)

7. How many days did you do volunteer work in the past 12 months?

1[] Per week (skip to section E on page 31)
2[] Per month (skip to section E on page 31)
3[] Per year (skip to section E on page 31)
9999[] DK

8. Does an ongoing health problem, impairment or disability limit your ability to work?

1[] Yes (Go to 9)
2[] No (Skip to 14 on page 18)
9[] DK (Go to 9)

9. Have you looked for work in the past two years?

1[] Yes (Skip to 11 on page 17)
2[] No (Go to 10 on page 17)
9[] DK (Skip to 11 on page 17)

[p. 341]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

10. Some people have encountered barriers which discouraged them from looking for work. Did you not look for work because you were concerned that --

a. You would lose your SSI, SSDI, or other sources of income if you went to work?
1[] Yes
2[] No
9[] DK


b. You would lose your housing if you went to work?
1[] Yes
2[] No
9[] DK


c. You would lose your health insurance or Medicaid if you went to work?
1[] Yes
2[] No
9[] DK


d. Your family or friends discouraged you from going to work?
1[] Yes
2[] No
9[] DK


e. Family responsibilities prevented you from going to work?
1[] Yes
2[] No
9[] DK


f. Appropriate information about jobs was not available to you?
1[] Yes
2[] No
9[] DK


g. If you went to work you would be refused a promotion or transfer?
1[] Yes
2[] No
9[] DK


h. If you went to work, you would be refused access to training?
1[] Yes
2[] No
9[] DK


i. Your training was not adequate?
1[] Yes
2[] No
9[] DK


j. You lacked transportation that you were able to get to and use?
1[] Yes
2[] No
9[] DK


k. There were no appropriate jobs available?
1[] Yes
2[] No
9[] DK

11. Do you think you will look for work at any time in the next six months?

1[] Yes
2[] No
9[] DK

12. In order to work, would you NEED any of these special features at your worksite --

a. Handrails or ramps?
1[] Yes
2[] No
9[] DK


b. Accessible parking or an accessible transportation stop close to the building?
1[] Yes
2[] No
9[] DK


c. An elevator?
1[] Yes
2[] No
9[] DK


d. An elevator designed for persons with special needs?
1[] Yes
2[] No
9[] DK


e. A work station specially adapted for your use?
1[] Yes
2[] No
9[] DK


f. A restroom designed for persons with special needs?
1[] Yes
2[] No
9[] DK


g. An automatic door?
1[] Yes
2[] No
9[] DK

[p. 342]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

13a. Because of an ongoing health problem, impairment, or disability, would you NEED any (other) special equipment, assistance or work arrangement in order to do your job?

1[] Yes (Go to13b)
2[] No (Skip to 14)
9[] DK (Skip to 14)

b. In order to work, would you NEED --

(1) A voice synthesizer, telecommunication device for the deaf (T.D.D.), infrared system, or other technical devices?
1[] Yes
2[] No
9[] DK
(2) Braille, enlarged print, special lighting or audio tape?
1[] Yes
2[] No
9[] DK
(3) A reader, oral or sign language interpreter to assist you at work?
1[] Yes
2[] No
9[] DK
(4) A job coach to help train you and supervise your work?
1[] Yes
2[] No
9[] DK
(5) A personal assistant to help with job related activities?
1[] Yes
2[] No
9[] DK
(6) Special pens or pencils, chairs, or other office supplies?
1[] Yes
2[] No
9[] DK
(7) Job redesign, that is, modification of difficult job duties or slowing the pace of tasks?
1[] Yes
2[] No
9[] DK
(8) Reduced work hours to allow for more breaks or rest periods?
1[] Yes
2[] No
9[] DK
(9) Reduced or part-time work hours?
1[] Yes
2[] No
9[] DK
(10) Some other equipment, help, or work arrangements?
1[] Yes
2[] No
9[] DK

14. DURING THE PAST 12 MONTHS, were you involved in unpaid volunteer work such as teaching or coaching, office work, or providing care?

1[] Yes (Go to 15)
2[] No (Skip to Section E on page 31)
9[] DK (Skip to Section E on page 31)

15. How many days did you do volunteer work in the past 12 months?

1[] Per week (skip to section E on page 31)
2[] Per month (skip to section E on page 31)
3[] Per year (skip to section E on page 31)
9999[] DK (skip to section E on page 31)

16. Do you NOW work at a job or business?

1[] Yes (Go to 17)
2[] No (Skip to 37 on page 22)
9[] DK (Skip to 37 on page 22)

17. Are you limited in the kind or amount of work you can do because of an ongoing health problem, impairment, or disability?

1[] Yes (Go to 18)
2[] No (Skip to 27 on page 20)
9[] DK (Skip to 28 on page 20)

18. About how many hours a week do you usually work at your current job?
(Note: If more than one job, include all jobs.)

____ Hours per week [number]
99[] DK

19. Because of an ongoing health problem, impairment or disability have you EVER changed --

a. The KIND of work you do?
1[] Yes
2[] No
9[] DK


b. The AMOUNT of work you do?
1[] Yes
2[] No
9[] DK


c. Your job?
1[] Yes
2[] No
9[] DK

20a. Does an ongoing health problem, impairment or disability now make it difficult for you to change jobs?

1[] Yes (Go to 20b)
2[] No (Skip to 21 on page 19)
9[] DK (Skip to 21 on page 19)

b. Would you say very difficult or somewhat difficult?

1[] Very difficult
2[] Somewhat difficult
9[] DK

[p. 343]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

21a. Does an ongoing health problem, impairment, or disability make it difficult for you to advance at your present job?

1[] Yes (Go to 21b)
2[] No (Skip to 22)
9[] DK (Skip to 22)

b. Would you say very difficult or somewhat difficult?

1[] Very difficult
2[] Somewhat difficult
9[] DK

Ask all of 22a(1)-(7) before going to 22b.

22a. In order to work, would you NEED any of these special features at your worksite, regardless of whether or not you actually have them --

(1) Handrails or ramps?
1[] Yes
2[] No
9[] DK
(2) Accessible parking or an accessible transportation stop close to the build?
1[] Yes
2[] No
9[] DK
(3) An elevator?
1[] Yes
2[] No
9[] DK
(4) An elevator designed for persons with special needs?
1[] Yes
2[] No
9[] DK
(5) A work station specially adapted for your use?
1[] Yes
2[] No
9[] DK
(6) A restroom designed for persons with special needs?
1[] Yes
2[] No
9[] DK
(7) An automatic door?
1[] Yes
2[] No
9[] DK

Ask for each "Yes" in 22a.
b. Do you have (feature) at work?

(1) Handrails or ramps
1[] Yes
2[] No
9[] DK
(2) Accessible parking or an accessible transportation stop close to the build
1[] Yes
2[] No
9[] DK
(3) An elevator
1[] Yes
2[] No
9[] DK
(4) An elevator designed for persons with special needs
1[] Yes
2[] No
9[] DK
(5) A work station specially adapted for your use
[] 1 Yes
[] 2 No
[] 9 DK

(6) A restroom designed for persons with special needs
1[] Yes
2[] No
9[] DK
(7) An automatic door
1[] Yes
2[] No
9[] DK

23a. Because of an ongoing health problem, impairment, or disability, do you NEED any (other) special equipment, assistance or work arrangements in order to do your job?

1[] Yes (Go to 23b)
2[] No (Skip to 24a on page 20)
9[] DK (Skip to 24a on page 20)

Ask all of 23b(1)-(10) before going to 23c.
b. In order to work, do you NEED --

(1) A voice synthesizer, telecommunications device for the deaf (T.D.D.), infrared system, or other technical devices?
1[] Yes
2[] No
9[] DK
(2) Braille, enlarged print, special lighting or audio tape?
1[] Yes
2[] No
9[] DK
(3) A reader, oral or sign language interpreter to assist you at work?
1[] Yes
2[] No
9[] DK
(4) A job coach to help train you and supervise your work?
1[] Yes
2[] No
9[] DK
(5) A personal assistant to help you with job related activities?
1[] Yes
2[] No
9[] DK
(6) Special pens or pencils, chairs, or other office supplies?
1[] Yes
2[] No
9[] DK
(7) Job redesign, that is, modification of difficult job duties or slowing the pace of tasks?
1[] Yes
2[] No
9[] DK
(8) Reduced work hours to allow for more breaks or rest periods?
1[] Yes
2[] No
9[] DK
(9) Reduced or part-time work hours?
1[] Yes
2[] No
9[] DK
(10) Some other equipment, help, or work arrangements?
1[] Yes
2[] No
9[] DK

Ask for each "Yes" in 23b.
c. Do you have ("Yes" response) at work?

(1) A voice synthesizer, telecommunications device for the deaf (T.D.D.), infrared system, or other technical devices
1[] Yes
2[] No
9[] DK
(2) Braille, enlarged print, special lighting or audio tape
1[] Yes
2[] No
9[] DK
(3) A reader, oral or sign language interpreter to assist you at work
1[] Yes
2[] No
9[] DK
(4) A job coach to help train you and supervise your work
1[] Yes
2[] No
9[] DK
(5) A personal assistant to help you with job related activities
1[] Yes
2[] No
9[] DK
(6) Special pens or pencils, chairs, or other office supplies
1[] Yes
2[] No
9[] DK
(7) Job redesign, that is, modification of difficult job duties or slowing the pace of tasks
1[] Yes
2[] No
9[] DK
(8) Reduced work hours to allow for more breaks or rest periods
1[] Yes
2[] No
9[] DK
(9) Reduced or part-time work hours
1[] Yes
2[] No
9[] DK
(10) Some other equipment, help, or work arrangements
1[] Yes
2[] No
9[] DK

[p.344]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

24a. How do you USUALLY get to work?
Read list if necessary.
Mark (X) all that apply.

01[] Car
02[] Work at home
03[] Rapid transit, subway, metro or regular bus
04[] Specialized bus or van service for persons with disabilities
05[] Commuter train
06[] Taxi
07[] Bicycle
08[] Walk
09[] Scooter/wheelchair
10[] Other
99[] DK

Ask 24b only if box 01 marked in 24a; otherwise, skip to 25.
b. Who USUALLY drives this car?
Mark (X) only one.

1[] Self
2[] Other family member
3[] Carpool
4[] Other
9[] DK

25. IN THE PAST FIVE YEARS, have you been fired from a job, laid off, or told to resign because of an ongoing health problem, impairment, or disability?

1[] Yes
2[] No
3[] Not sure
9[] DK

26a. IN THE PAST FIVE YEARS, because of an ongoing health problem, impairment, or disability, have you been --

(1) Refused employment?
1[] Yes
2[] No
9[] DK
(2) Refused a promotion?
1[] Yes
2[] No
9[] DK
(3) Refused a transfer?
1[] Yes
2[] No
9[] DK
(4) Refused access to training programs?
1[] Yes
2[] No
9[] DK

b. DURING THE PAST 12 MONTHS, were you involved in unpaid volunteer work such as teaching or coaching, office work, or providing care?

1[] Yes (Go to 26c)
2[] No (Skip to Section E on page 31)
9[] DK (Skip to Section E on page 31)

c. How many days did you do volunteer work in the past 12 months?

____ (Skip to section E on page 31)
(days)
1[] Per week
2[] Per month
3[] Per year

9999[] DK (Skip to section E on page 31)

27. About how many hours a week do you work at your current job?
Note: If more than one job, include all jobs.

____ Hours per week (Number)
99[] D

28. Because of an ongoing health problem, impairment or disability have you EVER changed --

a. The KIND of work you do?
1[] Yes
2[] No
9[] DK


b. The AMOUNT of work you do?
1[] Yes
2[] No
9[] DK


c. Your job?
1[] Yes
2[] No
9[] DK

29a. Does an ongoing health problem, impairment or disability now make it difficult for you to change jobs?

1[] Yes (Go to 29b)
2[] No (Skip to 30 on page 21)
9[] DK (Skip to 30 on page 21)

b. Would you say very difficult or somewhat difficult?

1[] Very difficult
2[] Somewhat difficult
9[] DK

[p. 345]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

30a. Does an ongoing health problem, impairment, or disability make it difficult for you to advance at your present job?

1[] Yes (Go to 30b)
2[] No (Skip to 31)
9[] DK (Skip to 31)

b. Would you say very difficult or somewhat difficult?

1[] Very difficult
2[] Somewhat difficult
9[] DK

Ask all of 32a(1)-(7) before going to 32b.

31a. In order to work, do you NEED any of these special features at your worksite, regardless of whether or not you actually have them --

(1) Handrails or ramps?
1[] Yes
2[] No
9[] DK
(2) Accessible parking or an accessible transportation stop close to the build?
1[] Yes
2[] No
9[] DK
(3) An elevator?
1[] Yes
2[] No
9[] DK
(4) An elevator designed for persons with special needs?
1[] Yes
2[] No
9[] DK
(5) A work station specially adapted for your use?
[] 1 Yes
[] 2 No
[] 9 DK

(6) A restroom designed for persons with special needs?
1[] Yes
2[] No
9[] DK
(7) An automatic door?
1[] Yes
2[] No
9[] DK

Ask for each "Yes" in 31a.
b. Do you have (feature) at work?

(1) Handrails or ramps
1[] Yes
2[] No
9[] DK
(2) Accessible parking or an accessible transportation stop close to the build
1[] Yes
2[] No
9[] DK
(3) An elevator
1[] Yes
2[] No
9[] DK
(4) An elevator designed for persons with special needs
1[] Yes
2[] No
9[] DK
(5) A work station specially adapted for your use
[] 1 Yes
[] 2 No
[] 9 DK

(6) A restroom designed for persons with special needs
1[] Yes
2[] No
9[] DK
(7) An automatic door
1[] Yes
2[] No
9[] DK

32. Because of an ongoing health problem, impairment, or disability, do you need any (other) special equipment, assistance or work arrangements in order to do your job?

1[] Yes (Go to 33)
2[] No (Skip to 34a on page 22)
9[] DK (Skip to 34a on page 22)

Ask all of 33a(1)-(10) before going to 33b.
33a. In order to work, do you NEED --

(1) A voice synthesizer, telecommunications device for the deaf (T.D.D.), infrared system, or other technical devices?
1[] Yes
2[] No
9[] DK
(2) Braille, enlarged print, special lighting or audio tape?
1[] Yes
2[] No
9[] DK
(3) A reader, oral or sign language interpreter to assist you at work?
1[] Yes
2[] No
9[] DK
(4) A job coach to help train you and supervise your work?
1[] Yes
2[] No
9[] DK
(5) A personal assistant to help you with job related activities?
1[] Yes
2[] No
9[] DK
(6) Special pens or pencils, chairs, or other office supplies?
1[] Yes
2[] No
9[] DK
(7) Job redesign, that is, modification of difficult job duties or slowing the pace of tasks?
1[] Yes
2[] No
9[] DK
(8) Reduced work hours to allow for more breaks or rest periods?
1[] Yes
2[] No
9[] DK
(9) Reduced or part-time work hours?
1[] Yes
2[] No
9[] DK
(10) Some other equipment, help, or work arrangements?
1[] Yes
2[] No
9[] DK

Ask for each "Yes" in 33a.
b. Do you have ("Yes" response) at work?

(1) A voice synthesizer, telecommunications device for the deaf (T.D.D.), infrared system, or other technical devices
1[] Yes
2[] No
9[] DK
(2) Braille, enlarged print, special lighting or audio tape
1[] Yes
2[] No
9[] DK
(3) A reader, oral or sign language interpreter to assist you at work
1[] Yes
2[] No
9[] DK
(4) A job coach to help train you and supervise your work
1[] Yes
2[] No
9[] DK
(5) A personal assistant to help you with job related activities
1[] Yes
2[] No
9[] DK
(6) Special pens or pencils, chairs, or other office supplies
1[] Yes
2[] No
9[] DK
(7) Job redesign, that is, modification of difficult job duties or slowing the pace of tasks
1[] Yes
2[] No
9[] DK
(8) Reduced work hours to allow for more breaks or rest periods
1[] Yes
2[] No
9[] DK
(9) Reduced or part-time work hours
1[] Yes
2[] No
9[] DK
(10) Some other equipment, help, or work arrangements
1[] Yes
2[] No
9[] DK

[p. 346]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

34a. How do you USUALLY get to work?
Read list if necessary.
Mark (X) all that apply.

01[] Car
02[] Work at home
03[] Rapid transit, subway, metro or regular bus
04[] Specialized bus, van, or taxi service for persons with disabilities
05[] Commuter train
06[] Regular taxi
07[] Bicycle
08[] Walk
09[] Scooter/wheelchair
10[] Other
99[] DK

Ask 34b only if box 01 marked in 34a; otherwise, skip to 35.
b. Who USUALLY drives this car?
Mark (X) only one.

1[] Self
2[] Other family member
3[] Carpool
4[] Other
9[] DK

35. IN THE PAST FIVE YEARS, have you been fired from a job, laid off, or told to resign because of an ongoing health problem, impairment, or disability?

1[] Yes
2[] No
3[] Not sure
9[] DK

36a. IN THE PAST FIVE YEARS, because of an ongoing health problem, impairment, or disability, have you been --

(1) Refused employment?
1[] Yes
2[] No
9[] DK
(2) Refused a promotion?
1[] Yes
2[] No
9[] DK
(3) Refused a transfer?
1[] Yes
2[] No
9[] DK
(4) Refused access to training programs?
1[] Yes
2[] No
9[] DK

b. DURING THE PAST 12 MONTHS, were you involved in unpaid volunteer work such as teaching or coaching, office work, or providing care?

1[] Yes (Go to 36c)
2[] No (Skip to Section E on page 31)
9[] DK (Skip to Section E on page 31)

c. How many days did you do volunteer work in the past 12 months?

____ (skip to section E on page 31)
(days)
1[] Per week
2[] Per month
3[] Per year


9999[] DK (skip to section E on page 31)

37. Are you looking for work or on layoff from a job?

1[] Yes (Go to 38)
2[] No (Skip to 54 on page 25)
9[] DK (Skip to 54 on page 25)

38. Are you limited in the kind or amount of work you can do because of an ongoing health problem, impairment, or disability?

1[] Yes (Go to 39)
2[] No (Skip to 48 on page 24)
9[] DK (Skip to 48 on page 24)

39. In what year did you stop working at your last job?

19____ Year
99[] DK

40. Does an ongoing health problem, impairment, or disability make it difficult for you to look for work?

1[] Yes
2[] No
9[] DK

[p. 347]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

41. Some people have encountered barriers which have discouraged them from looking for work. Did you not look for work because you were concerned that --

a. You would lose your SSI, SSDI, or other sources of income if you went to work?
1[] Yes
2[] No
9[] DK


b. You would lose your housing if you went to work?
1[] Yes
2[] No
9[] DK


c. You would lose your health insurance or Medicaid coverage if you went to work?
1[] Yes
2[] No
9[] DK


d. Your family or friends discouraged you from going to work?
1[] Yes
2[] No
9[] DK


e. Family responsibilities prevented you from going to work?
1[] Yes
2[] No
9[] DK


f. Appropriate information about jobs was not available to you?
1[] Yes
2[] No
9[] DK


g. If you went to work you would be refused a promotion or transfer?
1[] Yes
2[] No
9[] DK


h. If you went to work, you would be refused access to training?
1[] Yes
2[] No
9[] DK


i. Your training was not adequate?
1[] Yes
2[] No
9[] DK


j. You lacked transportation that you were able to get to and use?
1[] Yes
2[] No
9[] DK


k. There were no appropriate jobs available?
1[] Yes
2[] No
9[] DK

42. In order to work, would you NEED any of these special features at your worksite --

a. Handrails or ramps?
1[] Yes
2[] No
9[] DK


b. Accessible parking or an accessible transportation stop close to the building?
1[] Yes
2[] No
9[] DK


c. An elevator?
1[] Yes
2[] No
9[] DK


d. An elevator designed for persons with special needs?
1[] Yes
2[] No
9[] DK


e. A work station specially adapted for your use?
1[] Yes
2[] No
9[] DK


f. A restroom designed for persons with special needs?
1[] Yes
2[] No
9[] DK


g. An automatic door?
1[] Yes
2[] No
9[] DK

[p. 348]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

43a. Because of an ongoing health problem, impairment, or disability, would you NEED any (other) special equipment, assistance or work arrangement in order to do your job?

1[] Yes (Go to 43b)
2[] No (Skip to Item D1)
9[] DK (Skip to Item D1)

b. In order to work, would you NEED --

(1) A voice synthesizer, telecommunications device for the deaf (T.D.D.), infrared system, or other technical devices?
1[] Yes
2[] No
9[] DK
(2) Braille, enlarged print, special lighting or audio tape?
1[] Yes
2[] No
9[] DK
(3) A reader, oral or sign language interpreter to assist you at work?
1[] Yes
2[] No
9[] DK
(4) A job coach to help train you and supervise your work?
1[] Yes
2[] No
9[] DK
(5) A personal assistant to help you with job related activities?
1[] Yes
2[] No
9[] DK
(6) Special pens or pencils, chairs, or other office supplies?
1[] Yes
2[] No
9[] DK
(7) Job redesign, that is, modification of difficult job duties or slowing the pace of tasks?
1[] Yes
2[] No
9[] DK
(8) Reduced work hours to allow for more breaks or rest periods?
1[] Yes
2[] No
9[] DK
(9) Reduced or part-time work hours?
1[] Yes
2[] No
9[] DK
(10) Some other equipment, help, or work arrangements?
1[] Yes
2[] No
9[] DK

ITEM D1
Refer to question 39 on page 22. (Year last worked)

1[] 1989 or after (Go to 44)
2[] Before 1989 (Skip to 46)
9[] DK (Go to 44)
44. IN THE PAST FIVE YEARS, have you been fired from a job, laid off, or told to resign because of an ongoing health problem, impairment, or disability?

1[] Yes
2[] No
3[] Not sure
9[] DK

45. IN THE PAST FIVE YEARS, because of an ongoing health problem, impairment, or disability, have you been --

a. Refused employment?
1[] Yes
2[] No
9[] DK


b. Refused a promotion?
1[] Yes
2[] No
9[] DK


c. Refused a transfer?
1[] Yes
2[] No
9[] DK


d. Refused access to training programs?
1[] Yes
2[] No
9[] DK

46. DURING THE PAST 12 MONTHS, were you involved in unpaid volunteer work such as teaching or coaching, office work, or providing care?

1[] Yes (Go to 47)
2[] No (Skip to Section E on page 31)
9[] DK (Skip to Section E on page 31)

47. How many days did you do volunteer work in the past 12 months?

____ (skip to section E on page 31)
(days)
1[] Per week
2[] Per month
3[] Per year


9999[] DK (skip to section E on page 31)

48. In what year did you stop working at your last job?

19____ Year
99[] DK

49. Does an ongoing health problem, impairment, or disability now make it difficult for you to look for work?

1[] Yes
2[] No
9[] DK

[p. 349]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

ITEM D2
Refer to question 48 on page 24. (Year last worked)

1[] 1989 or after (Go to 50)
2[] Before 1989 (Skip to 52)
9[] DK (Go to 50)
50. IN THE PAST FIVE YEARS, have you been fired form a job, laid off, or told to resign because of an ongoing health problem, impairment or disability?

1[] Yes
2[] No
3[] Not sure
9[] DK

51. IN THE PAST FIVE YEARS, because of an ongoing health problem, impairment, or disability, have you been --

a. Refused employment?
1[] Yes
2[] No
9[] DK


b. Refused a promotion?
1[] Yes
2[] No
9[] DK


c. Refused a transfer?
1[] Yes
2[] No
9[] DK


d. Refused access to training programs?
1[] Yes
2[] No
9[] DK

52. DURING THE PAST 12 MONTHS, were you involved in unpaid volunteer work such as teaching or coaching, office work, or providing care?

1[] Yes (Go to 53)
2[] No (Skip to Section E on page 31)
9[] DK (Skip to Section E on page 31)

53. How many days did you do volunteer work in the past 12 months?

____ (skip to section E on page 31)
(days)
1[] Per week
2[] Per month
3[] Per year


9999[] DK (skip to section E on page 31)

54a. Have you retired on disability?

1[] Yes (Go to 54b)
2[] No (Skip to 57)
9[] DK (Skip to 57)

b. How old were you when you retired on disability?

____ Age
99[] DK

c. If enough accommodations were made at the work place or in transportation, would you have been able to continue working?

1[] Yes (Go to 55)
2[] No (Go to 55)
9[] DK (Go to 55)

55. DURING THE PAST 12 MONTHS, were you involved in unpaid volunteer work such as teaching or coaching, office work, or providing care?

1[] Yes (Go to 56)
2[] No (Skip to Section E on page 31)
9[] DK (Skip to Section E on page 31)

56. How many days did you do volunteer work in the past 12 months?

____ (skip to section E on page 31)
(days)
1[] Per week
2[] Per month
3[] Per year


9999[] DK (skip to section E on page 31)

57a. Have you retired form a job or business?

1[] Yes (Go to 57b)
2[] No (Skip to 61 on page 26)
9[] DK (Skip to 61 on page 26)

b. How old were you when you retired the last time?

Age ____
99[] DK

58. Did you retire because of an ongoing health problem, impairment, or disability?

1[] Yes
2[] No
9[] DK

59. DURING THE PAST 12 MONTHS, were you involved in unpaid volunteer work such as teaching or coaching, office work, or providing care?

1[] Yes (Go to 60 on page 26)
2[] No (Skip to Section E on page 31)
9[] DK (Skip to Section E on page 31)

[p. 350]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

60. How many days did you do volunteer work in the past 12 months?

____ (skip to section E on page 31)
(days)
1[] Per week
2[] Per month
3[] Per year


9999[] DK (skip to section E on page 31)

61. Does an ongoing health problem, impairment, or disability ENTIRELY prevent you from working?

1[] Yes (Go to 62)
2[] No (Skip to 73 on page 27)
9[] DK (Skip to 72 on page 27)

62. If enough accommodations were made in transportation and at the work place, would you be able to work?

1[] Yes (Go to 63)
2[] No (Skip to 71 on page 27)
9[] DK (Skip to 71 on page 27)

63. In what year did you last work at a job or business, even for a few days?

19____ Year
99[] DK

64. Does an ongoing health problem impairment or disability now make it difficult for you to look for work?

1[] Yes
2[] No
9[] DK

65. Some people have encountered barriers which have discouraged them from looking for work. Did you not look for work because you were concerned that --

a. You would lose your SSI, SSDI, or other sources of income if you went to work?
1[] Yes
2[] No
9[] DK


b. You would lose your housing if you went to work?
1[] Yes
2[] No
9[] DK


c. You would lose your health insurance or Medicaid coverage if you went to work?
1[] Yes
2[] No
9[] DK


d. Your family or friends discouraged you from going to work?
1[] Yes
2[] No
9[] DK


e. Family responsibilities prevented you from going to work?
1[] Yes
2[] No
9[] DK


f. Appropriate information about jobs was not available to you?
1[] Yes
2[] No
9[] DK


g. If you went to work you would be refused a promotion or transfer?
1[] Yes
2[] No
9[] DK


h. If you went to work, you would be refused access to training?
1[] Yes
2[] No
9[] DK


i. Your training was not adequate?
1[] Yes
2[] No
9[] DK


j. You lacked transportation that you were able to get to and use?
1[] Yes
2[] No
9[] DK


k. There were no appropriate jobs available?
1[] Yes
2[] No
9[] DK

66. Do you think you will look for work at any time in the next six months?

1[] Yes
2[] No
9[] DK

67. In order to work, would you NEED any of these special features at your worksite --

a. Handrails or ramps?
1[] Yes
2[] No
9[] DK


b. Accessible parking or an accessible transportation stop close to the building?
1[] Yes
2[] No
9[] DK


c. An elevator?
1[] Yes
2[] No
9[] DK


d. An elevator designed for persons with special needs?
1[] Yes
2[] No
9[] DK


e. A work station specially adapted for your use?
1[] Yes
2[] No
9[] DK


f. A restroom designed for persons with special needs?
1[] Yes
2[] No
9[] DK


g. An automatic door?
1[] Yes
2[] No
9[] DK

[p. 351]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

68a. Because of an ongoing health problem, impairment, or disability, would you NEED any (other) special equipment, assistance or work arrangement in order to do your job?

1[] Yes (Go to 68b)
2[] No (Skip to Item D3)
9[] DK (Skip to Item D3)

b. In order to work, would you NEED --

(1) A voice synthesizer, telecommunication device for the deaf (T.D.D.), infrared system, or other technical devices?
1[] Yes
2[] No
9[] DK
(2) Braille, enlarged print, special lighting or audio tape?
1[] Yes
2[] No
9[] DK
(3) A reader, oral or sign language interpreter to assist you at work?
1[] Yes
2[] No
9[] DK
(4) A job coach to help train you and supervise your work?
1[] Yes
2[] No
9[] DK
(5) A personal assistant to help with job related activities?
1[] Yes
2[] No
9[] DK
(6) Special pens or pencils, chairs, or other office supplies?
1[] Yes
2[] No
9[] DK
(7) Job redesign, that is, modification of difficult job duties or slowing the pace of tasks?
1[] Yes
2[] No
9[] DK
(8) Reduced work hours to allow for more breaks or rest periods?
1[] Yes
2[] No
9[] DK
(9) Reduced or part-time work hours?
1[] Yes
2[] No
9[] DK
(10) Some other equipment, help, or work arrangements?
1[] Yes
2[] No
9[] DK

ITEM D3
Refer to question 63 on page 26.
(Year last worked)

1[] 1989 or after (Go to 69)
2[] Before 1989 (Skip to 71)
9[] DK (Go to 69)
69. IN THE PAST FIVE YEARS, have you been fired from a job, laid off, or told to resign because of an ongoing health problem, impairment or disability?

1[] Yes
2[] No
3[] Not sure
9[] DK

70. IN THE PAST FIVE YEARS, because of an ongoing health problem, impairment, or disability, have you been --

a. Refused employment?
1[] Yes
2[] No
9[] DK


b. Refused a promotion?
1[] Yes
2[] No
9[] DK


c. Refused a transfer?
1[] Yes
2[] No
9[] DK


d. Refused access to training programs?
1[] Yes
2[] No
9[] DK

71. DURING THE PAST 12 MONTHS, were you involved in unpaid volunteer work such as teaching or coaching, office work, or providing care?

1[] Yes (Go to 72)
2[] No (Skip to Section E on page 31)
9[] DK (Skip to Section E on page 31)

72. How many days did you do volunteer work in the past 12 months?

____ (skip to section E on page 31)
(days)
1[] Per week
2[] Per month
3[] Per year


9999[] DK (skip to section E on page 31)

73. Are you limited in the kind or amount of work you can do because of an ongoing health problem, impairment, or disability?

[] 1 Yes (Go to 74)
[] 2 No (Skip to 85 on page 29)
[] 9 DK (Skip to 85 on page 29)

74. If enough accommodations were made in transportation and at the work place, would you be able to work?

1[] Yes (Go to 75 on page 28)
2[] No (Skip to 83 on page 29)
9[] DK (Skip to 83 on page 29)

[p. 352]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

75. In what year did you last work at a job or business, even for a few days?

Year 19____
99[] DK

76. Does an ongoing health problem now make it difficult for you to look for work?

1[] Yes
2[] No
9[] DK

77. Some people have encountered barriers which have discouraged them from looking for work. Did you not look for work because you were concerned that --

a. You would lose your SSI, SSDI, or other sources of income if you went to work?
1[] Yes
2[] No
9[] DK


b. You would lose your housing if you went to work?
1[] Yes
2[] No
9[] DK


c. You would lose your health insurance or Medicaid if you went to work?
1[] Yes
2[] No
9[] DK


d. Your family or friends discouraged you from going to work?
1[] Yes
2[] No
9[] DK


e. Family responsibilities prevented you from going to work?
1[] Yes
2[] No
9[] DK


f. Appropriate information about jobs was not available to you?
1[] Yes
2[] No
9[] DK


g. If you went to work you would be refused a promotion or transfer?
1[] Yes
2[] No
9[] DK


h. If you went to work, you would be refused access to training?
1[] Yes
2[] No
9[] DK


i. Your training was not adequate?
1[] Yes
2[] No
9[] DK


j. You lacked transportation that you were able to get to and use?
1[] Yes
2[] No
9[] DK


k. There were no appropriate jobs available?
1[] Yes
2[] No
9[] DK

78. Do you think you will look for work any time in the next six months?

1[] Yes
2[] No
9[] DK

79. In order to work, would you NEED any of these special features at your worksite --

a. Handrails or ramps?
1[] Yes
2[] No
9[] DK


b. Accessible parking or an accessible transportation stop close to the building?
1[] Yes
2[] No
9[] DK


c. An elevator?
1[] Yes
2[] No
9[] DK


d. An elevator designed for persons with special needs?
1[] Yes
2[] No
9[] DK


e. A work station specially adapted for your use?
1[] Yes
2[] No
9[] DK


f. A restroom designed for persons with special needs?
1[] Yes
2[] No
9[] DK


g. An automatic door?
1[] Yes
2[] No
9[] DK

[p. 353]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

80a. Because of an ongoing health problem, impairment, or disability, would you NEED any (other) special equipment, assistance or work arrangement in order to do your job?

1[] Yes (Go to 80b)
2[] No (Skip to Item D4)
9[] DK (Skip to Item D4)

b. In order to work, would you NEED --

(1) A voice synthesizer, telecommunication device for the deaf (T.D.D.), infrared system, or other technical devices?
1[] Yes
2[] No
9[] DK
(2) Braille, enlarged print, special lighting or audio tape?
1[] Yes
2[] No
9[] DK
(3) A reader, oral or sign language interpreter to assist you at work?
1[] Yes
2[] No
9[] DK
(4) A job coach to help train you and supervise your work?
1[] Yes
2[] No
9[] DK
(5) A personal assistant to help with job related activities?
1[] Yes
2[] No
9[] DK
(6) Special pens or pencils, chairs, or other office supplies?
1[] Yes
2[] No
9[] DK
(7) Job redesign, that is, modification of difficult job duties or slowing the pace of tasks?
1[] Yes
2[] No
9[] DK
(8) Reduced work hours to allow for more breaks or rest periods?
1[] Yes
2[] No
9[] DK
(9) Reduced or part-time work hours?
1[] Yes
2[] No
9[] DK
(10) Some other equipment, help, or work arrangements?
1[] Yes
2[] No
9[] DK

ITEM D4
Refer to question 75 on page 28. (Year last worked)

1[] 1989 or after (Go to 81)
2[] Before 1989 (Skip to 83)
9[] DK (Go to 81)
81. IN THE PAST FIVE YEARS, have you been fired from a job, laid off, or told to resign because of an ongoing health problem, impairment or disability?

1[] Yes
2[] No
3[] Not sure
9[] DK

82. IN THE PAST FIVE YEARS, because of an ongoing health problem, impairment, or disability, have you been --

a. Refused employment?
1[] Yes
2[] No
9[] DK


b. Refused a promotion?
1[] Yes
2[] No
9[] DK


c. Refused a transfer?
1[] Yes
2[] No
9[] DK


d. Refused access to training programs?
1[] Yes
2[] No
9[] DK

83. DURING THE PAST 12 MONTHS, were you involved in unpaid volunteer work such as teaching or coaching, office work, or providing care?

1[] Yes (Go to 84)
2[] No (Skip to Section E on page 31)
9[] DK (Skip to Section E on page 31)

84. How many days did you do volunteer work in the past 12 months?

____ (skip to section E on page 31)
(days)
1[] Per week
2[] Per month
3[] Per year


9999[] DK (skip to section E on page 31)

85. Because of an ongoing health problem, impairment or disability have you EVER changed --

a. The KIND of work you do?
1[] Yes
2[] No
9[] DK


b. The AMOUNT of work you do?
1[] Yes
2[] No
9[] DK


c. Your job?
1[] Yes
2[] No
9[] DK

[p. 354]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

86. In what year did you last work at a job or business, even for a few days?

19____ Year
99[] DK

ITEM D5
Refer to question 86. (Year last worked)

1[] 1989 or after (Go to 87)
2[] Before 1989 (Skip to 91)
9[] DK (Go to 87)
87. Does an ongoing health problem, impairment or disability now make it difficult for you to look for work?

1[] Yes
2[] No
9[] DK

88. Do you think you will look for work for any time in the next sixth months?

1[] Yes
2[] No
9[] DK

89. IN THE PAST FIVE YEARS, have you been fired from a job, laid off, or told to resign because of an ongoing health problem, impairment or disability?

1[] Yes
2[] No
9[] DK

90. IN THE PAST FIVE YEARS, because of an ongoing health problem, impairment, or disability, have you been --

a. Refused employment?
1[] Yes
2[] No
9[] DK


b. Refused a promotion?
1[] Yes
2[] No
9[] DK


c. Refused a transfer?
1[] Yes
2[] No
9[] DK


d. Refused access to training programs?
1[] Yes
2[] No
9[] DK

91. DURING THE PAST 12 MONTHS, were you involved in unpaid volunteer work, such as teaching or coaching, office work, or providing care?

1[] Yes (Go to 92)
2[] No (Skip to Section E on page 31)
9[] DK (Skip to Section E on page 31)

92. How many days did you do volunteer work in the past 12 months?

____ (skip to section E on page 31)
(days)
1[] Per week
2[] Per month
3[] Per year


9999[] DK (skip to section E on page 31)

[p. 355]

Section E -- VOCATIONAL REHABILITATION

READ: These next questions are about vocational rehabilitation. Vocational rehabilitation services are designed to help people find a job, get back to work, or simply function better in their everyday activities.

Ask all of 1a(1)-(15) before going to 1b.

1a. Have you ever received any of these vocational rehabilitation services?

(1) On-the-job training?
1[] Yes
2[] No
9[] DK
(2) Job placement?
1[] Yes
2[] No
9[] DK
(3) Training in job seeking skills?
1[] Yes
2[] No
9[] DK
(4) Vocational or business school training?
1[] Yes
2[] No
9[] DK
(5) College or university training?
1[] Yes
2[] No
9[] DK
(6) Personal adjustment training?
1[] Yes
2[] No
9[] DK
(7) Physical therapy?
1[] Yes
2[] No
9[] DK
(8) Occupational therapy?
1[] Yes
2[] No
9[] DK
(9) Other medical treatment?
1[] Yes
2[] No
9[] DK
(10) Special aids or technology such as wheelchairs, hearing aids, or computers?
1[] Yes
2[] No
9[] DK
(11) Training in homemaking or in self-care?
1[] Yes
2[] No
9[] DK
(12) Sheltered workshop?
1[] Yes
2[] No
9[] DK
(13) Supported employment?
1[] Yes
2[] No
9[] DK
(14) Driver training?
1[] Yes
2[] No
9[] DK
(15) Any other rehabilitation services?
1[] Yes
2[] No
9[] DK

Ask for each "Yes" in 1a.
b. Was the (service) arranged or provided by a state rehabilitation agency.

(1) On-the-job training?
1[] Yes
2[] No
9[] DK
(2) Job placement?
1[] Yes
2[] No
9[] DK
(3) Training in job seeking skills?
1[] Yes
2[] No
9[] DK
(4) Vocational or business school training?
1[] Yes
2[] No
9[] DK
(5) College or university training?
1[] Yes
2[] No
9[] DK
(6) Personal adjustment training?
1[] Yes
2[] No
9[] DK
(7) Physical therapy?
1[] Yes
2[] No
9[] DK
(8) Occupational therapy?
1[] Yes
2[] No
9[] DK
(9) Other medical treatment?
1[] Yes
2[] No
9[] DK
(10) Special aids or technology such as wheelchairs, hearing aids, or computers?
1[] Yes
2[] No
9[] DK
(11) Training in homemaking or in self-care?
1[] Yes
2[] No
9[] DK
(12) Sheltered workshop?
1[] Yes
2[] No
9[] DK
(13) Supported employment?
1[] Yes
2[] No
9[] DK
(14) Driver training?
1[] Yes
2[] No
9[] DK
(15) Any other rehabilitation services?
1[] Yes
2[] No
9[] DK


ITEM E1
Refer to question 1a. (Received rehabilitation services)

1[] Any "Yes" (Go to 2)
2[] All others (Skip to 4 on page 32)
2. In what year did you LAST receive vocational rehabilitation services?

19____ Year
99[] DK
00[] Now in rehabilitation program

3. Have the vocational rehabilitation services you received --

a. Helped you in getting a job?
1[] Yes
2[] No
9[] DK


b. Helped you in getting a better job?
1[] Yes
2[] No
9[] DK


c. Improved your ability to do your old job?
1[] Yes
2[] No
9[] DK


d. Improved your self-confidence and outlook?
1[] Yes
2[] No
9[] DK


e. Improved your ability to get around?
1[] Yes
2[] No
9[] DK


f. Improved your ability to take care of yourself?
1[] Yes
2[] No
9[] DK


g. Improved your ability to take care of your home?
1[] Yes
2[] No
9[] DK


h. Improved your communication skills?
1[] Yes
2[] No
9[] DK


i. Helped you in some other way?
1[] Yes
2[] No
9[] DK

[p. 356]

Section E -- VOCATIONAL REHABILITATION -- Continued

4. Do you need (additional) vocational rehabilitation services?

1[] Yes
2[] No
9[] DK

ITEM E2
Refer to SP's age.

1[] 70+ (Skip to Section F on page 33)
2[] Under 70 (Go to 5)

HAND CARD A4. Ask all of 5a(1)-(12) before going to 5b.

(Card A4 not found)

5a. Which of the following describe your current job or other activities?

(1) COMPETITIVE EMPLOYMENT; that is working at a regular job or business for at least minimum wage?
1[] Yes
2[] No
9[] DK
(2) Working with a paid JOB COACH?
1[] Yes
2[] No
9[] DK
(3) A WORK CREW, which consists of people with disabilities working as a team to provide services such as janitorial or lawn care in the community?
1[] Yes
2[] No
9[] DK
(4) AN ENCLAVE; that is, working in a group with disabled persons in a regular business?
1[] Yes
2[] No
9[] DK
(5) Any other SUPPORTED EMPLOYMENT not listed above?
1[] Yes
2[] No
9[] DK
(6) A SHELTERED WORKSHOP; that is, working for piece rate wages below minimum wage?
1[] Yes
2[] No
9[] DK
(7) A WORK ACTIVITY CENTER that teaching independent living and work skills?
1[] Yes
2[] No
9[] DK
(8) A DAY ACTIVITY CENTER that teaches independent living, non-vocational or pre-vocational skills, where one does not work or get paid?
1[] Yes
2[] No
9[] DK
(9) ATTENDING SCHOOL?
1[] Yes
2[] No
9[] DK
(10) A FORMAL JOB TRAINING PROGRAM, not yet mentioned?
1[] Yes
2[] No
9[] DK
(11) VOLUNTEER WORK?
1[] Yes
2[] No
9[] DK

Ask if all "No" in 5a (1-11); otherwise, go to Section F on page 33.

(12) No STRUCTURED ACTIVITY?
1[] Yes
2[] No
9[] DK

Ask for each "Yes" in 5a.
b. How many hours a week do you usually spend on (activity)?

(1) COMPETITIVE EMPLOYMENT; that is working at a regular job or business for at least minimum wage
00[] Less than 1 hours
Hours per week ____ (number)
99[] DK
(2) Working with a paid JOB COACH
00[] Less than 1 hours
Hours per week ____ (number)
99[] DK
(3) A WORK CREW, which consists of people with disabilities working as a team to provide services such as janitorial or lawn care in the community
00[] Less than 1 hours
Hours per week ____ (number)
99[] DK
(4) AN ENCLAVE; that is, working in a group with disabled persons in a regular business
00[] Less than 1 hours
Hours per week ____ (number)
99[] DK
(5) Any other SUPPORTED EMPLOYMENT not listed above
00[] Less than 1 hours
Hours per week ____ (number)
99[] DK
(6) A SHELTERED WORKSHOP; that is, working for piece rate wages below minimum wage
00[] Less than 1 hours
Hours per week ____ (number)
99[] DK
(7) A WORK ACTIVITY CENTER that teaching independent living and work skills
00[] Less than 1 hours
Hours per week ____ (number)
99[] DK
(8) A DAY ACTIVITY CENTER that teaches independent living, non-vocational or pre-vocational skills, where one does not work or get paid
00[] Less than 1 hours
Hours per week ____ (number)
99[] DK
(9) ATTENDING SCHOOL
00[] Less than 1 hours
Hours per week ____ (number)
99[] DK
(10) A FORMAL JOB TRAINING PROGRAM, not yet mentioned
00[] Less than 1 hours
Hours per week ____ (number)
99[] DK
(11) VOLUNTEER WORK
00[] Less than 1 hours
Hours per week ____ (number)
99[] DK

[p. 357]

Section F -- ASSISTIVE DEVICES AND TECHNOLOGIES

The next questions are about medical devices and implants.

Ask all of 1a-o before going to 2.
1. During the past 12 months, did you use any of the following medical devices or supplies?

a. A tracheotomy tube?
1[] Yes
2[] No
9[] DK


b. A respirator?
1[] Yes
2[] No
9[] DK


c. An ostomy bag?
1[] Yes
2[] No
9[] DK


d. Catheterization equipment?
1[] Yes
2[] No
9[] DK


e. A glucose monitor?
1[] Yes
2[] No
9[] DK


f. Diabetic equipment or supplies?
1[] Yes
2[] No
9[] DK


g. An inhaler?
1[] Yes
2[] No
9[] DK


h. A nebulizer?
1[] Yes
2[] No
9[] DK


i. A hearing aid?
1[] Yes
2[] No
9[] DK


j. Crutches?
1[] Yes
2[] No
9[] DK


k. A cane?
1[] Yes
2[] No
9[] DK


l. A walker?
1[] Yes
2[] No
9[] DK


m. A wheelchair?
1[] Yes
2[] No
9[] DK


n. A scooter?
1[] Yes
2[] No
9[] DK


o. A feeding tube?
1[] Yes
2[] No
9[] DK

Ask for each "Yes" in 1.
2. Did you use (device) in the past two weeks?

a. A tracheotomy tube
1[] Yes
2[] No
9[] DK


b. A respirator
1[] Yes
2[] No
9[] DK


c. An ostomy bag
1[] Yes
2[] No
9[] DK


d. Catheterization equipment
1[] Yes
2[] No
9[] DK


e. A glucose monitor
1[] Yes
2[] No
9[] DK


f. Diabetic equipment or supplies
1[] Yes
2[] No
9[] DK


g. An inhaler
1[] Yes
2[] No
9[] DK


h. A nebulizer
1[] Yes
2[] No
9[] DK


i. A hearing aid
1[] Yes
2[] No
9[] DK


j. Crutches
1[] Yes
2[] No
9[] DK


k. A cane
1[] Yes
2[] No
9[] DK


l. A walker
1[] Yes
2[] No
9[] DK


m. A wheelchair
1[] Yes
2[] No
9[] DK


n. A scooter
1[] Yes
2[] No
9[] DK


o. A feeding tube
1[] Yes
2[] No
9[] DK

ITEM F1
Refer to question 1 above. (Devices used)

1[] Any "Yes" in 1 (Go to 3)
2[] All other (Skip to 4)
3. During the past 12 months, about how much did you or your family pay for (this device/these devices)? Do not count any money that has been or will be reimbursed by insurance or any other source.

00000[] None
$____.00
99999[] DK

4. Do you now have any of the following implants?

a. Any shunt that drains away fluid?
1[] Yes
2[] No
9[] DK


b. An artificial joint?
1[] Yes
2[] No
9[] DK


c. Implanted lens?
1[] Yes
2[] No
9[] DK


d. Implanted pin, screw, nail, wire, rod, or plate?
1[] Yes
2[] No
9[] DK


e. An artificial heart valve?
1[] Yes
2[] No
9[] DK


f. A pacemaker?
1[] Yes
2[] No
9[] DK


g. Silicone implant?
1[] Yes
2[] No
9[] DK


h. Infusion pump?
1[] Yes
2[] No
9[] DK


i. Implanted catheter?
1[] Yes
2[] No
9[] DK


j. An organ implant?
1[] Yes
2[] No
9[] DK


k. A cochlear implant?
1[] Yes
2[] No
9[] DK

[p. 358]

Section G -- HEALTH INSURANCE

The next questions are about health insurance coverage.

There are several government programs that provide medical care or help pay medical bills.
People covered by Medicare have a card that looks like this.
SHOW MEDICARE CARD.

1a. In (month), were you covered by Medicare?

1[] Yes (Go to 1b)
2[] No (Skip to 2)
9[] DK (Skip to 2)

b. How long have you been covered by Medicare?
Read categories if necessary.
Mark (X) only one.

1[] Less than 6 months
2[] 6 months, but less than 1 year
3[] 1 year, but less than 2 years
4[] 2 years or more
9[] DK

There is a program called MEDICAID that pays for health care for persons in need. In this state, it is also called (state name).
2a. In (month), were you covered by MEDICAID or (state name)?

1[] Yes (Go to 2b)
2[] No (Skip to 3)
9[] DK (Skip to 3)

b. How long have you had MEDICAID or (state name) coverage?
Read categories if necessary.
Mark (X) only one.

1[] Less than 6 months
2[] 6 months, but less than 1 year
3[] 1 year, but less than 2 years
4[] 2 years, but less than 5 years
5[] 5 years or more
6[] On and off for less than 2 years
7[] On and off for 2 years, but less than 5 years
8[] On and off for 5 years or more
9[] DK

3. In (month), were you covered by any OTHER public assistance program (other than Medicaid) that pays for health care? Do NOT include use of public or free clinics if that is your ONLY source of care.

1[] Yes
2[] No
9[] DK

4a. In (month), were you covered by military health care, including armed forces retirement benefits, the VA (Department of Veterans' Affairs), CHAMPUS, or CHAMP-VA?

1[] Yes (Go to 4b)
2[] No (Skip to 5)
9[] DK (Skip to 5)

b. Was this CHAMPUS, or CHAMP-VA?
Read if necessary: CHAMPUS is a program of medical care for dependents of active duty or retired military personnel. CHAMP-VA is medical insurance for dependents or survivors of disabled veterans.

1[] Yes
2[] No
9[] DK

c. In (month), were you covered by any other military health care, including armed forces retirement benefits, or the VA (Department of Veterans' Affairs)?

1[] Yes
2[] No
9[] DK

5. In (month), were you covered by the Indian Health Service?

1[] Yes
2[] No
9[] DK

6a. (Not counting the government health programs we just mentioned), in (month), were you covered by a private health insurance plan?
Read if necessary: Besides government programs, people also get health insurance through their jobs or union, through other private groups, or directly from an insurance company. A variety of types of plans are available, including Health Maintenance Organizations or HMOs.

1[] Yes (Go to 6b)
2[] No (Skip to Section H on page 35)
9[] DK (Skip to Section H on page 35)

b. Was any of this private health insurance obtained originally through the workplace, that is through a present or former employer or union?
Mark (X) only one.

1[] Employer
2[] Union
3[] Through workplace, DK which
4[] No
9[] DK

[p. 359]

Section H -- ASSISTANCE WITH KEY ACTIVITIES

READ TO RESPONDENT: The next questions are about how well you are able to do certain activities. Please tell me if you have ANY difficulty when you do the following.
Ask 1a-j before asking 2 and 3.

1. By yourself and not using aids, do you have any difficulty --

a. Walking for a quarter of a mile, (that is about 2 or 3 blocks)?
1[] Yes
2[] No
9[] DK


b. Walking up 10 steps without resting?
1[] Yes
2[] No
9[] DK


c. Standing or being on your feet for about 2 hours?
1[] Yes
2[] No
9[] DK


d. Sitting for about 2 hours?
1[] Yes
2[] No
9[] DK

By yourself and not using aids, do you have any difficulty --

e. Stooping, crouching, or kneeling?
1[] Yes
2[] No
9[] DK


f. Reaching up over your head?
1[] Yes
2[] No
9[] DK


g. Reaching out (as if to shake someone's hand)?
1[] Yes
2[] No
9[] DK


h. Using your fingers to grasp or handle?
1[] Yes
2[] No
9[] DK

By yourself and not using any aids, do you have any difficulty --

i. Lifting or carrying something as heavy as 25 pounds, (such as two full bags of groceries)?
1[] Yes
2[] No
9[] DK


j. Lifting or carrying something as heavy as 10 pounds?
1[] Yes
2[] No
9[] DK

Ask 2 and 3 for each "Yes" in 1a-j.

2. How much difficulty do you have (activity), some, a lot, or are you unable to do it?

a. Walking for a quarter of a mile, (that is about 2 or 3 blocks)
1[] Some
2[] A lot
3[] Unable
9[] DK


b. Walking up 10 steps without resting
1[] Some
2[] A lot
3[] Unable
9[] DK


c. Standing or being on your feet for about 2 hours
1[] Some
2[] A lot
3[] Unable
9[] DK


d. Sitting for about 2 hours
1[] Some
2[] A lot
3[] Unable
9[] DK

By yourself and not using aids, do you have any difficulty --

e. Stooping, crouching, or kneeling
1[] Some
2[] A lot
3[] Unable
9[] DK


f. Reaching up over your head
1[] Some
2[] A lot
3[] Unable
9[] DK


g. Reaching out (as if to shake someone's hand)
1[] Some
2[] A lot
3[] Unable
9[] DK


h. Using your fingers to grasp or handle
1[] Some
2[] A lot
3[] Unable
9[] DK

By yourself and not using any aids, do you have any difficulty --

i. Lifting or carrying something as heavy as 25 pounds, (such as two full bags of groceries)?
1[] Some
2[] A lot
3[] Unable
9[] DK


j. Lifting or carrying something as heavy as 10 pounds
1[] Some
2[] A lot
3[] Unable
9[] DK

3. For how long have you (had some difficulty/had a lot of difficulty/been unable to) (activity)?

a. Walking for a quarter of a mile, (that is about 2 or 3 blocks)?
00[] Less than 1 year
99[] DK
____ Number of years


b. Walking up 10 steps without resting?
00[] Less than 1 year
99[] DK
____ Number of years


c. Standing or being on your feet for about 2 hours?
00[] Less than 1 year
99[] DK
____ Number of years


d. Sitting for about 2 hours?
00[] Less than 1 year
99[] DK
____ Number of years

By yourself and not using aids, do you have any difficulty --

e. Stooping, crouching, or kneeling?
00[] Less than 1 year
99[] DK
____ Number of years


f. Reaching up over your head?
00[] Less than 1 year
99[] DK
____ Number of years


g. Reaching out (as if to shake someone's hand)?
00[] Less than 1 year
99[] DK
____ Number of years


h. Using your fingers to grasp or handle?
00[] Less than 1 year
99[] DK
____ Number of years

By yourself and not using any aids, do you have any difficulty --

i. Lifting or carrying something as heavy as 25 pounds, (such as two full bags of groceries)?
00[] Less than 1 year
99[] DK
____ Number of years


j. Lifting or carrying something as heavy as 10 pounds?
00[] Less than 1 year
99[] DK
____ Number of years

[p. 360]

Section H -- ASSISTANCE WITH KEY ACTIVITIES -- Continued

READ TO RESPONDENT: These questions are about some other activities and how well you are able to do them by yourself and without using special equipment.

Ask questions 4A-G before continuing to Item H1.

4. Because of a health or physical problem, do you have ANY difficulty --
Ask if "Doesn't do": Is this because of a HEALTH or PHYSICAL problem? If "Yes", mark box 1; if "No" mark box 3.

(A) Bathing or showering?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK


(B) Dressing?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK


(C) Eating?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK


(D) Getting in and out of bed or chairs?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK


(E) Walking?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK


(F) Getting outside?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK


(G) Using the toilet, including getting to the toilet?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK
ITEM H1
(A) Bathing or showering
Refer to question 4
1[] "Yes" marked (go to 5)
2[] All other (Go to H1 for next activity)


(B) Dressing
Refer to question 4
1[] "Yes" marked (go to 5)
2[] All other (Go to H1 for next activity)


(C) Eating
Refer to question 4
1[] "Yes" marked (go to 5)
2[] All other (Go to H1 for next activity)


(D) Getting in and out of bed or chairs
Refer to question 4
1[] "Yes" marked (go to 5)
2[] All other (Go to H1 for next activity)


(E) Walking
Refer to question 4
1[] "Yes" marked (go to 5)
2[] All other (Go to H1 for next activity)


(F) Getting outside
Refer to question 4
1[] "Yes" marked (go to 5)
2[] All other (Go to H1 for next activity)


(G) Using the toilet, including getting to the toilet
Refer to question 4
1[] "Yes" marked (go to 5)
2[] All other (Skip to H2 for activity (A))

5. By yourself and without using special equipment, how much difficulty do you have (activity), some, a lot, or are you unable to do it?

(A) Bathing or showering
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (H1 for next activity)
9[] DK (Go to 6)


(B) Dressing
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (H1 for next activity)
9[] DK (Go to 6)


(C) Eating
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (H1 for next activity)
9[] DK (Go to 6)


(D) Getting in and out of bed or chairs?
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (H1 for next activity)
9[] DK (Go to 6)


(E) Walking?
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (H1 for next activity)
9[] DK (Go to 6)


(F) Getting outside?
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (H1 for next activity)
9[] DK (Go to 6)


(G) Using the toilet, including getting to the toilet?
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (H2 for activity (A))
9[] DK (Go to 6)

6. When you DO NOT HAVE HELP OR USE SPECIAL EQUIPMENT, is (activity) by yourself --

(A) Bathing or showering
0[] Never do without help or special equipment (H1 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H1 for next activity)
2[] No (Go to H1 for next activity)
9[] DK (Go to H1 for next activity)
(B) Dressing
[] 0 Never do without help or special equipment (H1 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H1 for next activity)
2[] No (Go to H1 for next activity)
9[] DK (Go to H1 for next activity)
(C) Eating
0[] Never do without help or special equipment (H1 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H1 for next activity)
2[] No (Go to H1 for next activity)
9[] DK (Go to H1 for next activity)

(D) Getting in and out of bed or chairs
0[] Never do without help or special equipment (H1 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H1 for next activity)
2[] No (Go to H1 for next activity)
9[] DK (Go to H1 for next activity)
(E) Walking
0[] Never do without help or special equipment (H1 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H1 for next activity)
2[] No (Go to H1 for next activity)
9[] DK (Go to H1 for next activity)
(F) Getting outside
0[] Never do without help or special equipment (H1 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H1 for next activity)
2[] No (Go to H1 for next activity)
9[] DK (Go to H1 for next activity)
(G) Using the toilet, including getting to the toilet
0[] Never do without help or special equipment (H2 for activity (A))
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H2 for activity (A))
2[] No (Go to H2 for activity (A))
9[] DK (Go to H2 for activity (A))

ITEM H2

(A) Bathing or showering
Refer to question 4.
1[] Box 3 marked (H2 for next activity)
2[] All other (Go to 7)


(B) Dressing
Refer to question 4.
1[] Box 3 marked (H2 for next activity)
2[] All other (Go to 7)

(C) Eating
Refer to question 4.
1[] Box 3 marked (H2 for next activity)
2[] All other (Go to 7)


(D) Getting in and out of bed or chairs
Refer to question 4.
1[] Box 3 marked (H2 for next activity)
2[] All other (Go to 7)


(E) Walking
Refer to question 4.
1[] Box 3 marked (H2 for next activity)
2[] All other (Go to 7)


(F) Getting outside
Refer to question 4.
1[] Box 3 marked (H2 for next activity)
2[] All other (Go to 7)


(G) Using the toilet, including getting to the toilet
Refer to question 4.
1[] Box 3 marked (Skip to H3 on page 38)
2[] All other (Go to 7)
7a. Do you use any special equipment or aids in (activity)?

(A) Bathing or showering
1[] Yes (Go to 7b)
2[] No (H2 for next activity)


(B) Dressing
1[] Yes (Go to 7b)
2[] No (H2 for next activity)


(C) Eating
1[] Yes (Go to 7b)
2[] No (H2 for next activity)


(D) Getting in and out of bed or chairs
1[] Yes (Go to 7b)
2[] No (H2 for next activity)


(E) Walking
1[] Yes (Go to 7b)
2[] No (H2 for next activity)


(F) Getting outside
1[] Yes (Go to 7b)
2[] No (H2 for next activity)


(G) Using the toilet, including getting to the toilet
1[] Yes (Go to 7b)
2[] No (Skip to H3 on page 38)

b. What special equipment or aids do you use?
Anything else?
Mark (X) all that apply.

(A) Bathing or showering
1[] Stool, seat or chair
2[] Handbar or rail
3[] Other
9[] DK


(B) Dressing
1[] Special clothes
2[] Special fasteners
3[] Cord, string, zipper pull
4[] Orthopedic shoes
5[] Other
9[] DK


(C) Eating
1[] Oversized eating equipment
2[] Bed or lap tray
3[] Covered cup/modified bowl
4[] Other
9[] DK


(D) Getting in and out of bed or chairs
1[] Cane or walking stick
2[] Walker
3[] Extra/special cushions
4[] Special *raising seat* chair/lift chair
5[] Hospital bed
6[] Trapeze/sling
7[] Ramp
8[] Other
9[] DK


(E) Walking
01[] Cane or walking stick
02[] Walker
03[] Crutch or crutches
04[] Wheel chair
05[] Artificial leg
06[] Brace
07[] Guide dog
08[] Oxygen/special breathing equipment
09[] Other
99[] DK


(F) Getting outside
01[] Cane or walking stick
02[] Walker
03[] Crutch or crutches
04[] Wheel chair
05[] Artificial leg
06[] Brace
07[] Guide dog
08[] Oxygen/special breathing equipment
09[] Other
99[] DK


(G) Using the toilet, including getting to the toilet
01[] Cane or walking stick
02[] Walker
03[] Crutch or crutches
04[] Wheel chair
05[] Artificial leg
06[] Brace
07[] Guide dog
08[] Bed pan
09[] Raised toilet seat
10[] Special toilet/portable toilet
11[] Hand holds/rails near toilet
12[] Other
99[] DK

c. When you USE SPECIAL EQUIPMENT AND DO NOT HAVE HELP, is (activity) --

(A) Bathing or showering
0[] Never do without help or special equipment (Go to H2 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H2 for next activity)
2[] No (Go to H2 for next activity)
9[] DK (Go to H2 for next activity)
(B) Dressing
[] 0 Never do without help or special equipment (H2 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H2 for next activity)
2[] No (Go to H2 for next activity)
9[] DK (Go to H2 for next activity)
(C) Eating
0[] Never do without help or special equipment (H2 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H2 for next activity)
2[] No (Go to H2 for next activity)
9[] DK (Go to H2 for next activity)

(D) Getting in and out of bed or chairs
0[] Never do without help or special equipment (H2 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H2 for next activity)
2[] No (Go to H2 for next activity)
9[] DK (Go to H2 for next activity)
(E) Walking
0[] Never do without help or special equipment (H2 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H2 for next activity)
2[] No (Go to H2 for next activity)
9[] DK (Go to H2 for next activity)
(F) Getting outside
0[] Never do without help or special equipment (H2 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H2 for next activity)
2[] No (Go to H2 for next activity)
9[] DK (Go to H2 for next activity)
(G) Using the toilet, including getting to the toilet
0[] Never do without help or special equipment (Go to H3 on page 38)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful?
1[] Yes (Go to H3 on page 38)
2[] No (Go to H3 on page 38)
9[] DK (Go to H3 on page 38)

[p.362]

Section H -- ASSISTANCE WITH KEY ACTIVITIES -- Continued

ITEM H3

(A) Bathing or showering
Refer to question 4 on page 36.
1[] Box 3 marked (Go to H3 for next activity)
2[] All other (Go to 8)


(B) Dressing
Refer to question 4 on page 36.
1[] Box 3 marked (Go to H3 for next activity)
2[] All other (Go to 8)


(C) Eating
Refer to question 4 on page 36.
1[] Box 3 marked (Go to H3 for next activity)
2[] All other (Go to 8)


(D) Getting in and out of bed or chairs
Refer to question 4 on page 36.
1[] Box 3 marked (Go to H3 for next activity)
2[] All other (Go to 8)


(E) Walking
Refer to question 4 on page 36.
1[] Box 3 marked (Go to H3 for next activity)
2[] All other (Go to 8)


(F) Getting outside
Refer to question 4 on page 36.
1[] Box 3 marked (Go to H3 for next activity)
2[] All other (Go to 8)


(G) Using the toilet, including getting to the toilet
Refer to question 4 on page 36.
1[] Box 3 marked (Skip to H4 for activity (A))
2[] All other (Go to 8)

8a. Do you receive help from another person in (activity)?

(A) Bathing or showering
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(B) Dressing
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(C) Eating
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(D) Getting in and out of bed or chairs
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(E) Walking
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(F) Getting outside
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(G) Using the toilet, including getting to the toilet
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)

b. Is this hands-on help?

(A) Bathing or showering
1[] Yes (Go to 8c)
2[] (Skip to 8e)
9[] DK (Skip to 8e)


(B) Dressing
1[] Yes (Go to 8c)
2[] (Skip to 8e)
9[] DK (Skip to 8e)


(C) Eating
1[] Yes (Go to 8c)
2[] (Skip to 8e)
9[] DK (Skip to 8e)


(D) Getting in and out of bed or chairs
1[] Yes (Go to 8c)
2[] (Skip to 8e)
9[] DK (Skip to 8e)


(E) Walking
1[] Yes (Go to 8c)
2[] (Skip to 8e)
9[] DK (Skip to 8e)


(F) Getting outside
1[] Yes (Go to 8c)
2[] (Skip to 8e)
9[] DK (Skip to 8e)


(G) Using the toilet, including getting to the toilet
1[] Yes (Go to 8c)
2[] (Skip to 8e)
9[] DK (Skip to 8e)

c. When you HAVE HANDS-ON HELP FROM ANOTHER PERSON, is (activity) --

(A) Bathing or showering
0[] Never does activity (Go to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful
1[] Yes
2[] No
9[] DK
(B) Dressing
0[] Never does activity (Go to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful
1[] Yes
2[] No
9[] DK
(C) Eating
0[] Never does activity (Go to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful
1[] Yes
2[] No
9[] DK

(D) Getting in and out of bed or chairs
0[] Never does activity (Go to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful
1[] Yes
2[] No
9[] DK

(E) Walking
0[] Never does activity (Go to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful
1[] Yes
2[] No
9[] DK

(F) Getting outside
0[] Never does activity (Go to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful
1[] Yes
2[] No
9[] DK
(G) Using the toilet, including getting to the toilet
0[] Never does activity (Go to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK
(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK
(3) Is it very painful
1[] Yes
2[] No
9[] DK

d. How often do you have hands-on help with (activity)? Would you say always, sometimes, or rarely?

(A) Bathing or showering
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(B) Dressing
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(C) Eating
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(D) Getting in and out of bed or chairs
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(E) Walking
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(F) Getting outside
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(G) Using the toilet, including getting to the toilet
1[] Always
2[] Sometimes
3[] Rarely
9[] DK

e. Do you need (more) hands-on help with (activity)?

(A) Bathing or showering
1[] Yes (Go to H3 for next activity)
2[] No (Go to H3 for next activity)
9[] DK (Go to H3 for next activity)


(B) Dressing
1[] Yes (Go to H3 for next activity)
2[] No (Go to H3 for next activity)
9[] DK (Go to H3 for next activity)


(C) Eating
1[] Yes (Go to H3 for next activity)
2[] No (Go to H3 for next activity)
9[] DK (Go to H3 for next activity)


(D) Getting in and out of bed or chairs
1[] Yes (Go to H3 for next activity)
2[] No (Go to H3 for next activity)
9[] DK (Go to H3 for next activity)


(E) Walking
1[] Yes (Go to H3 for next activity)
2[] No (Go to H3 for next activity)
9[] DK (Go to H3 for next activity)


(F) Getting outside
1[] Yes (Go to H3 for next activity)
2[] No (Go to H3 for next activity)
9[] DK (Go to H3 for next activity)


(G) Using the toilet, including getting to the toilet
1[] Yes (Go to H4 for activity (A1))
2[] No (Go to H4 for activity (A1))
9[] DK (Go to H4 for activity (A1))

ITEM H4

(A) Bathing or showering
Refer to H3 and 8b above.
1[] Box 1 marked in H3 (Go to H4 for next activity)
2[] "Yes" in 8b (Go to H4 for next activity)
3[] All other (Go to 9)


(B) Dressing
Refer to H3 and 8b above.
1[] Box 1 marked in H3 (Go to H4 for next activity)
2[] "Yes" in 8b (Go to H4 for next activity)
3[] All other (Go to 9)


(C) Eating
Refer to H3 and 8b above.
1[] Box 1 marked in H3 (Go to H4 for next activity)
2[] "Yes" in 8b (Go to H4 for next activity)
3[] All other (Go to 9)


(D) Getting in and out of bed or chairs
Refer to H3 and 8b above.
1[] Box 1 marked in H3 (Go to H4 for next activity)
2[] "Yes" in 8b (Go to H4 for next activity)
3[] All other (Go to 9)


(E) Walking
Refer to H3 and 8b above.
1[] Box 1 marked in H3 (Go to H4 for next activity)
2[] "Yes" in 8b (Go to H4 for next activity)
3[] All other (Go to 9)


(F) Getting outside
Refer to H3 and 8b above.
1[] Box 1 marked in H3 (Go to H4 for next activity)
2[] "Yes" in 8b (Go to H4 for next activity)
3[] All other (Go to 9)


(G) Using the toilet, including getting to the toilet
Refer to H3 and 8b above.
1[] Box 1 marked in H3 (Skip to H5 on page 40)
2[] "Yes" in 8b (Skip to H5 on page 40)
3[] All other (Go to 9)

READ ONCE -- Sometimes people just need to have someone supervise them or stay nearby in case any help is needed.
9a. Do you have someone who supervises you or stays nearby when you are (activity)?

(A) Bathing or showering
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)


(B) Dressing
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)


(C) Eating
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)


(D) Getting in and out of bed or chairs
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)


(E) Walking
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)


(F) Getting outside
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)


(G) Using the toilet, including getting to the toilet
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)

b. Does this person provide --

(A) Bathing or showering
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?

1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?

1[] Yes
2[] No
9[] DK


(B) Dressing
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?

1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?

1[] Yes
2[] No
9[] DK


(C) Eating
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?

1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?

1[] Yes
2[] No
9[] DK


(D) Getting in and out of bed or chairs
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?

1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?

1[] Yes
2[] No
9[] DK


(E) Walking
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?

1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?

1[] Yes
2[] No
9[] DK


(F) Getting outside
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?

1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?

1[] Yes
2[] No
9[] DK


(G) Using the toilet, including getting to the toilet
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?

1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?

1[] Yes
2[] No
9[] DK

10. How often do you have supervision or standby help when you are (activity)? Would you say always, sometimes, or rarely?

(A) Bathing or showering
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(B) Dressing
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(C) Eating
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(D) Getting in and out of bed or chairs
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(E) Walking
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(F) Getting outside
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(G) Using the toilet, including getting to the toilet
1[] Always
2[] Sometimes
3[] Rarely
9[] DK

11. Do you need (more) supervision or standby help with (activity)?

(A) Bathing or showering
1[] Yes (Go to H4 for next activity)
2[] No (Go to H4 for next activity)
9[] DK (Go to H4 for next activity)


(B) Dressing
1[] Yes (Go to H4 for next activity)
2[] No (Go to H4 for next activity)
9[] DK (Go to H4 for next activity)


(C) Eating
1[] Yes (Go to H4 for next activity)
2[] No (Go to H4 for next activity)
9[] DK (Go to H4 for next activity)


(D) Getting in and out of bed or chairs
1[] Yes (Go to H4 for next activity)
2[] No (Go to H4 for next activity)
9[] DK (Go to H4 for next activity)


(E) Walking
1[] Yes (Go to H4 for next activity)
2[] No (Go to H4 for next activity)
9[] DK (Go to H4 for next activity)


(F) Getting outside
1[] Yes (Go to H4 for next activity)
2[] No (Go to H4 for next activity)
9[] DK (Go to H4 for next activity)


(G) Using the toilet, including getting to the toilet
1[] Yes (Go to H5 on page 40)
2[] No (Go to H5 on page 40)
9[] DK (Go to H5 on page 40)

[p. 364]

Section H -- ASSISTANCE WITH KEY ACTIVITIES -- Continued

ITEM H5

(A) Bathing or showering
Refer to 8a, 8e, 9a and 11 on page 38.
1[] Any "Yes" (Go to 12)
2[] All other (Go to H5 for activity (B))


(B) Dressing
1[] Any "Yes" (Go to 12)
2[] All other (Go to H5 for activity (C))


(C) Eating
1[] Any "Yes" (Go to 12)
2[] All other (Go to H5 for activity (D))


(D) Getting in and out of bed or chairs
1[] Any "Yes" (Go to 12)
2[] All other (Go to H5 for activity (E))


(E) Walking
1[] Any "Yes" (Go to 12)
2[] All other (Go to H5 for activity (G))


(G) Using the toilet, including getting to the toilet
1[] Any "Yes" (Go to 12)
2[] All other (Skip to H6 on page 42)

(A) Bathing and showering
12a. How often do you have a complete bath? This could be a tub bath, shower, sink bath or bed bath. Would you say --
(Read categories)

1[] Everyday,
2[] 2-3 times per week,
3[] Once a week, or
4[] Less than once a week?
9[] DK

b. How often do you have a partial bath? Would you say --
(Read categories)

1[] Everyday
2[] 2-3 times per week,
3[] Once a week, or
4[] Less than once a week?
9[] DK

13a. During the past month, did you experience discomfort because you were not able to bathe as often as you would have liked?

If necessary: That can be either physical or emotional discomfort.

1[] Yes
2[] No
9[] DK

b. During the past month, did you experience a burn or scald caused by bathing with water that was too hot?

1[] Yes (Go to H5 for activity (B))
2[] No (Go to H5 for activity (B))
9[] DK (Go to H5 for activity (B))

(B) Dressing
12a. Do you get dressed for the day --
(Read categories)

1[] Everyday, (Skip to 13)
2[] 2-3 times per week, (Go to 12b)
3[] Once a week, or (Go to 12b)
4[] Do you stay in night clothes? (Go to 12b)
9[] DK

b. How often do you change your night clothes? Would you say --
(Read categories)

1[] Everyday,
2[] 2-3 times per week,
3[] Once a week, or
4[] Less than once a week?
9[] DK

13. During the past month, did you experience discomfort because you were not able to change your clothes as often as you would have liked because you did not have help?

1[] Yes (Go to H5 for activity (C))
2[] No (Go to H5 for activity (C))
9[] DK (Go to H5 for activity (C))

(C) Eating
12a. During the past month, were there times you were unable to eat when you were hungry because no one was available to help you eat?

1[] Yes
2[] No
9[] DK

b. During the past month, have you --

(1) Lost any weight because you were on a diet?
1[] Yes
2[] No
9[] DK
(2) Lost weight even though you were not on a diet?
1[] Yes
2[] No
9[] DK
(3) Been dehydrated, that is not have enough liquid in your diet?
1[] Yes (Go to H5 for activity (D))
2[] No (Go to H5 for activity (D))
9[] DK (Go to H5 for activity (D))

If necessary: If you were dehydrated, you might have been thirsty or lost body fluids.

[p. 365]

Section H -- ASSISTANCE WITH KEY ACTIVITIES -- Continued

(D) Getting in and out of bed or chairs
12a. Because of a health or physical problem, do you usually stay in bed all or most of the time?

1[] Yes (Go to H5 for activity (E))
2[] No (Go to 12b)
9[] DK (Go to 12b)

b. Because of a health or physical problem, do you usually stay in a chair all or most of the time?

1[] Yes
2[] No
9[] DK

c. How often do you get out of bed? Would you say --
(Read categories)

1[] Everyday, (Go to H5 for activity (E))
2[] 2-3 times per week, (Go to H5 for activity (E))
3[] Once a week, or (Go to H5 for activity (E))
4[] Less than once a week? (Go to H5 for activity (E))
9[] DK (Go to H5 for activity (E))

(E) Walking
12a. How often do you move around your (house/apartment/room)? Would you say -- (Read categories)

1[] Whenever you want, (Go to H5 for activity in (G))
2[] Often enough to stretch and have a change of scenery now and then,
3[] Often enough to take care of toileting needs but not much more than that, or (Go to H5 for activity in (G))
4[] Not often enough even to use the bathroom? (Go to H5 for activity in (G))
9[] DK (Go to H5 for activity in (G))

(G) Using the toilet, including getting to the toilet
12a. During the past month, did you experience discomfort because you did not have help getting to the bathroom or changing soiled clothing as often as you needed to?
If necessary: That can be either physical or emotional discomfort.

1[] yes
2[] No
9[] DK

b. During the past month, did you wet or soil yourself because you did not have help getting to the bathroom, using a bed pan or using a commode?

1[] Yes (Go to 12c)
2[] No (Skip to 12d)
9[] DK (Skip to 12d)

c. During the past month, did you experience skin problems such as a rash or irritation because of this?

1[] Yes
2[] No
9[] DK

d. During the past month, did you use a commode or bed pan because no help was available?

1[] Yes (Go to H5 on page 42)
2[] No (Go to H5 on page 42)
9[] DK (Go to H5 on page 42)

[p. 366]

Section H -- ASSISTANCE WITH KEY ACTIVITIES -- Continued

ITEM H6
Refer to question 4 for activities A-G on pages 36 and 37. Indicate the activities marked "Yes".
Insert these marked activities when asking 14.

[] A. Bathing or showering
[] B. Dressing
[] C Eating
[] D. Getting in and out of bed or chairs
[] E. Walking
[] F. Getting outside
[] G. Using the toilet, including getting to the toilet
[] No activities marked (Skip to 16)

Insert activities marked in H6.
14a. What (other) condition causes the trouble in (activities)?
Read conditions and ask 14b.
Ask if operation:
For what condition did you have the operation?
Record up to 5 conditions.

00[] No condition (Skip to 16)
01[] Old age (Go to 14c)
(a) ____
(b) ____
(c) ____
(d) ____
(f) ____

b. Besides (condition), is there any other condition which causes this trouble in (activities)?

1[] 1 Yes (Reask 14a and 14b)
2[] No (Skip to 15)
9[] DK (Skip to 15)

c. Is this trouble in (activities) caused by any specific condition?

1[] Yes (Reask 14a and 14b)
2[] No (Go to 15)
9[] DK (Go to 15)

15. (Was this/were any of these) condition(s) a result of a motor vehicle accident?

1[] Yes
2[] No
9[] DK

16. During the past 12 months, did you receive training to increase your independence in daily living skills such as bathing, eating, or toileting?

1[] Yes
2[] No
9[] DK

17a. Do you have difficulty controlling your bowels?

1[] yes (Go to 17b)
2[] No (Skip to 17c)
9[] DK (Skip to 17c)

b. How frequently do you have this difficulty -- daily, several times a week, once a week, or less than once a week.
Mark (X) only one.

1[] Daily
2[] Several times a week
3[] Once a week
4[] Less than once a week
9[] DK

c. Do you have a colostomy or a device to help control bowel movements?

1[] Yes (Go to 17d)
2[] No (Skip to 18a on page 43)
9[] DK (Skip to 18a on page 43)

d. Do you need help from another person in taking care of this device?

1[] Yes
2[] No
9[] DK

[p. 367]

Section H -- ASSISTANCE WITH KEY ACTIVITES -- Continued

18a. Do you have difficulty controlling urination?

1[] Yes (Go to 18b)
2[] No (Skip to 18c)
9[] DK (Skip to 18c)

b. How frequently do you have this difficulty -- daily, several times a week, once a week, or less than once a week?
Mark (X) only one.

1[] Daily
2[] Several times a week
3[] Once week
4[] Less than once a week
9[] DK

c. Do you have a urinary catheter or a device to help control urination?

1[] Yes (Go 18d)
2[] No (Skip to Item H8)
9[] DK (Skip to Item H8)

d. Do you need help from another person in taking care of this device?

1[] Yes
2[] No
9[] DK

ITEM H8
Status of SP.

1[] Institutionalized (Skip to page 31 on page 50)
2[] All others (Go to 19 on page 44)
[p.368-369]

Section H - ASSISTANCE WITH KEY ACTIVITIES - Continued

READ TO RESPONDENT: These questions are about some other activities. Please tell me about doing them by yourself.

Ask questions 19(H)-(O) before continuing to Item H9.

19. Because of a health or physical problem, do you have ANY difficulty --
Ask if "Doesn't do": Is it because of a HEALTH or PHYSICAL problem?
If "Yes", mark box 1; if "No" mark box 3.

(H) Preparing your own meals?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(I) Shopping for groceries and personal items, such as toilet items or medicines?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(J) Managing your money, such as keeping track of expenses or paying bills?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(K) Using the telephone?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(L) Doing heavy housework, like scrubbing floors, or washing windows?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(M) Doing light housework, like doing dishes, straightening up, or light cleaning?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(N) Getting to places outside of walking distance?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(O) Managing your medication?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No

ITEM H9
(H) Preparing your own meals
Refer to 19.

1[] Box 1 "Yes" marked (Go to 20)
2[] All other (Go to H9 for next activity)

(I) Shopping for groceries and personal items
Refer to 19.

1[] Box 1 "Yes" marked (Go to 20)
2[] All other (Go to H9 for next activity)

(J) Managing your money
Refer to 19.

1[] Box 1 "Yes" marked (Go to 20)
2[] All other (Go to H9 for next activity)

(K) Using the telephone
Refer to 19.

1[] Box 1 "Yes" marked (Go to 20)
2[] All other (Go to H9 for next activity)

(L) Doing heavy housework
Refer to 19.

1[] Box 1 "Yes" marked (Go to 20)
2[] All other (Go to H9 for next activity)

(M) Doing light housework
Refer to 19.

1[] Box 1 "Yes" marked (Go to 20)
2[] All other (Go to H9 for next activity)

(N) Getting to places outside of walking distance
Refer to 19.

1[] Box 1 "Yes" marked (Go to 20)
2[] All other (Go to H9 for next activity)

(O) Managing your medication
Refer to 19.

1[] Box 1 "Yes" marked (Go to 20)
2[] All other (Go to H9 for next activity)

20. By yourself, how much difficulty do you have (activity), -- some, a lot, or are you unable to do it?

(H) Preparing your own meals
1[] Some (Go to 21)
2[] A lot (Go to 21)
3[] Unable (Got to H9 for next activity)
9[] DK (go to 21)


(I) Shopping for groceries and personal items
1[] Some (Go to 21)
2[] A lot (Go to 21)
3[] Unable (Got to H9 for next activity)
9[] DK (go to 21)


(J) Managing your money
1[] Some (Go to 21)
2[] A lot (Go to 21)
3[] Unable (Got to H9 for next activity)
9[] DK (go to 21)


(K) Using the telephone
1[] Some (Go to 21)
2[] A lot (Go to 21)
3[] Unable (Got to H9 for next activity)
9[] DK (go to 21)


(L) Doing heavy housework
1[] Some (Go to 21)
2[] A lot (Go to 21)
3[] Unable (Got to H9 for next activity)
9[] DK (go to 21)


(M) Doing light housework
1[] Some (Go to 21)
2[] A lot (Go to 21)
3[] Unable (Got to H9 for next activity)
9[] DK (go to 21)


(N) Getting to places outside of walking distance
1[] Some (Go to 21)
2[] A lot (Go to 21)
3[] Unable (Got to H9 for next activity)
9[] DK (go to 21)


(O) Managing your medication
1[] Some (Go to 21)
2[] A lot (Go to 21)
3[] Unable (Skip to H10 on page 46)
9[] DK (Go to 21)

21. When you DO NOT HAVE HELP, is (activity) by yourself --

(H) Preparing your own meals
0[] Never do without help (Go to H9 for next activity)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK

(Go to H9 for next activity)


(I) Shopping for groceries and personal items
0[] Never do without help (Go to H9 for next activity)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK

(Go to H9 for next activity)


(J) Managing your money
0[] Never do without help (Go to H9 for next activity)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK

(Go to H9 for next activity)


(K) Using the telephone
0[] Never do without help (Go to H9 for next activity)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK

(Go to H9 for next activity)


(L) Doing heavy housework
0[] Never do without help (Go to H9 for next activity)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK

(Go to H9 for next activity)


(M) Doing light housework
0[] Never do without help (Go to H9 for next activity)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK

(Go to H9 for next activity)


(N) Getting to places outside of walking distance
0[] Never do without help (Go to H9 for next activity)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK

(Go to H9 for next activity)


(O) Managing your medication
0[] Never do without help (Go to H10 on page 46)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK

(Go to H10 on page 46)

[p.370-371]

Section H - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM H10
(H) Preparing your own meals
Refer to 19 on page 44.

1[] Box 3 marked (Go to H10 for next activity)
2[] All others (Go to 22)

(I) Shopping for groceries and personal items

1[] Box 3 marked (Go to H10 for next activity)
2[] All others (Go to 22)

(J) Managing your money?

1[] Box 3 marked (Go to H10 for next activity)
2[] All others (Go to 22)

(K) Using the telephone

1[] Box 3 marked (Go to H10 for next activity)
2[] All others (Go to 22)

(L) Doing heavy housework

1[] Box 3 marked (Go to H10 for next activity)
2[] All others (Go to 22)

(M) Doing light housework

1[] Box 3 marked (Go to H10 for next activity)
2[] All others (Go to 22)

(N) Getting to places outside of walking distance

1[] Box 3 marked (Go to H10 for next activity)
2[] All others (Go to 22)

(O) Managing your medication

1[] Box 3 marked (Go to H10 for next activity)
2[] All others (Go to 22)

22a. Do you receive help from another person in (activity)?

(H) Preparing your own meals
1[] Yes (Go to 22b)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(I) Shopping for groceries and personal items
1[] Yes (Go to 22b)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(J) Managing your money?
1[] Yes (Go to 22b)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(K) Using the telephone
1[] Yes (Go to 22b)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(L) Doing heavy housework
1[] Yes (Go to 22b)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(M) Doing light housework
1[] Yes (Go to 22b)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(N) Getting to places outside of walking distance
1[] Yes (Go to 22b)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(O) Managing your medication
1[] Yes (Go to 22b)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)

b. Is this hands-on help?

(H) Preparing your own meals
1[] Yes (Go to 22c)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(I) Shopping for groceries and personal items
1[] Yes (Go to 22c)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(J) Managing your money?
1[] Yes (Go to 22c)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(K) Using the telephone
1[] Yes (Go to 22c)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(L) Doing heavy housework
1[] Yes (Go to 22c)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(M) Doing light housework
1[] Yes (Go to 22c)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(N) Getting to places outside of walking distance
1[] Yes (Go to 22c)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)


(O) Managing your medication
1[] Yes (Go to 22c)
2[] No (Skip to 22e)
9[] DK (Skip to 22e)

c. When you HAVE HANDS-ON HELP FROM ANOTHER PERSON, is (activity):

(H) Preparing your own meals
0[] Never does activity (Go to 22e)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK


(I) Shopping for groceries and personal items
0[] Never does activity (Go to 22e)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK


(J) Managing your money
0[] Never does activity (Go to 22e)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK


(K) Using the telephone
0[] Never does activity (Go to 22e)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK


(L) Doing heavy housework
0[] Never does activity (Go to 22e)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK


(M) Doing light housework
0[] Never does activity (Go to 22e)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK


(N) Getting to places outside of walking distance
0[] Never does activity (Go to 22e)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK


(O) Managing your medication
0[] Never does activity (Go to 22e)
a. Very tiring?

1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?

1[] Yes
2[] No
9[] DK

c. Is it very painful?

1[] Yes
2[] No
9[] DK

d. How often do you have hands-on help with (activity)? Would you say always, sometimes, or rarely?

(H) Preparing your own meals
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(I) Shopping for groceries and personal items
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(J) Managing your money?
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(K) Using the telephone
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(L) Doing heavy housework
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(M) Doing light housework
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(N) Getting to places outside of walking distance
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(O) Managing your medication
1[] Always
2[] Sometimes
3[] Rarely
9[] DK

e. Do you need (more) hands-on help with (activity)?

(H) Preparing your own meals
1[] Yes (Go to H10 for next activity)
2[] No (Go to H10 for next activity)
9[] DK (Go to H10 for next activity)


(I) Shopping for groceries and personal items
1[] Yes (Go to H10 for next activity)
2[] No (Go to H10 for next activity)
9[] DK (Go to H10 for next activity)


(J) Managing your money?
1[] Yes (Go to H10 for next activity)
2[] No (Go to H10 for next activity)
9[] DK (Go to H10 for next activity)


(K) Using the telephone
1[] Yes (Go to H10 for next activity)
2[] No (Go to H10 for next activity)
9[] DK (Go to H10 for next activity)


(L) Doing heavy housework
1[] Yes (Go to H10 for next activity)
2[] No (Go to H10 for next activity)
9[] DK (Go to H10 for next activity)


(M) Doing light housework
1[] Yes (Go to H10 for next activity)
2[] No (Go to H10 for next activity)
9[] DK (Go to H10 for next activity)


(N) Getting to places outside of walking distance
1[] Yes (Go to H10 for next activity)
2[] No (Go to H10 for next activity)
9[] DK (Go to H10 for next activity)


(O) Managing your medication
1[] Yes (Skip to H11 for activity (H))
2[] No (Skip to H11 for activity (H))
9[] DK (Skip to H11 for activity (H))

ITEM H11
(H) Preparing your own meals
Refer to h10 and 22b:

1[] Box 1 marked in H10 (Go to H11 for next activity)
2[] "Yes" marked in 22b (Go to H11 for next activity)
3[] Other (Go to 23)

(I) Shopping for groceries and personal items

1[] Box 1 marked in H10 (Go to H11 for next activity)
2[] "Yes" marked in 22b (Go to H11 for next activity)
3[] Other (Go to 23)

(J) Managing your money

1[] Box 1 marked in H10 (Go to H11 for next activity)
2[] "Yes" marked in 22b (Go to H11 for next activity)
3[] Other (Go to 23)

(K) Using the telephone

1[] Box 1 marked in H10 (Go to H11 for next activity)
2[] "Yes" marked in 22b (Go to H11 for next activity)
3[] Other (Go to 23)

(L) Doing heavy housework

1[] Box 1 marked in H10 (Go to H11 for next activity)
2[] "Yes" marked in 22b (Go to H11 for next activity)
3[] Other (Go to 23)

(M) Doing light housework

1[] Box 1 marked in H10 (Go to H11 for next activity)
2[] "Yes" marked in 22b (Go to H11 for next activity)
3[] Other (Go to 23)

(N) Getting to places outside pf walking distance

1[] Box 1 marked in H10 (Go to H11 for next activity)
2[] "Yes" marked in 22b (Go to H11 for next activity)
3[] Other (Go to 23)

(O) Managing your medication

1[] Box 1 marked in H10 (Go to H11 for next activity)
2[] "Yes" marked in 22b (Go to H11 for next activity)
3[] Other (Go to 23)

READ ONCE: Sometimes people just need to have someone supervise them or stay nearby in case any help is needed.
23a. Do you have someone who supervises you or stays nearby when you are (activity)?

(H) Preparing your own meals
1[] Yes (Go to 23b)
2[] No (Skip to 25)
9[] DK (Skip to 25)


(I) Shopping for groceries and personal items
1[] Yes (Go to 23b)
2[] No (Skip to 25)
9[] DK (Skip to 25)


(J) Managing your money
1[] Yes (Go to 23b)
2[] No (Skip to 25)
9[] DK (Skip to 25)


(K) Using the telephone
1[] Yes (Go to 23b)
2[] No (Skip to 25)
9[] DK (Skip to 25)


(L) Doing heavy housework
1[] Yes (Go to 23b)
2[] No (Skip to 25)
9[] DK (Skip to 25)


(M) Doing light housework
1[] Yes (Go to 23b)
2[] No (Skip to 25)
9[] DK (Skip to 25)


(N) Getting to places outside pf walking distance
1[] Yes (Go to 23b)
2[] No (Skip to 25)
9[] DK (Skip to 25)


(O) Managing your medication
1[] Yes (Go to 23b)
2[] No (Skip to 25)
9[] DK (Skip to 25)

b. Does this person provide --
Supervisory help, such as making sure this activity is performed correctly when you are (activity)?

(H) Preparing your own meals
1[] Yes
2[] No
9[] DK


(I) Shopping for groceries and personal items
1[] Yes
2[] No
9[] DK


(J) Managing your money
1[] Yes
2[] No
9[] DK


(K) Using the telephone
1[] Yes
2[] No
9[] DK


(L) Doing heavy housework
1[] Yes
2[] No
9[] DK


(M) Doing light housework
1[] Yes
2[] No
9[] DK


(N) Getting to places outside pf walking distance
1[] Yes
2[] No
9[] DK


(O) Managing your medication
1[] Yes
2[] No
9[] DK

c. Stand-by help, such as observing to see if any help is needed when you are (activity)?

(H) Preparing your own meals
1[] Yes
2[] No
9[] DK


(I) Shopping for groceries and personal items
1[] Yes
2[] No
9[] DK


(J) Managing your money
1[] Yes
2[] No
9[] DK


(K) Using the telephone
1[] Yes
2[] No
9[] DK


(L) Doing heavy housework
1[] Yes
2[] No
9[] DK


(M) Doing light housework
1[] Yes
2[] No
9[] DK


(N) Getting to places outside pf walking distance
1[] Yes
2[] No
9[] DK


(O) Managing your medication
1[] Yes
2[] No
9[] DK

24. How often do you have supervision or standby help when you are (activity)? Would you say always, sometimes, or rarely?

(H) Preparing your own meals
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(I) Shopping for groceries and personal items
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(J) Managing your money?
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(K) Using the telephone
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(L) Doing heavy housework
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(M) Doing light housework
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(N) Getting to places outside of walking distance
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(O) Managing your medication
1[] Always
2[] Sometimes
3[] Rarely
9[] DK

25. Do you need (more) supervision or standby help with (activity)?

(H) Preparing your own meals
1[] Yes (Go to H11 for next activity)
2[] No (Go to H11 for next activity)
9[] DK (Go to H11 for next activity)


(I) Shopping for groceries and personal items
1[] Yes (Go to H11 for next activity)
2[] No (Go to H11 for next activity)
9[] DK (Go to H11 for next activity)


(J) Managing your money?
1[] Yes (Go to H11 for next activity)
2[] No (Go to H11 for next activity)
9[] DK (Go to H11 for next activity)


(K) Using the telephone
1[] Yes (Go to H11 for next activity)
2[] No (Go to H11 for next activity)
9[] DK (Go to H11 for next activity)


(L) Doing heavy housework
1[] Yes (Go to H11 for next activity)
2[] No (Go to H11 for next activity)
9[] DK (Go to H11 for next activity)


(M) Doing light housework
1[] Yes (Go to H11 for next activity)
2[] No (Go to H11 for next activity)
9[] DK (Go to H11 for next activity)


(N) Getting to places outside of walking distance
1[] Yes (Go to H11 for next activity)
2[] No (Go to H11 for next activity)
9[] DK (Go to H11 for next activity)


(O) Managing your medication
1[] Yes (Skip to H12 on page 48)
2[] No (Skip to H12 on page 48)
9[] DK (Skip to H12 on page 48)

[p.372-373]
Section H - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM H12
(H) Preparing your own meals
Refer to 22a, 22e, 23a, and 25 on page 46.

1[] Any "Yes" (Go to 26)
2[] All other (Go to H12 for activity (I))

(I) Shopping for groceries and personal items
Refer to 22a, 22e, 23a, and 25 on page 46.

1[] Any "Yes" (Go to 26)
2[] All other (Go to H12 for activity (L))

(L) Doing heavy housework
Refer to 22a, 22e, 23a, and 25 on page 47.

1[] Any "Yes" (Go to 26)
2[] All other (Go to H12 for activity (M))

(M) Doing light housework
Refer to 22a, 22e, 23a, and 25 on page 47.

1[] Any "Yes" (Go to 26)
2[] All other (Go to H12 for activity (N))

(N) Getting to places outside of walking distance
Refer to 22a, 22e, 23a, and 25 on page 47.

1[] Any "Yes" (Go to 26)
2[] All other (Skip to H13 for activity (H))

(H) Preparing your own meals
26a. During the past month did you experience discomfort because you were unable to eat when you were hungry because no one was available to prepare food?

1[] Yes
2[] No
9[] DK

b. During the past month, were you unable to follow a special diet because you needed help cooking?

1[] Yes
2[] No
9[] DK

c. During the past month, were you unable to eat the kind of food you are used to and you prefer because you needed help cooking?

1[] Yes (Go to H12 for activity (I))
2[] No (Go to H12 for activity (I))
9[] DK (Go to H12 for activity (I))

(I) Shopping for groceries and personal items
26a. During the past month, were you unable to follow a special diet because you needed help shopping?

1[] Yes
2[] No
9[] DK

b. During the past month, did you miss a meal because you were unable to shop?

1[] Yes (Go to H12 for activity (L))
2[] No (Go to H12 for activity (L))
9[] DK (Go to H12 for activity (L))

(L) Doing heavy housework
26. During the past month, did you experience distress because you were not able to wash clothes or clean up around the house?

1[] Yes (Go to H12 for next activity (M))
2[] No (Go to H12 for next activity (M))
9[] DK (Go to H12 for next activity (M))

(M) Doing light housework
26. During the past month, did you experience distress because you were not able to do dishes or straighten up around the house?

1[] Yes (Go to H12 for next activity (N))
2[] No (Go to H12 for next activity (N))
9[] DK (Go to H12 for next activity (N))

(N) Getting to places outside of walking distance
26a. During the past month, did you miss a doctor's or other medical appointment
because you were unable to get there?

1[] Yes
2[] No
9[] DK

b. During the past month, were you unable to go places you wanted to for fun or recreation because you did not have transportation?

1[] Yes
2[] No
9[] DK

c. During the past month, did you run out of food because you were unable to get to the store?

1[] Yes (Go to H13 for activity (H))
2[] No (Go to H13 for activity (H))
9[] DK (Go to H13 for activity (H))

ITEM H13
(H) Prepare your own meals
Refer to 19 on page 44

1[] Box 3 marked (Go to H13 for next activity)
2[] All other (Go to 27)

(I) Shop for groceries and personal items
Refer to 19 on page 44

1[] Box 3 marked (Go to H13 for next activity)
2[] All other (Go to 27)

(J) Manage your money
Refer to 19 on page 44

1[] Box 3 marked (Go to H13 for activity (L))
2[] All other (Go to 27)

(L) Doing heavy housework
Refer to 19 on page 45

1[] Box 3 marked (Go to H13 for activity (M))
2[] All other (Go to 27)

(M) Doing light housework
Refer to 19 on page 45

1[] Box 3 marked (Go to H13 for activity (M))
2[] All other (Go to 27)

27. In your household, how often do YOU (activity)? Would you say always, sometimes, rarely, or never?

(H) Prepare your own meals
1[] Always (Go to H13 for next activity)
2[] Sometimes (Go to H13 for next activity)
3[] Rarely (Go to H13 for next activity)
4[] Never (Go to H13 for next activity)
9[] DK (Go to H13 for next activity)


(I) Shop for groceries and personal items
1[] Always (Go to H13 for next activity)
2[] Sometimes (Go to H13 for next activity)
3[] Rarely (Go to H13 for next activity)
4[] Never (Go to H13 for next activity)
9[] DK (Go to H13 for next activity)


(J) Manage your money
1[] Always (Go to H13 for activity (L))
2[] Sometimes (Go to H13 for activity (L))
3[] Rarely (Go to H13 for activity (L))
4[] Never (Go to H13 for activity (L))
9[] DK (Go to H13 for activity (L))


(L)
Doing heavy housework
1[] Always (Go to H13 for next activity)
2[] Sometimes (Go to H13 for next activity)
3[] Rarely (Go to H13 for next activity)
4[] Never (Go to H13 for next activity)
9[] DK (Go to H13 for next activity)


(M) Doing light housework
1[] Always (Go to H14 on page 50)
2[] Sometimes (Go to H14 on page 50)
3[] Rarely (Go to H14 on page 50)
4[] Never (Go to H14 on page 50)
9[] DK (Go to H14 on page 50)

[p.374]
Section H - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM H14
Refer to question 19 for activities H-O on pages 44 and 45. Indicate the activities marked "Yes."
Insert these marked activities when asking 28.

[] H. Preparing your own meals
[] I. Shopping for groceries and personal items
[] J. Managing your money
[] K. Using the telephone
[] L. Doing heavy housework
[] M. Doing light housework
[] N. Getting to places outside of walking distance
[] O. Managing your medication
[] No activities marked (Skip to 30)

Insert activities marked in H14.
28a. What (other) conditions cause the trouble in activities)?
Record conditions and ask 28b.
Ask if operation:
For what condition did you have the operation?
Record up to 5 conditions

00[] No condition (Skip to 30)
01[] Old age (Skip to 28c)
(a) ____
(b) ____
(c) ____
(d) ____
(e) ____

b. Besides (condition), Is there any other condition which causes this trouble in (activities)?

1[] Yes (Reask 28a and b)
2[] No (Skip to 29)
9[] DK (Skip to 29)

c. Is this trouble in (activities) caused by any specific condition?

1[] Yes (Reask 28a and b)
2[] No (Go to 29)
9[] DK (Go to 29)

29. [Was this/Were any of these] condition(s) a result of a motor vehicle accident?

1[] Yes
2[] No
9[] DK

30. During the past 12 months, did you receive training to increase your independence in life skills such as managing money, preparing meals, or doing housework?

1[] Yes
2[] No
9[] DK

31a. During the past 12 months, that is, since (today's date) a year ago, have you fallen?

1[] Yes (Go to 31b)
2[] No (Skip to Item H16 on page 51)
9[] DK (Skip to Item H16 on page 5)

b. Have you fallen more than once in the past 12 months?

1[] Yes
2[] No
9[] DK

c. Were you injured as a result of the fall(s)?

1[] Yes (Go to 31d)
2[] No (Skip to 31e)
9[] DK (Skip to 31e)

d. What kind of injuries did you have -- a fracture, bruise, scrape or cut; did you lose consciousness, or did you have some other injury?
Mark (X) all that apply.

1[] Fracture
2[] Bruise, cut, or scrape
3[] Lost consciousness
4[] Other
9[] DK

e. [Did you fall/Were any of your falls] because you did not have help getting around or because your helper could not prevent you from falling?

1[] Yes
2[] No
9[] DK

f. [Did you fall/Were any of these falls] because you felt dizzy?

1[] Yes
2[] No
9[] DK

[p.375]
Section H - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM H16
Status of SP

1[] Institutionalized (Skip to 55 on page 56)
2[] All others (Go to 32)
32a. During the past three months, did you experience bedsores or pressure sores?

1[] Yes (Go to 32)
2[] No (Skip to 33)
9[] DK (Skip to 33)

b. Were any of these NEW bedsores or pressure sores?

1[] Yes
2[] No
9[] DK

33a. During the past three months, did you experience contractures, that is, joints that won't straighten out?

1[] Yes (Go to 33b)
2[] No (Skip to Item H17)
9[] DK (Skip to Item H17)

b. Were any of these NEW contractures?

1[] Yes
2[] No
9[] DK

ITEM H17
Refer to questions 8a on pages 38 and 39, columns A, D, and G. (Receives help)
Mark (X) all that apply.

1[] "Yes" in 8a for A. Bathing (Go to 34)
2[] "Yes" in 8a for D. Getting in/out of bed/chairs (Go to 34)
3[] "Yes in 8a for G. Using the toilet (Go to 34)
4[] All others (Skip to 35)
34. You said that you receive help with [bathing/(and) getting in or out of a bed or chair/(and) using the toilet]. Is the person who helps you most with [this/these activities] strong enough to give you the help you need or is helping physically difficult for him/her?

1[] Yes, strong enough
2[] No, physically difficult
9[] DK

If proxy respondent, ask; otherwise, skip to H18.
35. Does (sample person) need supervision to ensure [his/her] personal safety or the safety of others?

1[] Yes
2[] No
9[] DK

ITEM H18
Refer to questions 8a and 9a on pages 38 and 39 and questions 22a and 23a on page 46 and 47. (Receives help and/or supervision)
Mark (X) all that apply.

[] "Yes" in 8a or 9a for A. Bathing (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for B. Dressing (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for C. Eating (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for D. Getting in/out of bed/chairs (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for E. Walking (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for F. Getting outside (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for G. Using the toilet (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for H. Preparing your own meals (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for I. Shopping (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for J. Managing your money (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for K. Using the toilet (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for L. Doing heavy housework (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for M. Doing light housework (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for N. Getting places (Insert marked activities when asking question 36 on 52)
[] "Yes" in 8a or 9a for O. Managing your medication (Insert marked activities when asking question 36 on 52)
[] All others (Skip to Item H20 on page 55)
[p.376]
Section H - ASSISTANCE WITH KEY ACTIVITIES - Continued

36. Who usually helps you with (activities marked in H18)?
Anyone else? Enter the name or description of each helper in separate columns.

(01) ____ First helper

Ask 37-41 for each helper in 36.
ASK OR VERIFY:
37. Which activities does (Helper) help you with?
Mark (X) all that apply.

01[] Bathing or showering
02[] Dressing
03[] Eating
04[] Getting in or out of bed/chairs
05[] Walking
06[] Getting outside
07[] Using or getting to the toilet
08[] Preparing your own meals
09[] Shopping for groceries
10[] Managing your money
11[] Using the telephone
12[] Doing heavy housework
13[] Doing light housework
14[] Getting to places
15[] Managing your medications
99[] DK

ASK OR VERIFY:
HAND CARD A5. Read answers if telephone interview.

(card A5 not found)

38a. Which of these best describes (Helper)?
Mark (X) only one.

01[] Spouse (In household)
02[] Child (In household)
03[] Parent (In household)
04[] Spouse (Not in household)
05[] Child (Not in household)
06[] Parent (Not in household)
07[] Other HH relative
08[] Non-HH relative
09[] HH non-relative
10[] Friend/Neighbor
11[] Unpaid volunteer from organization/business
12[] Paid employee of organization/business
13[] Paid employee of yours
14[] Other
99[] DK

ASK OR VERIFY:
b. Is (Helper) male or female?

1[] Male
2[] Female
9[] DK

If parent, child, spouse, or unpaid volunteer in 38a, skip to 40; otherwise ask:
39a. Is (Helper) paid?

1[] Yes (Go to 39b)
2[] No (Skip to 40)

HAND CARD A1. Read answers if telephone interview.

(card A1 not found)

b. Who pays for this help?
(Anyone else?)
Mark (X) all that apply.

01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free
99[] DK

40. DURING THE PAST 2 WEEKS, how many days did (Helper) help you?

00[] None in the past 2 weeks
____(number) Days
99[] DK

41. On the days you receive help from (Helper), about how many hours per day does [he/she] usually help you?

____(number) Hours/day (Go to 37 for next helper, or H19)
99[] DK (Go to 37 for next helper, or H19)

ITEM H19
Refer to 36 above.
(Number of helpers)

[] Only one helper (Skip to 43 on page 54)
[] More than one helper (Go to 42 on page 54)
[p.377]
Section H - ASSISTANCE WITH KEY ACTIVITIES - Continued

42. You said that (Read all helpers) assist you. Who helps you the most? If 2 or more equally, ask the respondent to specify who he/she considers the main helper.

Helper No. ____
Name: ____

43a. During the past 12 months, has someone other than (main helper) stayed with you or assisted you so that (main helper) could go out for awhile, take a break, or go on vacation?

1[] Yes (Go to 43b)
2[] No (Skip to 44)
9[] DK (Skip to 44)

b. How many days in the past 12 months?

____(Days)
999[] DK

Ask 44 about only helper in 36 or main helper in 42.
44. How satisfied are you with --

a. (Helper's) scheduled hours or availability when you need [him/her]? Would you say very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK


b. The amount of assistance (helper) provides? (Would you say -- (Read categories)?)
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK


c. (Helper's) willingness to do what you ask? (Would you say -- (Read categories)?)
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK


d. (Helper's) ability to do what you need [him/her] to do? (Would you say -- (Read categories)?)
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK

How satisfied are you with --

e. (Helper's) reliability? (Would you say -- (Read categories)?)
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK


f. (Helper's) trustworthiness? (Would you say -- (Read categories)?)
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK


g. How (helper) treats you? (Would you say -- (Read categories)?)
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK

45. Are you EVER home alone for more than two hours at a time?

1[] Yes (Skip to 47)
2[] No (Go to 46)
9[] DK (Go to 46)

46. Would it be a problem for you to be alone at home for more than two hours at a time because you would need help or feel afraid?

1[] Yes (Skip to 48)
2[] No (Skip to 48)
9[] DK (Skip to 48)

47. If it could be arranged, would it be better if you did not have to stay alone for as long as two hours?

1[] Yes
2[] No
9[] DK

48a. Including the other persons living here, is there a friend, relative, or neighbor who would take care of you for a few DAYS, if necessary?

1[] Yes (Go to 48b)
2[] No (Skip to Item H20 on page 55)
9[] DK (Skip to Item H20 on page 55)

b. Who is this person?
Probe for description if necessary
Mark (X) only one.

1[] HH member - related
2[] HH member - unrelated
3[] Non HH member - related
4[] Non HH member - unrelated
9[] DK

49a. Again, including the other persons living here, is there a friend, relative, or neighbor who would take care of you for a few WEEKS, if necessary?

1[] Yes (Go to 49b)
2[] No (Skip to Item H20 on page 55)
9[] DK (Skip to Item H20 on page 55)

b. Who is this person?
Probe for description if necessary
Mark (X) only one.

1[] HH member - related
2[] HH member - unrelated
3[] Non HH member - related
4[] Non HH member - unrelated
9[] DK

[p.378]
Section H - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM H20
Refer to questions 8e and 11 for activities A-G on pages 38 and 39. (Need [more] help or supervision)

1[] Any "Yes" in questions 8e or 11 (Skip to 50)
2[] All other (Go to Item H21)
ITEM H21
Refer to questions 22e for activities H-O on pages 46 and 47. (Need [more] help)

1[] Any "Yes" in question 22e (Skip to 50)
2[] All other (Go to Item H22)
ITEM H22
Refer to question 25 for activities H-O on pages 46 and 47. (Need [more] supervision)

1[] Any "Yes" in question 25 (Skip to 50)
2[] All other (Skip to 53)
50a. You mentioned earlier that you need help or more help with certain activities. Have you or someone else ever tried to hire help or get someone from a program or agency to help you?

1[] Yes (Skip to 51)
2[] No (Go to 50b)
9[] DK (Skip to 52)

b. Why not?
Anything else?
Read categories if necessary.
Mark (X) all that apply.

01[] Does not want stranger for helper (Skip to 52)
02[] Too expensive/can't afford (Skip to 52)
03[] Not sick enough to get help from agency (Skip to 52)
04[] Income too high to get help from agency (Skip to 52)
05[] Type of help needed probably not available (Skip to 52)
06[] Quality help not available (Skip to 52)
07[] Did not know where to look for help (Skip to 52)
08[] Too sick to look for help (Skip to 52)
09[] Other (Skip to 52)
99[] DK (Skip to 52)

51. What problems have you had in trying to find help?
Anything else?
Read categories if necessary.
Mark (X) all that apply.

0[] No problems
1[] Too expensive
2[] Can't locate right type of help
3[] Can't locate adequately trained helper
4[] Can't locate helper who is available when needed
5[] Not sick enough to get help from agency
6[] Income too high to get help from agency
7[] Other
9[] DK

52. Has any agency or organization tried to find someone to help you?

1[] Yes
2[] No
3[] DK

53. Have you ever hired someone or received help from a public agency or a non-profit agency?

1[] Yes (Go to 54a)
2[] No (Skip to 55)
3[] DK (Skip to 55)

54a. Did you stop getting help from the person or agency even though you still needed it?

1[] Yes (Skip to 54b)
2[] No (Skip to 55)
3[] DK (Skip to 55)

b. Why did you stop getting help?
Any other reason?
Read categories if necessary.
Mark (X) all that apply.

1[] Too expensive
2[] Inadequate training
3[] Unavailable when needed
4[] No longer sick enough to qualify for public agency or non-profit agency help
5[] Income too high to get help from public or non-profit agency
6[] Unreliable
7[] Language problems
8[] Other
9[] DK

[p.379]
Section H - ASSISTANCE WITH KEY ACTIVITIES - Continued

55a. [In the past 12 months/in the 12 months prior to moving to this (type of institution)], did you experience problems of any kind because you were home by yourself?

1[] Yes (Go to 55b)
2[] No (Skip to 56)
3[] DK (Skip to 56)

b. What kind of problems did you have?
Anything else?
Read categories if necessary.
Mark (X) all that apply.

01[] Fall
02[] Other accident or injury
03[] Incontinence - no reminders
04[] Incontinence - unable to get to toilet
05[] Confinement to bed or chairs
06[] Hunger or thirst
07[] Fire on stove/left stove on
08[] Fell asleep while smoking
09[] Got lost/wandered off
10[] Forgot medications
11[] Took wrong dose of medication (too much/too little)
12[] Fear
13[] Other
99[] DK

56. Because of YOUR health, did anyone in your family EVER --

a. Quit a job or retire early?
1[] Yes
2[] No
9[] DK
b. Change jobs?
1[] Yes
2[] No
9[] DK
c. Change or reduce work hours?
1[] Yes
2[] No
9[] DK
d. Not take a job in order to care for you?
1[] Yes
2[] No
9[] DK

[p.380]
Section I - OTHER SERVICES

ITEM I1
Status of SP

1[] Institutionalized (Skip to Section K on page 78)
2[] All others (Go to 1)

The next questions are about medical care received at home.
1. DURING THE PAST 3 MONTHS, did you get any medical treatments at home such as injections, therapy, blood or urine testing, or catheter care?

1[] Yes (Go to 2)
2[] No (Skip to 7)
9[] DK (Skip to 7)

2. Do you need more help or a different kind of help with your medical treatments at home?

1[] Yes (Go to 3)
2[] No (Skip to 4)
9[] DK (Skip to 4)

3. Have you experienced any problems because you did not have enough help or the right kind of help with home medical treatments?

1[] Yes
2[] No
9[] DK

4. Do family members or friends help you with medical treatments at home?

1[] Yes (Go to 5)
2[] No (Skip to 7)
9[] DK (Skip to 7)

5. Have these friends or family members been trained by a health care professional to administer these medical treatments?

1[] Yes, all have been trained
2[] Yes, some have been trained
3[] No, none have been trained
9[] DK

6a. Do you receive any home medical treatments from friends or relatives that you feel should be administered by a health professional?

1[] Yes (Go to 6b)
2[] No (Skip to 7)
9[] DK (Skip to 7)

b. Why aren't you getting this help from a health professional?
Any other reason?
Mark (X) all that apply.

1[] Don't know where to go for help
2[] Looked for help, help not available
3[] No insurance coverage
4[] Cannot afford, even with insurance coverage
5[] Don't want the treatment
6[] Getting new helper/in between helpers
7[] Other
9[] DK

7. Are there any home medical treatments that have been prescribed for you but you are not getting?

1[] Yes (Go to 8)
2[] No (Skip to 9)
9[] DK (Skip to 9)

8. Why aren't you getting this treatment?
Any other reason?
Mark (X) all that apply.

1[] Don't know where to go for help
2[] Looked for help, help not available
3[] No insurance coverage
4[] Cannot afford, even with insurance coverage
5[] Don't want the treatment
6[] Getting new helper/in between helpers
7[] Other
9[] DK

Now I would like to ask about prescription medicines.
9. How many different prescription medicines are you supposed to use? Please count ones you should use each day and those you use regularly but not every day. Include injections, eye drops, suppositories, creams, ointments, and skin patches, but not vitamins, oxygen, or medicines you get through an IV>
Mark (X) only one.

0[] None (Skip to 17 on page 58)
1[] One or two (Go to 10)
2[] Three-five (Go to 10)
3[] Six-nine (Go to 10)
4[] Ten or more (Go to 10)
9[] DK (Go to 10)

The next questions are about these prescription medicines.
10. Would you say that you use medicine(s) as prescribed by the doctor -- (Read all categories)
Mark (X) only one.

1[] All of the time, (Skip to 14 on page 58)
2[] Most of the time, (Skip to 11 on page 58)
3[] Some of the time. (Skip to 11 on page 58)
4[] Rarely, or, (Skip to 11 on page 58)
5[] Never? (Skip to 11 on page 58)
9[] DK (Skip to 11 on page 58)

[p.381]
Section I - OTHER SERVICES - Continued

11. Are there any prescription medicines that you are supposed to use, but --

a. did not get when first prescribed because of the cost?
1[] Yes
2[] No
9[] DK
b. did not get the entire prescription filled because of the cost?
1[] Yes
2[] No
9[] DK
c. did not refill when you ran out because of the cost?
1[] Yes
2[] No
9[] DK
d. use less often than prescribed in order to stretch them out because of the cost?
1[] Yes
2[] No
9[] DK
e. sometimes forget to use?
1[] Yes
2[] No
9[] DK
f. don't use as prescribed because of the side effects?
1[] Yes
2[] No
9[] DK
g. cannot pick up from the drug store or get delivered?
1[] Yes
2[] No
9[] DK
h. don't use because you think you don't need it?
1[] Yes
2[] No
9[] DK

12. Have you experienced any problems because you forgot to use your medicine or didn't use your medicine as prescribed?

1[] Yes (Go to 13)
2[] No (Skip to 14)
9[] DK (Skip to 14)

13. What problems did you experience?
Anything else?
Mark (X) all that apply.

01[] Pain/Discomfort
02[] Dizziness/Fainting
03[] Disorientation
04[] Overdose/Withdrawal
05[] Change in blood pressure, breathing, or other vital signs
06[] Condition for which medicine prescribed got worse
07[] Other condition(s) got worse
08[] Had to be admitted to hospital
09[] Had to go to doctor/emergency room
10[] Drug reaction
11[] Other
99[] DK

14. Do you receive help using your medications? This includes reminding you or measuring the medicines, and setting them up for you, or do you use all of your medicine completely by yourself?
Mark (X) only one.

1[] Receive help
2[] All by self
9[] DK

15. Not counting financial help, do you NEED (more) help with your medicine?

1[] Yes (Go to 16)
2[] No (Skip to 17)
9[] DK (Skip to 17)

16. What do you NEED (more) help with?
Anything else?
Mark (X) all that apply.

1[] Ordering/Shopping for/Getting medicines from pharmacy
2[] Reminder/Monitoring/Measuring/Setting up/Taking medicines
3[] Other
9[] DK

These next questions are about your sources of medical care.
17. Do you have a general practitioner, internist, or family doctor whom you see regularly?

1[] Yes (Go to 18)
2[] No (Skip to 26 on page 59)
9[] DK (Skip to 26 on page 59)

18. Which do you see most often -- a general practitioner, an internist, or family doctor?
Mark (X) only one.

1[] General practitioner
2[] Internist
3[] Family doctor
4[] DK specialty/title
5[] DK which seen most often

19. Have you seen this [(provider in 18)/doctor] in the past 12 months?

1[] Yes (Go to 20)
2[] No (Skip to 25 on page 59)
9[] DK (Skip to 25 on page 59)

20. In the past 3 months, how many times have you seen this [(provider in 18)/doctor]?

00[] None (Skip to 22 on page 59)

____(number) Times (Go to 21 on page 59)

99[] DK (Go to 21 on page 59)

[p.382]
Section I - OTHER SERVICES - Continued

21. Did this [(provider in 18)/doctor] ask to see you for more [than the (number in 20) visit(s)/visit]?

1[] Yes
2[] No
9[] DK

22. In the past 3 months, did this [(provider in 18)/doctor] refer to you to another doctor, therapist, or medical professional, or send you for tests or x-rays?

1[] Yes (Go to 23)
2[] No (Skip to Item I2)
9[] DK (Skip to Item I2)

23. Did you or will you go for all, some, or none of the visits or tests recommended by this [(provider in 18)/doctor]?
Mark (X) only one.

1[] All (Go to Item I2)
2[] Some (Skip to 24)
3[] None (Skip to 24)
9[] DK (Go to Item I2)

ITEM I2
Refer to question 21.
(Additional visits recommended)

1[] "Yes" in 21 (Go to 224)
2[] All others (Skip to 25)

HAND CARD A6. Read categories if telephone interview.

(Card A6 not found)

24. Why did you not go for (all) your recommended visits or tests?
Anything else?
Mark (X) all that apply.

01[] Waiting for upcoming appointment
02[] Did not like doctor or doctor's advice
03[] Went to another doctor instead
04[] Problems at place -- long wait, no bathroom, not accessible
05[] Clinic/Office in unsafe neighborhood
06[] No insurance
07[] Insurance did not cover
08[] Can't afford it
09[] Transportation problem
10[] Could not get convenient appointment
11[] Thought problem would go away, or problem went away
12[] Used home remedy
13[] Health got worse
14[] Health of other family member interfered
15[] Other reason
99[] DK

25. How would you rate this [(provider in 18)/doctor] in terms of overall quality of care and services? Would you say excellent, good, fair, or poor?
Mark (X) only one.

1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK

Now, I'd like to ask about the (other) types of doctors you see most often.
26a. What types of specialists do you see regularly?
Any others?
Read categories if necessary.
Mark (X) all that apply.

00[] None (Skip to 35 on page 61)
01[] Allergist/Immunologist (Allergy doctor)
02[] Cardiologist (Heart doctor)
03[] Dermatologist (Skin doctor)
04[] Endocrinologist (Gland/Hormone doctor)
05[] Gastroenterologist (Stomach doctor)
06[] Hematologist (Blood doctor)
07[] Nephrologist (Kidney doctor)
08[] Neurologist/Neuropathologist (Nervous system doctor)
09[] Neurosurgeon (Nervous system surgeon)
10[] Obstetrician/Gynecologist (OB/GYN)
11[] Oncologist (Cancer doctor)
12[] Ophthalmologist (Eye doctor)
13[] Orthopedist/Orthopedic surgeon (Bone and muscle doctor)
14[] Otolaryngologist/Otorhinolaryngologist (Ear, nose, throat doctor)
15[] Physical medicine/Rehabilitation specialist (Physical therapy)
16[] Podiatrist (Foot doctor)
17[] Psychiatrist (Mental health doctor)
18[] Pulmonary/Lung specialist (Respiratory doctor)
19[] Radiologist (X-Ray/Nuclear medicine doctor)
20[] Rheumatologist (Joint doctor)
21[] Urologist (Urinary tract doctor)
22[] Other
99[] Specialist - DK type

Ask only if more than one specialist in 26a. If only one, transcribe the number of the box in 26b without asking.
b. Which of these specialists have you seen most often?
Mark (X) only one)

____Specialist

[p.383]
Section I - OTHER SERVICES - Continued

27. Have you seen this [(specialist in 26b)/doctor] in the past 12 months?

1[] Yes (Go to 28)
2[] No (Skip to 29)
9[] DK (Skip to 29)

28. In the past 3 months, how many times have you seen this [(specialist in 26b)/doctor]? Do not count times while an overnight patient in a hospital.

00[] None (Skip to 30)
01[] Only while overnight patient (Go to 29)

____(Number) Times

99[] DK

29. Did this [(specialist in 26b)/doctor] ask to see you for more [than the (number in 28) visit(s)/visit]?

1[] Yes
2[] No
9[] DK

30. In the past 3 months, did this [(specialist in 26b)/doctor] refer you to another doctor, therapist, or medical professional, or send you for tests or x-rays?

1[] Yes (Go to 31)
2[] No (Skip to Item I3)
9[] DK (Skip to Item I3)

31. Did you or will you go for all, some, or none of the visits or tests recommended by this [(specialist in 26b)/doctor]?
Mark (X) only one.

1[] All (Go to Item I3)
2[] Some (Skip to 32)
3[] None (Skip to 32)
9[] DK (Go to Item I3)

ITEM I3
Refer to question 29.
(Additional visits recommended)

1[] "Yes" in 29 (Go to 32)
2[] All others (Skip to 33)

HAND CARD A6. Read categories if telephone interview.

(Card A6 not found)

32. Why did you not go for (all) your recommended visits or tests?
(Anything else?)
Mark (X) all that apply.

01[] Waiting for upcoming appointment
02[] Did not like doctor or doctor's advice
03[] Went to another doctor instead
04[] Problems at place -- long wait, no bathroom, not accessible
05[] Clinic/Office in unsafe neighborhood
06[] No insurance
07[] Insurance did not cover
08[] Can't afford it
09[] Transportation problem
10[] Could not get convenient appointment
11[] Thought problem would go away, or problem went away
12[] Used home remedy
13[] Health got worse
14[] Health of other family member interfered
15[] Other reason
99[] DK

33. How would you rate this [(specialist in 26b)/doctor] in terms of overall quality of care and services? Would you say excellent, good, fair, or poor?
Mark (X) only one.

1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK

Refer to questions 19 and 27, then ASK or VERIFY:
34. During the past 12 months, which doctor have you seen the most often -- the (provider in 18) or the (specialist in 26b)?

1[] Neither seen in past 12 months (Skip to 37 on page 62)
2[] GP/Internist/Family doctor (Go to 35 on page 61)
3[] Specialist (Go to 35 on page 61)
9[] DK (Go to 35 on page 61)

[p.384]
Section I - OTHER SERVICES - Continued
35. Now, I'm going to read you a list of items which concern visits to the doctor you see most often.
For each item, tell me if you would rate it as excellent, good, fair, or poor.

a. The thoroughness of the examination. Would you say excellent, good, fair, or poor?
1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK


b. Their respect and attention to your privacy. (Would you say excellent, good, fair, or poor?)
1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK


c. Their personal interest in you and your condition. (Would you say excellent, good, fair, or poor?
1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK


d. Availability in an emergency. (Would you say excellent, good, fair, or poor?)
1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK


e. Office hours for appointments. (Would you say excellent, good, fair, or poor?)
1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK


f. Being able to receive answers to questions over the telephone. (Would you say excellent, good, fair, or poor?)
1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK


g. Being able to make appointments over the telephone. (Would you say excellent, good, fair, or poor?)
1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK


h. Wait time for an appointment. (Would you say excellent, good, fair, or poor?)
1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK


i. Wait time to see the doctor. (Would you say excellent, good, fair, or poor?)
1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK


j. The location of the office or clinic. (Would you say excellent, good, fair, or poor?)
1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK


k. The accessibility of transportation to the office. (Would you say excellent, good, fair, or poor?)
1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK


l. Their handling of insurance claims. (Would you say excellent, good, fair, or poor?)
1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK

36. Has a medical professional told you that because you did not have follow-up care --

a. Your condition worsened?
1[] Yes
2[] No
9[] DK


b. You need to be hospitalized?
1[] Yes
2[] No
9[] DK


c. You need more medical care?
1[] Yes
2[] No
9[] DK

[p.385-388]
Section I - OTHER SERVICES - Continued

The next questions are about other services you may have received.
37a. During the past 12 months, did you receive any service from ____ ?

(A) A physical therapist
1[] Yes (Skip to 38)
2[] No (Go to 37b)
9[] DK (Go to 37b)


(B) An occupational therapist
1[] Yes (Skip to 38)
2[] No (Go to 37b)
9[] DK (Go to 37b)


(C) An audiologist
1[] Yes (Skip to 38)
2[] No (Go to 37b)
9[] DK (Go to 37b)


(D) A speech therapist or pathologist
1[] Yes (Skip to 38)
2[] No (Go to 37b)
9[] DK (Go to 37b)


(E) A recreational therapist
1[] Yes (Skip to 38)
2[] No (Go to 37b)
9[] DK (Go to 37b)


(F) A visiting nurse
1[] Yes (Skip to 38)
2[] No (Go to 37b)
9[] DK (Go to 37b)


(G) A personal care attendant (other than family or a friend)
1[] Yes (Skip to 38)
2[] No (Go to 37b)
9[] DK (Go to 37b)


(H) A reader or interpreter
1[] Yes (Skip to 38)
2[] No (Go to 37b)
9[] DK (Go to 37b)


(I) An adult day care center or day activity center
1[] Yes (Skip to 38)
2[] No (Go to 37b)
9[] DK (Go to 37b)

b. Did you need the services of ____ in the past 12 months?

(A) A physical therapist
1[] Yes (Skip to 41)
2[] No (Go to 37a for next service)
9[] DK (Go to 37a for next service)


(B) An occupational therapist
1[] Yes (Skip to 41)
2[] No (Go to 37a for next service)
9[] DK (Go to 37a for next service)


(C) An audiologist
1[] Yes (Skip to 41)
2[] No (Go to 37a for next service)
9[] DK (Go to 37a for next service)


(D) A speech therapist or pathologist
1[] Yes (Skip to 41)
2[] No (Go to 37a for next service)
9[] DK (Go to 37a for next service)


(E) A recreational therapist
1[] Yes (Skip to 41)
2[] No (Go to 37a for next service)
9[] DK (Go to 37a for next service)


(F) A visiting nurse
1[] Yes (Skip to 41)
2[] No (Go to 37a for next service)
9[] DK (Go to 37a for next service)


(G) A personal care attendant (other than family or a friend)
1[] Yes (Skip to 41)
2[] No (Go to 37a for next service)
9[] DK (Go to 37a for next service)


(H) A reader or interpreter
1[] Yes (Skip to 41)
2[] No (Go to 37a for next service)
9[] DK (Go to 37a for next service)


(I) An adult day care center or day activity center
1[] Yes (Skip to 41)
2[] No (Go to 42 for next service on page 66)
9[] DK (Go to 42 for next service on page 66)

38a. During the past 12 months, in how many months did you receive services from ___?

(A) A physical therapist
____(Number) Months
99[] DK


(B) An occupational therapist
____(Number) Months
99[] DK


(C) An audiologist
____(Number) Months
99[] DK


(D) A speech therapist or pathologist
____(Number) Months
99[] DK


(E) A recreational therapist
____(Number) Months
99[] DK


(F) A visiting nurse
____(Number) Months
99[] DK


(G) A personal care attendant (other than family or a friend)
____(Number) Months
99[] DK


(H) A reader or interpreter
____(Number) Months
99[] DK


(I) An adult day care center or day activity center
____(Number) Months
99[] DK

b. What was the total number of times you received services from ____ during [that/those] month(s)?

(A) A physical therapist
____(Number) Times
99[] DK


(B) An occupational therapist
____(Number) Times
99[] DK


(C) An audiologist
____(Number) Times
99[] DK


(D) A speech therapist or pathologist
____(Number) Times
99[] DK


(E) A recreational therapist
____(Number) Times
99[] DK


(F) A visiting nurse
____(Number) Times
99[] DK


(G) A personal care attendant (other than family or a friend)
____(Number) Times
99[] DK


(H) A reader or interpreter
____(Number) Times
99[] DK


(I) An adult day care center or day activity center
____(Number) Times
99[] DK

HAND CARD A1. Read categories if telephone interview.

(Card A1 not found)

39a. Who paid or will pay for the services received from ___ in the past 12 months?
(Anyone else)
Mark (X) all that apply.

(A) A physical therapist
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 40)
99[] DK (Skip to 40)


(B) An occupational therapist
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 40)
99[] DK (Skip to 40)


(C) An audiologist
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 40)
99[] DK (Skip to 40)


(D) A speech therapist or pathologist
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 40)
99[] DK (Skip to 40)


(E) A recreational therapist
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 40)
99[] DK (Skip to 40)


(F) A visiting nurse
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 40)
99[] DK (Skip to 40)


(G) A personal care attendant (other than family or a friend)
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 40)
99[] DK (Skip to 40)


(H) A reader or interpreter
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 40)
99[] DK (Skip to 40)


(I) An adult day care center or day activity center
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 40)
99[] DK (Skip to 40)

Ask if more than one source in 39a. If only one, transcribe number of box marked without asking.
b. Who paid most of the cost for the services received from ____ in the past 12 months? Record number of main source.

(A) A physical therapist
___ ___(Number) Paid most
99[] DK


(B) An occupational therapist
___ ___(Number) Paid most
99[] DK


(C) An audiologist
___ ___(Number) Paid most
99[] DK


(D) A speech therapist or pathologist
___ ___(Number) Paid most
99[] DK


(E) A recreational therapist
___ ___(Number) Paid most
99[] DK


(F) A visiting nurse
___ ___(Number) Paid most
99[] DK


(G) A personal care attendant (other than family or a friend)
___ ___(Number) Paid most
99[] DK


(H) A reader or interpreter
___ ___(Number) Paid most
99[] DK


(I) An adult day care center or day activity center
___ ___(Number) Paid most
99[] DK

Ask only if box 01 marked in 39a; otherwise, skip to 40.
c. During the past 12 months, about how much did you or your family pay for the services received from ____? Do not count any money that has been or will be reimbursed by insurance or any other source.

(A) A physical therapist
00000[] None

$___.[00]

99999[]DK


(B) An occupational therapist
00000[] None

$___.[00]

99999[]DK


(C) An audiologist
00000[] None

$___.[00]

99999[]DK


(D) A speech therapist or pathologist
00000[] None

$___.[00]

99999[]DK


(E) A recreational therapist
00000[] None

$___.[00]

99999[]DK


(F) A visiting nurse
00000[] None

$___.[00]

99999[]DK


(G) A personal care attendant (other than family or a friend)
00000[] None

$___.[00]

99999[]DK


(H) A reader or interpreter
00000[] None

$___.[00]

99999[]DK


(I) An adult day care center or day activity center
00000[] None

$___.[00]

99999[]DK

40. During (month), did you receive services from ____ ?

(A) A physical therapist
1[] Yes (Skip to 37a for next service)
2[] No (Go to 41)
9[] DK (Skip to 37a for next service)


(B) An occupational therapist
1[] Yes (Skip to 37a for next service)
2[] No (Go to 41)
9[] DK (Skip to 37a for next service)


(C) An audiologist
1[] Yes (Skip to 37a for next service)
2[] No (Go to 41)
9[] DK (Skip to 37a for next service)


(D) A speech therapist or pathologist
1[] Yes (Skip to 37a for next service)
2[] No (Go to 41)
9[] DK (Skip to 37a for next service)


(E) A recreational therapist
1[] Yes (Skip to 37a for next service)
2[] No (Go to 41)
9[] DK (Skip to 37a for next service)


(F) A visiting nurse
1[] Yes (Skip to 37a for next service)
2[] No (Go to 41)
9[] DK (Skip to 37a for next service)


(G) A personal care attendant (other than family or a friend)
1[] Yes (Skip to 37a for next service)
2[] No (Go to 41)
9[] DK (Skip to 37a for next service)


(H) A reader or interpreter
1[] Yes (Skip to 37a for next service)
2[] No (Go to 41)
9[] DK (Skip to 37a for next service)


(I) An adult day care center or day activity center
1[] Yes (Skip to 42 for next service on page 66)
2[] No (Go to 41)
9[] DK (Skip to 42 for next service on page 66)

HAND CARD A7. Read categories if telephone interview.

(Card A7 not found)

41. Why didn't you receive services from ____ [in (month)/ in the past 12 months]?
(Anything else)
Mark (X) all that apply.

(A) A physical therapist
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(B) An occupational therapist
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(C) An audiologist
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(D) A speech therapist or pathologist
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(E) A recreational therapist
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(F) A visiting nurse
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(G) A personal care attendant (other than family or a friend)
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(H) A reader or interpreter
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(I) An adult day care center or day activity center
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK

[p.389-390]
Section I - OTHER SERVICES - Continued

42a. During the past 12 months, did you receive ____?

(J) Services for alcohol or drug abuse
1[] Yes (Skip to 43)
2[] No (Go to 42b)
9[] DK (Go to 42b)


(K) Services from a center for independent living
1[] Yes (Skip to 43)
2[] No (Go to 42b)
9[] DK (Go to 42b)


(L) Respiratory therapy services
1[] Yes (Skip to 43)
2[] No (Go to 42b)
9[] DK (Go to 42b)


(M) Social work services
1[] Yes (Skip to 43)
2[] No (Go to 42b)
9[] DK (Go to 42b)


(N) Transportation services
1[] Yes (Skip to 43)
2[] No (Go to 42b)
9[] DK (Go to 42b)

b. Did you need ___ in the past 12 months?

(J) Services for alcohol or drug abuse
1[] Yes (Skip to 46)
2[] No (Go to 42a for next service)
9[] DK (Go to 42a for next service)


(K) Services from a center for independent living
1[] Yes (Skip to 46)
2[] No (Go to 42a for next service)
9[] DK (Go to 42a for next service)


(L) Respiratory therapy services
1[] Yes (Skip to 46)
2[] No (Go to 42a for next service)
9[] DK (Go to 42a for next service)


(M) Social work services
1[] Yes (Skip to 46)
2[] No (Go to 42a for next service)
9[] DK (Go to 42a for next service)


(N) Transportation services
1[] Yes (Skip to 46)
2[] No (Skip to 47 on page 68)
9[] DK (Skip to 47 on page 68)

43a. During the past 12 months in how many months did you receive ____ ?

(J) Services for alcohol or drug abuse
_____ (Number) Months
99[]DK


(K) Services from a center for independent living
_____ (Number) Months
99[]DK


(L) Respiratory therapy services
_____ (Number) Months
99[]DK


(M) Social work services
_____ (Number) Months
99[]DK


(N) Transportation services
_____ (Number) Months
99[]DK

b. What was the total number of times you received ____ during [that/those] month(s)?

(J) Services for alcohol or drug abuse
_____ (Number) Times
99[]DK


(K) Services from a center for independent living
_____ (Number) Times
99[]DK


(L) Respiratory therapy services
_____ (Number) Times
99[]DK


(M) Social work services
_____ (Number) Times
99[]DK


(N) Transportation services
_____ (Number) Times
99[]DK

HAND CARD A1. Read categories if telephone interview.

(Card A1 not found)

44a. Who paid or will pay for ___ in the past 12 months?
(Anyone else?)
Mark (X) all that apply.

(J) Services for alcohol or drug abuse
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 45)
99[] DK (Skip to 45)


(K) Services from a center for independent living
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 45)
99[] DK (Skip to 45)


(L) Respiratory therapy services
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 45)
99[] DK (Skip to 45)


(M) Social work services
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 45)
99[] DK (Skip to 45)


(N) Transportation services
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 45)
99[] DK (Skip to 45)

Ask if more than one source in 44a. If only one, transcribe number of box marked without asking.
b. Who paid most of the cost for ____ in the past 12 months?
Record number of main source.

(J) Services for alcohol or drug abuse
___ ___ (Number) Paid most
99[] DK


(K) Services from a center for independent living
___ ___ (Number) Paid most
99[] DK


(L) Respiratory therapy services
___ ___ (Number) Paid most
99[] DK


(M) Social work services
___ ___ (Number) Paid most
99[] DK


(N) Transportation services
___ ___ (Number) Paid most
99[] DK

Ask only if box 01 marked in 44a; otherwise, skip to 45.
c. During the past 12 months, about how much did you or your family pay for ____ ? Do not count any money that has or will be reimbursed by insurance or any other source.

(J) Services for alcohol or drug abuse
00000[] None

$___.[00]

99999[]DK


(K) Services from a center for independent living
00000[] None

$___.[00]

99999[]DK


(L) Respiratory therapy services
00000[] None

$___.[00]

99999[]DK


(M) Social work services
00000[] None

$___.[00]

99999[]DK


(N) Transportation services
00000[] None

$___.[00]

99999[]DK

45. During (month), did you receive ____ ?

(J) Services for alcohol or drug abuse
1[] Yes (Skip to 42a for next service)
2[] No (Go to 46)
9[] DK (Skip to 42a for next service)


(K) Services from a center for independent living
1[] Yes (Skip to 42a for next service)
2[] No (Go to 46)
9[] DK (Skip to 42a for next service)


(L) Respiratory therapy services
1[] Yes (Skip to 42a for next service)
2[] No (Go to 46)
9[] DK (Skip to 42a for next service)


(M) Social work services
1[] Yes (Skip to 42a for next service)
2[] No (Go to 46)
9[] DK (Skip to 42a for next service)


(N) Transportation services
1[] Yes (Skip to 47 on page 68)
2[] No (Go to 46)
9[] DK (Skip to 47 on page 68)

HAND CARD A7. Read categories if telephone interview.

(Card A7 not found)

46. Why didn't you receive ____ [in (month)/in the past 12 months]?
(Anything else?)
Mark (X) all that apply.

(J) Services for alcohol or drug abuse
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(K) Services from a center for independent living
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(L) Respiratory therapy services
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(M) Social work services
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(N) Transportation services
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK

[p.391]
Section I - OTHER SERVICES - Continued

HAND CARD A8.

(Card A8 not found)

47a. Are you currently on a waiting list for any of these services? Read categories in 47b if telephone interview.

1[] Yes (Go to 47b)
2[] No (Skip to 48)
9[] DK (Skip to 48)

b. For which of these services are you on a waiting list?
(Any others?)
Mark (X) all that apply.

01[] A physical therapist
02[] An occupational therapist
03[] An audiologist
04[] A speech therapist or pathologist
05[] A recreational therapist
06[] A visiting nurse
07[] A personal care attendant, other than a family member or friend
08[] A reader or interpreter
09[] An adult day care center or day activity center
10[] Services for alcohol or drug abuse
11[] Services from a center for independent living
12[] Respiratory therapy services
13[] Social work services
14[] Transportation services
99[] DK

48a. During the past 12 months, did you stay OVERNIGHT in a hospital or other facility to receive mental health services? Do not include treatment for substance abuse.

1[] Yes (Go to 48b)
2[] No (Skip to 52 on page 69)
9[] DK (Skip to 52 on page 69)

HAND CARD A9. Read categories if telephone interview.

(Card A9 not found)

b. Where did you receive inpatient mental health services in the past 12 months?
(Anywhere else?)
Mark (X) all that apply.

1[] Private or public psychiatric hospital
2[] Psychiatric services in a general hospital
3[] Other hospital
4[] Residential treatment center
5[] Other place
9[] DK

49a. During the past 12 months, how many times altogether were you admitted to (place(s) in 48b) for mental health care?

_____ (Number) Times admitted
99[] DK

b. During the past 12 months, how many nights altogether did you spend in the (place(s) in 48b)?

_____ (Number) Nights
99[] DK

ITEM I4
Refer to question 49a.
(Number of admissions)

1[] 1 admission (Go to 50a)
2[] 2 or more admissions (Skip to 50b)
3[] All other (Skip to 50c)
50a. Was that admission on an emergency basis?

1[] Yes (Skip to 51 on page 69)
2[] No (Skip to 51 on page 69)
9[] DK (Skip to 51 on page 69)

b. How many of the (number in 49a) admissions were on an emergency basis?

00[] None (Skip to 51 on page 69)

____ (Number) Emergency admissions (Skip to 51 on page 69)

99[] DK (Skip to 51 on page 69)

c. Were any of the admissions in the past 12 months on an emergency basis?

1[] Yes (Go to 50d)
2[] No (Skip to 51 on page 69)
9[] DK (Skip to 51 on page 69)

d. How many of the admissions were on an emergency basis?

____ (Number) Emergency admissions

99[] DK

[p.392]
Section I - OTHER SERVICES - Continued

HAND CARD A1. Read categories if telephone interview.

(Card A1 not found)

51a. Who paid or will pay for inpatient mental health services you received during the past 12 months?
(Anyone else)
Mark (X) all that apply.

01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 52)
99[] DK (Skip to 52)

Ask if more than one source in 51a. If only one source, transcribe number of box marked without asking.
b. Who paid most of the cost for the inpatient mental health services?
Record number of main source.

___ ___ (Number) Paid most
99[] DK

Ask only if box 01 marked in 51a; otherwise, skip to 52.
c. During the past 12 months, about how much did you or your family pay for your inpatient mental health services? Do not count any money that has been or will be reimbursed by insurance or any other source.

00000[] None

$____.[00]

99999[] DK

52a. During the past 12 months, did you receive any outpatient mental health services, including mental health services received from a general practitioner? Do not include treatment for substance abuse or smoking cessation.

1[] Yes (Go to 52b)
2[] No (Skip to 56 on page 70)
9[] DK (Skip to 56 on page 70)

HAND CARD A10. Read categories if telephone interview.

(Card A10 not found)

b. From whom did you receive outpatient mental health services during the past 12 months?
(Anyone else?)
Mark (X) all that apply.

1[] Psychiatrist
2[] Psychologist
3[] Nurse
4[] Social worker
5[] Other mental health counselor or therapist
6[] General practitioner or other medical doctor
7[] Other health professional
9[] DK

HAND CARD A11. Read categories if telephone interview.

(Card A11 not found)

c. Where did you receive outpatient mental health services during the past 12 months?
(Anywhere else?)
Mark (X) all that apply.

1[] Doctor's/Other health professional's office, NOT a clinic
2[] Outpatient mental health clinic, such as a community mental health center
3[] Outpatient medical clinic
4[] HMO
5[] Other place
9[] DK

53a. During the past 12 months, in how many months did you receive outpatient mental health services?

____ (Number) Month(s)
99[] DK

b. Altogether, how many outpatient mental health visits did you make during [that/those] (number in 53a) month(s)?

____ (Number) Outpatient visit(s)
999[] DK

ITEM I5
Refer to question 53b.
(Number of visits)

1[] 1 visit (Go to 54a on page 70)
2[] 2 or more visits (Skip to 54 b on page 70)
9[] All other (Skip to 54c on page 70)
[p.393]
Section I - OTHER SERVICES - Continued

54a. Was that visit on an emergency basis?

1[] Yes (Skip to 55)
2[] No (Skip to 55)
9[] DK (Skip to 55)

b. How many of the (number in 53b) visits were on an emergency basis?

000[] None (Skip to 55)

____ (Number) Emergency visits (Skip to 55)

999[] DK (Skip to 55)

c. Were any of the visits in the past 12 months on an emergency basis?

1[] Yes (Go to 54d)
2[] No (Skip to 55)
9[] DK (Skip to 55)

d. How many visits were on an emergency basis?

____ (Number) Emergency visits

999[] DK

HAND CARD A1. Read categories if telephone interview.

(Card A1 not found)

55a. Who paid or will pay for the outpatient mental health services you received during the past 12 months?
(Anyone else?)
Mark (X) all that apply.

01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 56)
99[] DK (Skip to 56)

Ask if more than one source in 55a. If only one source, transcribe the number of the box marked without asking.
b. Who paid for most of the cost of the outpatient mental health services?
Record number of main source.

___ ___ (Number) Paid Most
99 [] DK

Ask only if box 01 marked in 55a, otherwise, skip to 56.
c. During the past 12 months, about how much did you or your family pay for the outpatient mental health services? Do not count any money that has been or will be reimbursed by insurance or any other source.

00000 [] None

$____.[00]

99999[] DK

56. During the past 12 months, did you receive any services from a mental health community support program?
Read if necessary: A community support program for clients with mental or emotional problems makes available mental health, health, social and support services based on individual need.

1[] Yes
2[] No
9[] DK

57. During the past 12 months, were you on a waiting list for outpatient mental health services?

1[] Yes
2[] No
9[] DK

ITEM I6
Refer to questions 48a on page 68, 52a on page 69, and question 56 above. (Any mental health services)

1[] "Yes" in 48a, 52a, or 56 (Go to 58 on page 71)
2[] All other (Skip to 59 on page 71)
[p.394]

Section I - OTHER SERVICES - Continued

58a. Did you receive any mental health services during (month)? Do not include treatment for substance abuse or smoking cessation.

1[] Yes (Skip to 59)
2[] No (Go to 59b)
9[] DK (Skip to 59)

HAND CARD A7. Read categories if telephone interview.

(Card A7 not found)

b. Why didn't you get mental health services during (month)?
(Any other reason?)
Mark (X) all that apply.

00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK

59a. During the past 12 months, have you needed any mental health services or counseling that you have not received?

1[] Yes (Go to 59b)
2[] No (Skip to 60)
9[] DK (Skip to 60)

HAND CARD A12. Read categories if telephone interview.

(Card A12 not found)

b. Which of these statements explain why you did not receive the mental health services you needed?
(Any other reason?)
Mark (X) all that apply.

00[] Did not try to get mental health services during the past 12 months
01[] Too expensive/can't afford
02[] Didn't know where to go to get services
03[] No mental health services nearby
04[] No nearby provider who accepts Medicaid
05[] Private insurance does not cover the services
06[] Did not have insurance
07[] Transportation problems
08[] Trouble finding the right kind of mental health professional
09[] Language barrier
10[] Could not take time off from work
11[] Other reasons
99[] DK

60. Because of a physical, mental or emotional problem, did you receive any training during the past 12 months in social skills, such as making and keeping friends or how to interact with other people?

1[] Yes
2[] No
9[] DK

The next questions are about the coordination of services.
61a. Is there any one doctor who you think of as the one who coordinates your overall medical care? By coordinating, I mean one who keeps in touch with the different doctors or therapists whom you see, who knows the results of all tests and treatments that you have, and who is aware of your different prescription medicines?

1[] Yes
2[] No
9[] DK

b. Do your doctors talk to each other about your health and the care you get, including any tests or medications?

1[] Yes
2[] No
3[] Only one doctor
9[] DK

62a. Is there anyone who is not a doctor who coordinates your medical care?

1[] Yes (Go to 62b)
2[] No (Skip to 63 on page 72)
3[] Does by self (Skip to 63 on page 72)
9[] DK (Skip to 63 on page 72)

b. Who does this for you?
Anyone else?
Mark (X) all that apply.

0[] Self
1[] Friend/Family member
2[] Nurse
3[] Therapist
4[] Social worker
5[] Hospital discharger planner
6[] Case manager
7[] Other
9[] DK

[p.395]
Section I - OTHER SERVICES - Continued

63a. Does any physician or someone in a physician's office help you with arranging non-medical care, like social services and personal care?

1[] Yes (Go to 63b)
2[] No (Skip to 64)
3[] Does by self (Skip to 64)
9[] DK (Skip to 64)

b. Is this person or does this person work for a general care physician or a specialist?
Mark (X) only one.

1[] General care physician
2[] Specialist
3[] Someone else
9[] DK

c. Is this person a -- (Read category)
Mark (X) all that apply.

1[] Physician?
2[] Therapist?
3[] Nurse?
4[] Social worker?
5[] Hospital discharge planner?
6[] Case manager?
7[] Something else?
9[] DK

64a. Does anyone NOT in a physician's office help you with arranging non-medical services?

1[] Yes (Go to 64b)
2[] No (Skip to Item I7)
3[] Does by self (Skip to Item I7)
9[] DK (Skip to Item I7)

b. Who does this for you?
Anyone else?
Mark (X) all that apply.

0[] Self
1[] Friend/Family member
2[] Nurse
3[] Therapist
4[] Social worker
5[] Hospital discharger planner
6[] Case manager
7[] Other
9[] DK

ITEM I7
Refer to questions 61a and 62 a on page 71, 63a and 64a above. (Service coordinator)

1[] "Yes" marked in 61a and/or 63a (Skip to 65)
2[] "Yes" marked in 62a and/or 64a (Go to Item I8)
3[] All others (Skip to 69 on page 73)
ITEM I8
Refer to questions 62b on page 71 and 64b above. (Who arranges services)

1[] Anyone other than "Self" marked in 62b or 64b (Go to 65)
2[] "Self" only in 62b and 64b (Skip to 70 on page 73)

HAND CARD A13. Read categories if telephone interview.

(Card A13 not found)

65. What kinds of medical or non-medical services are provided for you?
(Anything else?)
Mark (X) all that apply.

01[] Helps make medical appointments with (other) doctors
02[] Makes appointments with nurses/therapists/dieticians
03[] Follows up to be sure appointments are kept
04[] Arranges transportation to appointments
05[] Makes referrals to doctors
06[] Makes referrals to nurses/therapists/dieticians
07[] Checks to see if needs or conditions have changed
08[] Makes sure I am doing exercises or following diet
09[] Reviews medications
10[] Explains medical procedures or terms
11[] Helps with insurance or other benefits
12[] Arranges for home care
13[] Arranges for vocational rehabilitation services
14[] Helps develop a personal care plan
15[] Evaluates need for services
16[] Arranges special education services
17[] Tries to find volunteers to help me
18[] Tries to find workers/agencies to help me
19[] Arranges for home delivered meals
20[] Makes sure friends/family are able to help me
21[] Other
99[] DK

ITEM I9
Refer to question 64b above.
(Who arranges services)

1[] Any of boxes 2-9 marked (Go to 66 on page 73)
2[] All others (Skip to 70 on page 73)
[p.396]
Section I - OTHER SERVICES - Continued

66a. You said that someone not in a physician's office helps you with arranging non-medical services. Was any of this help paid for?

1[] Yes (Go to 66b)
2[] No (Skip to 68)
9[] DK (Skip to 68)

HAND CARD A1. Read categories if telephone interview.

(Card A1 not found)

b. Who paid or will pay for this help?
(Anyone else?)
Mark (X) all that apply.

01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
99[] DK (Skip to 67)

Ask if more than one source in 66b. If only one source, transcribe the number of the box marked without asking.
c. Who paid for most of the cost of this help?
Record number of the main source.

___ ___ (Number) Paid most
99[] DK

67. In the past 6 months, about how many times did you see or talk to the person or persons who help arrange your non-medical services?

000[] None

____ (Number)
1[] Per week
2[] Per month
3[] Per six months


999[] DK

68. Overall, how satisfied are you with the job of the person or persons have done with arranging your non-medical services? Would you say very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
Mark (X) only one.

1[] Very satisfied (Skip to 70)
2[] Somewhat satisfied (Skip to 70)
3[] Somewhat dissatisfied (Skip to 70)
4[] Very dissatisfied (Skip to 70)
9[] DK (Skip to 70)

69. During the past 12 months, have you felt that you NEEDED someone to arrange or coordinate personal care or social services?

1[] Yes
2[] No
3[] Never thought about it
9[] DK

70. Do you NEED help filling out insurance forms or benefit applications?
Mark (X) only one.

1[] Yes (go to 70b)
2[] No (go to 70b)
3[] Never filled forms/applications (Skip to item I10 on page 74)
9[] DK (Go to 70b)

b. Who helps you fill out insurance forms or applications for public programs or benefits?
Mark (X) all that apply.

0[] No one
1[] Household member
2[] Friend/Other relative not in household
3[] Paid caregiver
4[] Volunteer from organization
5[] Other
9[] DK

[p.397]

Section I - OTHER SERVICES - Continued

ITEM I10
Refer to question 42a, Service K on page 68.
(Center for independent living)

1[] "Yes" in 42a for K (Go to 71)
2[] All others (Skip to Item I11)
71. Did you receive any of the following services from the Center for Independent Living --

a. Peer counseling?
1[] Yes
2[] No
9[] DK


b. Employment counseling, training, or referral?
1[] Yes
2[] No
9[] DK


c. Help with accommodations at home?
1[] Yes
2[] No
9[] DK


d. Help with accommodations at work?
1[] Yes
2[] No
9[] DK


e. Help with accommodations in transportation?
1[] Yes
2[] No
9[] DK


f. Legal rights counseling?
1[] Yes
2[] No
9[] DK


g. Attendant referral or personal assistant services?
1[] Yes
2[] No
9[] DK


h. Recreational services?
1[] Yes
2[] No
9[] DK


i. Transportation services?
1[] Yes
2[] No
9[] DK


j. Getting assistive technology?
1[] Yes
2[] No
9[] DK


k. Advocacy services?
1[] Yes
2[] No
9[] DK

ITEM I11
Refer to 37a, Service I on page 65.
(Adult Day Care)

1[] "Yes" in 37a for I (Go to 72)
2[] All others (Skip to Section J on page 75)

HAND CARD A14. Reade categories if telephone interview.

(Card A14 not found)

72. Which services did you receive from and adult day care center or day activities center?
(Anything else?)
Mark (X) all that apply.

01[] Transportation
02[] Socialization
03[] Recreational activities
04[] Recreational therapy
05[] Speech therapy
06[] Physical therapy
07[] Occupational therapy
08[] Social services
09[] Nutrition services
10[] Meals
11[] Counseling for participants or families
12[] Referrals to outside services
13[] Nursing services
14[] Monitoring medications
15[] Coordinating care with physicians
16[] Personal care services (such as bathing, feeding)
17[] Vocational rehabilitation services
18[] Other
00[] None
99[] DK

[p.398]

Section J - SELF DIRECTION

Reminder: if SP is institutionalized, skip to Section K on page 78.

1a. Do you give your own consent for medical care, or does someone do that for you?

1[] Gives own consent (Skip to Item J1)
2[] Someone else gives consent (Go to 1b)
3[] It varies (Go to 1b)
9[] DK (Skip to Item J1)

b. Who generally gives medical consent for you?
Mark (X) only one.

1[] Family member
2[] Legal guardian
3[] Agency or school staff member
4[] Someone else
9[] DK

ITEM J1
Refer to SP's age.

1[] Under 21 (Go to 2)
2[] Age 21 and over (Skip to Section K on page 78)
2. Do you now have Individual Education Plan or IEP?

1[] Yes
2[] No
9[] DK

3. Do you currently have Individual Written Rehabilitation Plan or IWRP?

1[] Yes
2[] No
9[] DK

[p.399]

Section J - SELF DIRECTION - Continued

Special education is a program designed to meet the individual needs of persons with special needs. It is paid for by the public school system and may take place at a regular school, a special school, a private school, at home, or at a hospital.

4a. DURING THE PAST 12 MONTHS, have you received any type of services or benefits through special education? Do not include gifted or talented programs.

1[] Yes (Go to 4b)
2[] No (Skip to 5 on page 77)
9[] DK (Skip to 5 on page 77)

HAND CARD A15. Read categories if telephone interview.

(Card A15 not found)

b. DURING THE PAST 12 MONTHS, which of these services or benefits did you receive through special education programs?
(Anything else?)
Mark (X) all that apply.

01[] Transportation services
02[] Speech/Language therapy
03[] Audiology services for hearing problems (such as testing, evaluation, and training)
04[] Mental health or counseling services
05[] Development testing
06[] Physical therapy
07[] Occupational therapy
08[] Recreational therapy
09[] Respiratory therapy
10[] Social work services
11[] Eyeglasses
12[] Hearing aids
13[] Wheelchair
14[] Other assistive devices and training in their use
15[] Medical services for diagnostic and evaluation purposes
16[] Communication services (such as a reader, interpreter, or writer)
17[] Nursing services
18[] Other
99[] DK

HAND CARD A16. Read categories if telephone interview.

(Card A16 not found)

c. DURING THE PAST 12 MONTHS, have you received special education for any of these conditions?
(Anything else?)
Mark (X) all that apply.

01[] Learning disabilities
02[] Speech or language problems
03[] Mental retardation
04[] Emotional disturbances
05[] Deaf and blind
06[] Hearing, including deafness or hard of hearing
07[] Visual, including blindness and other problems
08[] Orthopedic problems
09[] Autism
10[] Traumatic brain injury
11[] Developmental delay
12[] Multiple disabilities
13[] Other health problem
14[] Not a specific condition
99[] DK

HAND CARD A17. Read categories if telephone interview.

(Card A17 not found)

d. During the past 12 months, where did you receive these special education services?
Mark (X) all that apply.

01[] Regular classroom setting
02[] Resource room in regular school
03[] Separate class all day or part of a day in regular school
04[] Special school-day school
05[] Special school-residential school
06[] Home
07[] Hospital or institution
08[] Provider's office
09[] Other
99[] DK

e. Have you received any of these special education services during the past month?

1[] Yes (Skip to 5 on page 77)
2[] No (Go to 4f)
9[] DK (Skip to 5 on page 77)

f. Why haven't you received any special education services in the past month?
Any other reason?
Mark (X) all that apply.

0[] Did not need the service during the past month
1[] Provider/school thinks services no longer necessary
2[] On vacation from school
3[] Provider/service no longer available
4[] Didn't like provider/service
5[] Transportation problems
6[] Could not take time off work to arrange it
7[] Other reason
9[] DK

[p.400]

Section J - SELF DIRECTION - Continued

5. DURING THE PAST 12 MONTHS, did you receive any instruction through special education about how to get and keep a job?

1[] Yes
2[] No
9[] DK

6a. DURING THE PAST 12 MONTHS, have you tried to get any (additional) special education services?

1[] Yes (Go to 6b)
2[] No (Skip to 7)
9[] DK (Skip to 7)

HAND CARD A15. Read categories if telephone interview.

(Card A15 not found)

b. What (additional) special education services did you try to get?
(Anything else?)
Mark (X) all that apply.

01[] Transportation services
02[] Speech/Language therapy
03[] Audiology services for hearing problems (such as testing, evaluation, and training)
04[] Mental health or counseling services
05[] Development testing
06[] Physical therapy
07[] Occupational therapy
08[] Recreational therapy
09[] Respiratory therapy
10[] Social work services
11[] Eyeglasses
12[] Hearing aids
13[] Wheelchair
14[] Other assistive devices and training in their use
15[] Medical services for diagnostic and evaluation purposes
16[] Communication services (such as a reader, interpreter, or writer)
17[] Nursing services
18[] Other
99[] DK

c. During the past 12 months were you on a waiting list for any special education services?

1[] Yes
2[] No
9[] DK

HAND CARD A18. Read categories if telephone interview.

(Card A18 not found)

d. What problems did you have trying to get (additional) special education services during the past 12 months?
(Anything else?)
Mark (X) all that apply.

0[] No problem getting services
1[] Service not available
2[] Had trouble finding the right kind of service
3[] Services available are inadequate
4[] School did not think services were needed
5[] School would not test for disabilities
6[] School would not help in finding services
7[] Could not take time off from work to arrange it
8[] Other problems
9[] DK

7. Overall, how satisfied are you with the educational services that you receive? Are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?

0[] Does not receive any educational services
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK

[p.401]

Section K - FAMILY STRUCTURE, RELATIONSHIPS, AND LIVING ARRANGEMENTS

1. Are you now married, widowed, divorced, separated, or have you never been married?
If married, probe as necessary to determine if the spouse is a current household member.
Mark (X) only one.

1[] Married - spouse in HH (Go to 2a)
2[] Married - spouse not in HH (Go to 2a)
3[] Widowed (Go to 2b)
4[] Divorced (Go to 2b)
5[] Separated (Go to 2b)
6[] Never married (Skip to Item K1)
9[] DK (Skip to Item K1)

2a. How long have you been married to your current spouse?

00[] Less than 1 year (Skip to Item K1)

____(Number) Years (Skip to Item K1)

99[] DK (Skip to Item K1)

b. How long have you been [widowed/divorced/separated]?

00[] Less than 1 year

____(Number) Years

99[] DK
ITEM K1
Status of SP

1[] Institutionalized (Skip to 5 on page 79)
2[] All others (Go to 3)

3. Including yourself, how many people altogether live in this household?

01[] SP only (Skip to 5 on page 79)

____ (Number) Household members (Go to 4)

99[] DK (Go to 4a)

4a. What are the names of all persons living in your household?
Enter SP on line 1, all others on subsequent lines.
If more than 9 household members, continue listing in the Notes space.

Name (First/Middle initial/Last)
01 ____
02 ____
03 ____
04 ____
05 ____
06 ____
07 ____
08 ____
09 ____

b. If necessary, ask: What is (name's) sex?

01
1[] M
2[] F

02
1[] M
2[] F

03
1[] M
2[] F

04
1[] M
2[] F

05
1[] M
2[] F

06
1[] M
2[] F

07
1[] M
2[] F

08
1[] M
2[] F

09
1[] M
2[] F

c. If necessary ask: How is (name) related TO YOU? Record relationship to sample person

01 77[] SAMPLE PERSON
02 ____
03 ____
04 ____
05 ____
06 ____
07 ____
08 ____
09 ____

[p.402]

Section K - FAMILY STRUCTURE, RELATIONSHIPS, AND LIVING ARRANGEMENTS - Continued

5a. Including step and adopted children, how many LIVING SONS do you have?

00[] None

____ (Number) Sons

99[]DK

b. Including step and adopted children, how many LIVING DAUGHTERS do you have?

00[] None

____ (Number) Daughters

99[]DK

ITEM K2
Refer to 5a and 5b above.
(Living children)

1[] 1+ living children (Go to Item K3)
2[] All others (Skip to Item K4 on page 80)
ITEM K3
Refer to question 4 on page 78.
(Household composition)

1[] Any of SP's child(ren) in HH (Skip to 7)
2[] All others (Go to 6)
6a. How quickly can [any of your children/your son/your daughter] get here?
If asked, "Here" means where the SP resides.

____ (Number)
1[] Minutes
2[] Hours
3[] Days


999[] DK

b. How often do you see [any of your children/your son/your daughter]?

000[] Less than once a year/Never

____ (Times)
1[] Per day
2[] Per week
3[] Per month
4[] Per year


999[] DK

c. How often do you talk on the telephone with [any of your children/your son/your daughter]?

000[] Less than once a year/Never

____ (Times)
1[] Per day
2[] Per week
3[] Per month
4[] Per year


999[] DK

d. How often do you get mail from [any of your children/your son/your daughter]?

000[] Less than once a year/Never

____ (Times)
1[] Per day
2[] Per week
3[] Per month
4[] Per year


999[] DK

7. [Do your children/Does your son/Does your daughter] routinely give you money to help with your living expenses or pay your bills?

1[] Yes
2[] No
3[] DK

[p.403]

Section K - FAMILY STRUCTURE, RELATIONSHIPS, AND LIVING ARRANGEMENTS - Continued

ITEM K4
Refer to question 4 on page 78.
(Household composition)
Mark (X) first appropriate box.

1[] SP institutionalized (Skip to 11)
2[] SP lives alone (Skip to 11)
3[] SP lives w/spouse only (Skip to 11)
4[] Other (Go to 8)
8. (Other than your spouse) [is/are any of] the person(s) living with you 18 years of age or older?

1[] Yes (Go to 9)
2[] No (Skip to 11)
9[] DK (Skip to 11)

9. Do you live with [these people/this person] NOW because YOU need to share living expenses?

1[] Yes
2[] No
9[] DK

10. Do you live with [these people/this person] NOW because of a health or physical problem YOU have?

1[] Yes
2[] No
9[] DK

11. Including step and adopted brothers, how many LIVING brothers do you have?

00[] None

____ (Number) Brothers

99[]DK

12. Including step and adopted sisters, how many LIVING sisters do you have?

00[] None

____ (Number) Sisters

99[]DK

ASK OR VERIFY:
13a. Is your mother still living?

1[] Yes
2[] No
9[] DK

b. Is your father still living?

1[] Yes
2[] No
9[] DK

[p.404]

Section K - FAMILY STRUCTURE, RELATIONSHIPS, AND LIVING ARRANGEMENTS - Continued

ITEM K5
Refer to Item K4.
(SP's living arrangements)

1[] Box 1, 2, or 3 marked (Go to 14)
2[] Box 4 marked (Skip to 15)

The next few questions are about contact you have with family members (other than your spouse or children).
14a. How quickly can any member of your family (other than your spouse or children) get here?
If asked, "Here" means where the SP resides.

000[] No other family (Skip to Section L on page 82)

____ (Number)
1[] Minutes
2[] Hours
3[] Days

999[] DK

b. How often do you see any member of your family (other than your spouse or children)?

000[] Less than once a year/Never

____ (Times)
1[] Per day
2[] Per week
3[] Per month
4[] Per year


999[] DK

c. How often do you talk on the telephone with any member of your family (other than your spouse or children?

000[] Less than once a year/Never

____ (Times)
1[] Per day
2[] Per week
3[] Per month
4[] Per year


999[] DK

d. How often do you get mail from any member of your family (other than your spouse or children)?

000[] Less than once a year/Never

____ (Times)
1[] Per day
2[] Per week
3[] Per month
4[] Per year


999[] DK

15. Do any members of your family (other than your spouse or children) routinely give you money to help with your living expenses or pay your bills?

1[] Yes
2[] No
9[] DK

[p.405]

Section L - CONDITIONS AND IMPAIRMENTS

ITEM L1
Refer to SP's age

1[] 70+ (Go to 1)
2[] Under 70 (Skip to Section O on page 87)

Now I'm going to ask some questions about vision and hearing. Please tell me if you have any of the following conditions, even if you have mentioned them before.
1. Do you NOW have --

a. Cataracts?
1[] Yes
2[] No
9[] DK


b. Glaucoma?
1[] Yes
2[] No
9[] DK


c. Blindness in both eyes?
1[] Yes (Skip to 3)
2[] No
9[] DK


d. Blindness in one eye?
1[] Yes
2[] No
9[] DK


e. Any other trouble seeing with one or both eyes, even when wearing glasses?
1[] Yes
2[] No
9[] DK

2a. Do you use eyeglasses? Include eyeglasses that just magnify.

1[] Yes (Go to 2b)
2[] No (Skip to 2c)
9[] DK (Skip to 2c)

b. Were these eyeglasses prescribed for you?

1[] Yes
2[] No
9[] DK

c. Do you use contact lenses?

1[] Yes
2[] No
9[] DK

3. Have you EVER had an operation for cataracts?

1[] Yes
2[] No
9[] DK

ITEM L2
Refer to 1c above.
(Blind in both eyes)

1[] "Yes" marked in 1c (Skip to 6)
2[] All others (Go to 4)
4. Do you have a lens implant?

1[] Yes
2[] No
9[] DK

5. Do you use a magnifying glass to read or to do other close work?

1[] Yes
2[] No
9[] DK

6. Do you NOW have --

a. Deafness in both ears?
1[] Yes (Skip to 7)
2[] No
9[] DK


b. Deafness in one ear?
1[] Yes
2[] No
9[] DK


c. Any other trouble hearing with one or both ears?
1[] Yes
2[] No
9[] DK

[p.406]

Section L - CONDITIONS AND IMPAIRMENTS - Continued

Now I'm going to ask about some other conditions. Again, please tell me if you ever had any of these conditions, even if you have mentioned them before.

Ask all of 7a(1)-(11) before going to 7b-d across.
7a. Have you EVER had --

(1) A broken hip?
1[] Yes
2[] No
9[] DK


(2) Osteoporosis?
1[] Yes
2[] No
9[] DK


(3) Diabetes?
1[] Yes
2[] No
9[] DK


(4) Arthritis?
1[] Yes
2[] No
9[] DK


(5) Chronic bronchitis or emphysema?
1[] Yes
2[] No
9[] DK


(6) Asthma?
1[] Yes
2[] No
9[] DK


(7) Hypertension, sometimes called high blood pressure?
1[] Yes
2[] No
9[] DK


(8) Heart disease, including coronary heart disease, angina, heart attack or myocardial infarction?
1[] Yes
2[] No
9[] DK


(9) Any other heart disease?
1[] Yes
2[] No
9[] DK


(10) A stroke or cerebrovascular accident?
1[] Yes
2[] No
9[] DK


(11) Cancer of any kind?
1[] Yes
2[] No
9[] DK

Ask 7b-d as appropriate for each "Yes" in 7a.
b. In what year [did/was] (condition) first [occur/noticed]?

(1) [A broken hip]
19___ Year
99[] DK


(2) [Osteoporosis]
19___ Year
99[] DK


(3) [Diabetes]
19___ Year
99[] DK


(4) [Arthritis]
19___ Year
99[] DK


(5) [Chronic bronchitis or emphysema]
19___ Year
99[] DK


(6) [Asthma]
19___ Year
99[] DK


(7) [Hypertension, sometimes called high blood pressure]
19___ Year
99[] DK


(8) [Heart disease, including coronary heart disease, angina, heart attack or myocardial infarction?]
19___ Year
99[] DK


(9) [Any other heart disease?]
19___ Year
99[] DK


(10) [A stroke or cerebrovascular accident?]
19___ Year
99[] DK


(11) [Cancer of any kind?]
19___ Year
99[] DK

c. Did a doctor ever tell you that you had (condition)?

(2) [Osteoporosis]
1[] Yes
2[] No
9[] DK


(3) [Diabetes]
1[] Yes
2[] No
9[] DK


(4) [Arthritis]
1[] Yes
2[] No
9[] DK


(5) [Chronic bronchitis or emphysema]
1[] Yes
2[] No
9[] DK


(6) [Asthma]
1[] Yes
2[] No
9[] DK


(7) [Hypertension, sometimes called high blood pressure]
1[] Yes
2[] No
9[] DK


(8) [Heart disease, including coronary heart disease, angina, heart attack or myocardial infarction?]
1[] Yes
2[] No
9[] DK


(9) [Any other heart disease?]
1[] Yes
2[] No
9[] DK


(10) [A stroke or cerebrovascular accident?]
1[] Yes
2[] No
9[] DK


(11) [Cancer of any kind?]
1[] Yes
2[] No
9[] DK

d. Do you still have (condition)?

(3) [Diabetes]
1[] Yes
2[] No
9[] DK


(5) [Chronic bronchitis or emphysema]
1[] Yes
2[] No
9[] DK


(6) [Asthma]
1[] Yes
2[] No
9[] DK


(7) [Hypertension, sometimes called high blood pressure]
1[] Yes
2[] No
9[] DK


(11) [Cancer of any kind?]
1[] Yes
2[] No
9[] DK

ITEM L3
Refer to 7a (11).
(Cancer of any kind)

1[] "Yes" marked in 7a (11) (Go to 8)
2[] All others (Skip to 9 on page 84)

HAND CARD A19. Read categories if telephone interview.

(Card A19 not found)

8. What kind of cancer [was/is] it?
(Anything else?)
Mark (X) all that apply.

01[] Colon/rectal/bowel
02[] Skin - melanoma
03[] Skin - nonmelanoma
04[] Skin - unknown type
05[] Uterine/ovarian
06[] Prostate
07[] Stomach
08[] Leukemia
09[] Breast
10[] Cervical
11[] Lung
12[] Other
99[] DK

[p.407]

Section L - CONDITIONS AND IMPAIRMENTS - Continued

9a. Do you sometimes have trouble with dizziness?

1[] Yes (Go to 9b)
2[] No (Skip to 10)
9[] DK (Skip to 10)

b. Does dizziness prevent you in any way from doing things you otherwise could do?

1[] Yes
2[] No
9[] DK

10. Do you have trouble biting or chewing any kinds of food, such as firm meat or apples?
If asked, this includes while wearing false teeth or dentures.

1[] Yes
2[] No
9[] DK

[p.408]

Section M - HEALTH OPINIONS AND BEHAVIORS

Reminder - If SP is less than 70 years old, skip to Section O on page 87.

READ TO RESPONDENT - Now I'd like to ask your personal opinions about health related matters.
1. Would you say your health in general is excellent, very good, good, fair, or poor?

1[] Excellent
2[] Very good
3[] Good
4[] Fair
5[] Poor
9[] DK

If proxy respondent, skip to 3; otherwise ask.
2. In the past 12 months, how often did you feel sad or depressed? Would you say you were sad or depressed -- (Read all categories)
Mark (X) only one.

1[] All of the time,
2[] Some of the time,
3[] A little of the time, or
4[] None of the time?
9[] DK

3. Compared to your own level of physical activity 1 year ago, would you say you are now more active, less active, or about the same as you were then?
Mark (X) only one.

1[] More active
2[] Less active
3[] About the same
9[] DK

4. Do you follow a REGULAR routine of physical exercise?

1[] Yes
2[] No
9[] DK

5. About how tall are you without shoes?

____ Feet ____ Inches

999[] DK

6. About how much do you weight without shoes?

____ Pounds

999[] DK

If proxy respondent, skip to 8; otherwise ask.
7. What was your usual weight at the age of 50?

____ Pounds

999[] DK

8. Have you ever smoked at least 100 cigarettes in your entire life?
If asked: Approximately 5 packs.

1[] Yes (Go to 9)
2[] No (Skip to 11)
9[] DK (Skip to 11)

9. Do you NOW smoke cigarettes every day, some days, or not at all?

1[] Every day
2[] Some days
3[] Not at all
9[] DK

10. For how many years [have you smoked/did you smoke] cigarettes?

00[] Less than 1 year

____ (Number) Years

99[] DK

11. Now I would like to ask about drinking alcoholic beverages. By alcoholic beverages I mean beer, wine, or liquor. Have you had at least one drink of beer, wine, or liquor during the past year?

1[] Yes (Go to 12)
2[] No (Skip to Section N on page 86)
9[] DK (Skip to Section N on page 86)

12. During the past year, on the average, on how many days did you drink alcoholic beverages, that is beer, wine, or liquor?

0000[] Every day

____ (Number) Days
1[] Per week
2[] Per month
3[] Per year


9999[] DK

13. On [the/those] day(s) when you drank, about how many drinks would you say you had?

____ (Number) Drink(s)

99[] DK

[p.409]
Section N - COMMUNITY SERVICES

REMINDER - If SP is less than 70 years old, skip to Section O on page 87.

NOTE - Ask 2 immediately after a "Yes" in 1a-f.
READ TO RESPONDENT - The next questions are about community services

1. [In the past 12 months/In the 12 months prior to coming to this (type of institution)] , did you --

a. Use a senior center?
1[] Yes (Go to 2a)
2[] No (Go to 1b)
9[] DK (Go to 1b)


b. Use special transportation for the elderly?
1[] Yes (Go to 2b)
2[] No (Go to 1c)
9[] DK (Go to 1c)


c. Have meals delivered to your home by an agency or organization like Meals on Wheels?
1[] Yes (Go to 2c)
2[] No (Go to 1d)
9[] DK (Go to 1d)


d. Eat meals in a senior center or in some place with a special meal program for the elderly?
1[] Yes (Go to 2d)
2[] No (Go to 1e)
9[] DK (Go to 1e)


e. Use a homemaker service for the elderly that provides services like cleaning and cooking in the home?
1[] Yes (Go to 2e)
2[] No (Go to 1f)
9[] DK (Go to 1f)


f. Use information and referral services?
1[] Yes (Go to 2f)
2[] No (Go to Section O on page 87)
9[] DK (Go to Section O on page 87)

2. How often did you use it -- frequently, sometimes, or rarely?

a. [Use a senior center]
1[] Frequently (Go to 1b)
2[] Sometimes (Go to 1b)
3[] Rarely (Go to 1b)
9[] DK (Go to 1b)


b. [special transportation for the elderly]
1[] Frequently (Go to 1c)
2[] Sometimes (Go to 1c)
3[] Rarely (Go to 1c)
9[] DK (Go to 1c)


c. [meals delivered to your home by an agency or organization like Meals on Wheels]
1[] Frequently (Go to 1d)
2[] Sometimes (Go to 1d)
3[] Rarely (Go to 1d)
9[] DK (Go to 1d)


d. [meals in a senior center or in some place with a special meal program for the elderly]
1[] Frequently (Go to 1e)
2[] Sometimes (Go to 1e)
3[] Rarely (Go to 1e)
9[] DK (Go to 1e)


e. [homemaker service for the elderly that provides services like cleaning and cooking in the home]
1[] Frequently (Go to 1f)
2[] Sometimes (Go to 1f)
3[] Rarely (Go to 1f)
9[] DK (Go to 1f)


f. [information and referral services]
1[] Frequently (Go to Section O on page 87)
2[] Sometimes (Go to Section O on page 87)
3[] Rarely (Go to Section O on page 87)
9[] DK (Go to Section O on page 87)

[p.410]

Section O - UPDATE CONTACT PERSON INFORMATION

The National Center for Health Statistics may wish to contact you again to obtain additional health related information

ITEM O1
Refer to CP on label.

1[] CP on label (Ask 1a)
2[] No CP on label (Ask 1b)
1a. The last time a Census Bureau interviewer talked to you or your family, we were told that (CP on label) will always know how to get in touch with you if we want to contact you again. Is (CP on label) still the best person to contact if we are unable to reach you?

1[] Yes (Verify CP's address and phone number. If incorrect, enter correct information in 2 below.)
2[] No (Go to 1b)

b. The National Center for Health Statistics would like the name, address, and telephone number of a relative or friend who would know where you could be reached in case we need additional health information in the future but cannot reach you. Please give me the name of someone who is not currently living in the household.
(Record information in 2.)

2. Contact Person Information

Last name _____
First name _____
MI _____
Number and street _____
City _____
State _____
ZIP Code _____

Telephone
Area code _____
Number _____
1[] None
7[] Refused
9[] DK

[p.411]

Section P - INTERVIEWER OBSERVATIONS

ITEM P1
Mark (X) the one that best represents this interview.

1[] Self response without assistance (Skip to Item P2)
2[] Self response with assistance (Go to 1a)
3[] Proxy (Skip to 1b)

ASK OR VERIFY:
1a. How is (assistant) related to you?
If more than one assistant, indicate the relationship of the one you consider to be the main assistant.

00[] Parent (Skip to 1c)
01[] Spouse (Skip to 1c)
02[] Son/Daughter (Skip to 1c)
03[] Son-in-law/Daughter-in-law (Skip to 1c)
04[] Grandchild/Great grandchild (Skip to 1c)
05[] Brother/Sister (Skip to 1c)
06[] Brother-in-law/Sister-in-law (Skip to 1c)
07[] Aunt/Uncle/Cousin (Skip to 1c)
08[] Niece/Nephew (Skip to 1c)
09[] Other relative (Skip to 1c)
10[] Roommate/Friend/Neighbor (Skip to 1c)
11[] Other non-relative (Skip to 1c)

b. How are you related to (sample person)?
If more than one proxy, direct this question to the one you consider to be the main proxy.

00[] Parent
01[] Spouse
02[] Son/Daughter
03[] Son-in-law/Daughter-in-law
04[] Grandchild/Great grandchild
05[] Brother/Sister
06[] Brother-in-law/Sister-in-law
07[] Aunt/Uncle/Cousin
08[] Niece/Nephew
09[] Other relative
10[] Roommate/Friend/Neighbor
11[] Other non-relative

ASK OR VERIFY:
c. Do(es) [you/(assistant)] live here?

1[] Yes
2[] No
9[] DK

Mark each to indicate why a proxy/assistant was needed.
2a. Sample person hospitalized

1[] Yes
2[] No

b. Sample person institutionalized

1[] Yes
2[] No

c. Sample person's hearing problem

1[] Yes
2[] No

d. Sample person's speech problem

1[] Yes
2[] No

e. Sample person's language problem

1[] Yes
2[] No

f. Sample person's poor memory, senility, or confusion

1[] Yes
2[] No

g. Sample person's Alzheimer's disease

1[] Yes
2[] No

h. Sample person's other mental condition

1[] Yes
2[] No

i. Sample person's other physical illness and/or disability

1[] Yes
2[] No

j. Other non-health related reason

1[] Yes
2[] No

ITEM P2
Refer to SP's age.

1[] 70+ (Go to 3)
2[] Under 70 (END interview)

The "respondent" in the following items refers to the sample person if he/she answered questions with or without assistance, or to the proxy if the sample person was not interviewed.
3. Do you feel the --

a. Respondent was intellectually capable of responding?
1[] Yes
2[] No


b. Respondent's answers were reasonably accurate?
1[] Yes
2[] No


c. Respondent understood the questions?
1[] Yes
2[] No

[p.412]

Section P - INTERVIEWER OBSERVATIONS - Continued

4a. Was there a section which seemed to be particularly upsetting or problematic to the respondent?

1[] Yes (Go to 4b)
2[] No (Skip to 5)

b. Which section(s)?
Mark (X) all that apply.

01[] A. Housing and long-term care services
02[] B. Transportation
03[] C. Social activity
04[] D. Work history/employment
05[] E. Vocational rehabilitation
06[] F. Assistive devices and technologies
07[] G. Health insurance
08[] H. Assistance with key activities
09[] I. Other services
10[] J. Self direction
11[] K. Family structure, relationships, and living arrangements
12[] L. Conditions and impairments
13[] M. Health opinions and behaviors
14[] N. Community services
15[] O. Contact person

5. How tiring did the interview seem to be for the respondent?

1[] Very tiring
2[] A little tiring
3[] Not tiring

6. Did the respondent have difficulty hearing you during the interview?

1[] Yes (Go to 7)
2[] No (END interview)
9[] DK (END interview)

7. Do you feel the respondent's hearing difficulty affected the interview?

1[] Yes
2[] No

[p.413]

DISABILITY FOLLOWBACK SURVEY (NHIS PHASE II) SUPPLEMENT ON AGING QUESTIONNAIRE

Part 1 - CALL RECORD
Date

Month ____
Date ____

Beginning time

____ a.m.
____ p.m.

Results ____

Ending time

____ a.m.
____ p.m.

Comments ____

Part II - STATUS

A. Final Status
Interview

01[] Complete
02[] Partial (Explain in Notes)

Non interview

03[] SP refused (Explain in Notes)
04[] Proxy refused (Explain in Notes)
05[] Unable to contact (Explain in Notes)
06[] Unable to located (Explain in Notes)
07[] Deceased (Explain in Notes)
08[] Institutionalized, no proxy (Explain in Notes)
09[] Incapable, no proxy (Explain in Notes)
10[] Move o/s PSU, unable to phone (Explain in Notes)
11[] Other noninterview (Explain in Notes)

B. Mode

1[] Telephone
2[] Personal visit

C. Respondent

1[] Self
2[] Proxy
Reason for Proxy
1[] SP incapable (Fill II.D)
2[] SP institutionalized (Fill II.D)
3[] SP unavailable (Fill II.D)
4[] Other - Specify ____ (Fill II.D)

D. Proxy

Name ____

E. Field Representative's Name

____

Code ____

Part III - NEW ADDRESS

A. Address (Different from label)

Number and street ____
City ____
State ____
ZIP Code ____

B. Telephone (Different from label)

Area Code (____)
Number ____
1[] None
7[] Refused
9[] DK Number

[p.414]

INITIAL SCREENING

1. May I please speak with (sample person)?

1[] Yes (Skip to A below)
2[] No (Go to 2)

2. Why is (sample person) not available to be interviewed?

1[] SP deceased (Skip to 6)
2[] SP moved (Skip to 4)
3[] SP temporarily absent/unavailable (Go to 3)
4[] SP incapable (Skip to 5)
5[] Other (Skip to 5)

3. Will (sample person) [return/be available] before (closeout date)?

1[] Yes (Schedule appointment)
2[] No (Go to 4)
9[] DK (Go t 4)

4a. Has (sample person) moved to a new residence or is [he/she] in a health facility, group home, or some other place?

1[] SP moved (Record new address and telephone no.)
2[] SP in health facility/group home (Go to 4b)
3[] SP in jail (Skip to 5)
4[] SP in prison (END interview - non interview)
5[] SP on vacation/visiting/temporarily absent (Skip to 4d)

b. What type of facility or group home is this?
Mark (X) first appropriate box.

01[] Hospital (Go to 4c)
02[] Nursing/convalescent home (Go to 4c)
03[] Retirement home (Record new address and telephone no.)
04[] Group home (Record new address and telephone no.)
05[] Supervised apartment (Record new address and telephone no.)
06[] Halfway house (Record new address and telephone no.)
07[] Board and Care home (Record new address and telephone no.)
08[] Developmental Center (Record new address and telephone no.)
09[] Other supervise group residence or facility (Record new address and telephone no.)
10[] Other (Record new address and telephone no.)

c. Refer to age on label.

1[] Under 69 (Skip to 5)
2[] 69+ (Go to 4d)

d. Is it possible to interview (sample person) at the [facility/present location]?

1[] Yes (Record address and telephone no.)
2[] No (Go to 5)

5. Since I won't be able to interview (sample person), I need to talk to the person who knows the most about (sample person's) health. Who would that be?

1[] Respondent (Skip to A below)
2[] Other person (Record person's name, address, and telephone no.)
3[] No one (END interview - noninterview)
4[] DK/Ref (END interview - noninterview)

6. On what date did (sample person) die?

Month ___ ___ (Go to 7)
Day ___ ___ (Go to 7)
Year ___ ___ (Go to 7)
999999[] DK (Go to 7)

7. Did (sample person) die at home, in a hospital, in a nursing or convalescent home, or some other place?

1[] At home (END interview - noninterview)
2[] In hospital (END interview - noninterview)
3[] In nursing/convalescent home (END interview - noninterview)
4[] Other place (END interview - noninterview)
9[] DK (END interview - noninterview)

A
Begin interview by asking: When we conducted the interview several months ago we recorded (sample person's) age as (age from label). Is this still correct?

1[] Yes (Skip to Section A on page 4)
2[] No (Correct age on label, then skip to Section A on page 4)
[p.415]

INITIAL SCREENING - Continued

NEW ADDRESS (First or only)

Name of place (if appropriate) ___
Number and street ___
City ___
State ___
ZIP Code ___

Telephone
Area code ___
Number ___
1[] None
7[] Refused
9[] DK number

Second (if appropriate)

Name of place (if appropriate) ___
Number and street ___
City ___
State ___
ZIP Code ___

Telephone
Area code ___
Number ___
1[] None
7[] Refused
9[] DK number

PROXY RESPONDENT

Name ___
1[] Mark box if same address/phone as SP (Skip to A1 on page 4)
City ___
State ___
ZIP Code ___

Telephone
Area code ___
Number ___
1[] None
7[] Refused
9[] DK number
General instructions here, not typed elsewhere in survey so I skipped it. (EB)

[p.416]
Section A - HOUSING AND LONG-TERM CARE SERVICES

ITEM A1
Status of Sample Person (SP).

1[] Institutionalized (Skip to 6 on page 5)
2[] All others (Go to 1)

These first questions are about the place you live.
1. How long have you been living here?

00[] Less than 1 year

____ (Number) Years

99[] DK

2a. Is it NECESSARY to use any steps or stairs to get into this home from the outside?

1[] Yes
2[] No
9[] DK

b. Counting basements and step down living areas as separate levels, does this home have more than one floor or level?

1[] Yes (Go to 2c)
2[] No (Skip to 3)
9[] DK (Skip to 3)

c. Does this home have a bathroom, bedroom, and kitchen ALL on the SAME floor or level?

1[] Yes
2[] No
9[] DK

3. Because of a physical impairment or health problem, do you have any difficulty --

a. Entering or leaving your home?
1[] Yes
2[] No
9[] DK


b. Opening or closing any of the doors in your home?
1[] Yes
2[] No
9[] DK


c. Reaching or opening cabinets in your home?
1[] Yes
2[] No
9[] DK


d. Using the bathroom in your home?
1[] Yes
2[] No
9[] DK

4. Some residences have special features to assist persons who have physical impairments or health problems. Whether you use them or not, does your residence have any of these features?

a. Widened doorways or hallways?
1[] Yes
2[] No
9[] DK


b. Ramps or street level entrances?
1[] Yes
2[] No
9[] DK


c. Railings?
1[] Yes
2[] No
9[] DK


d. Automatic or easy to open doors?
1[] Yes
2[] No
9[] DK


e. Accessible parking or drop-off sites?
1[] Yes
2[] No
9[] DK


f. Bathroom modifications?
1[] Yes
2[] No
9[] DK


g. Kitchen modifications?
1[] Yes
2[] No
9[] DK


h. Elevator, chair lift, or stair glide?
1[] Yes
2[] No
9[] DK


i. Alerting devices?
1[] Yes
2[] No
9[] DK


j. Any other special features?
1[] Yes
2[] No
9[] DK

If all "Yes" in 4, skip to 6 on page 5; otherwise ask 5 only for those features NOT marked "Yes" in 4.
5. Which of these special features do you NEED to get around this home, but do not have?

a. [Widened doorways or hallways]
1[] Yes
2[] No
9[] DK


b. [Ramps or street level entrances]
1[] Yes
2[] No
9[] DK


c. [Railings]
1[] Yes
2[] No
9[] DK


d. [Automatic or easy to open doors]
1[] Yes
2[] No
9[] DK


e. [Accessible parking or drop-off sites]
1[] Yes
2[] No
9[] DK


f. [Bathroom modifications]
1[] Yes
2[] No
9[] DK


g. [Kitchen modifications]
1[] Yes
2[] No
9[] DK


h. [Elevator, chair lift, or stair glide]
1[] Yes
2[] No
9[] DK


i. [Alerting devices]
1[] Yes
2[] No
9[] DK


j. [Any other special features]
1[] Yes
2[] No
9[] DK

[p.417]
Section A - HOUSING AND LONG-TERM CARE SERVICES - Continued

ASK OR VERIFY:
6a. Is this place a -- (Read all categories)
Mark (X) only one.

01[] Single family house or townhouse that is not part of a retirement community, (Skip to 9 on page 6)
02[] Single family house, townhouse, or apartment that is part of a retirement community, (Skip to 7)
03[] Regular apartment, (Skip to 9 on page 6)
04[] Supervised apartment, (Go to 6b)
05[] Group home, (Go to 6b)
06[] Halfway house, (Go to 6b)
07[] Personal care or board and care home, (Go to 6b)
08[] Developmental center, (Go to 6b)
09[] Some other type of supervised group residence or facility, (Go to 6b)
10[] Assisted living facility, (Go to 6b)
11[] Nursing or convalescent home, (Go to 6b)
12[] Retirement home, (Go to 6b)
13[] Center for Independent Living, or (Go to 6b)
14[] Something else? (Go to 6b)
99[] DK (Go to 6b)

ASK OR VERIFY:
b. Does this place primarily or exclusively serve people who are elderly?

1[] Yes
2[] No
9[] DK

ITEM A2
Status of SP.

1[] Institutionalized (Skip to 10 on page 6)
2[] All others (Go to 7)
7. Whether you use them or not, does this place routinely provide services such as meals, help with housework or personal care, transportation, or recreation?

1[] Yes (Go to 8 on page 6)
2[] No (Skip to 9 on page 6)
9[] DK (Skip to 9 on page 6)

[p.418]

Section A - HOUSING AND LONG-TERM CARE SERVICES - Continued

8. Whether you use them or not, does this place routinely provide --

a. Group meals for residents?
1[] Yes
2[] No
9[] DK


b. Housekeeping or maid service?
1[] Yes
2[] No
9[] DK


c. Nursing or medical care?
1[] Yes
2[] No
9[] DK


d. Supervision or residents who give themselves their own medication?
1[] Yes
2[] No
9[] DK


e. Help with bathing, eating, or dressing?
1[] Yes
2[] No
9[] DK


f. Help with walking or getting about?
1[] Yes
2[] No
9[] DK


g. Help with shopping?
1[] Yes
2[] No
9[] DK


h. Planned social activities or trips?
1[] Yes
2[] No
9[] DK


i. Educational or training programs?
1[] Yes
2[] No
9[] DK


j. Help with laundry?
1[] Yes
2[] No
9[] DK


k. Help with money management?
1[] Yes
2[] No
9[] DK


l. Transportation?
1[] Yes
2[] No
9[] DK


m. Protective oversight?
1[] Yes
2[] No
9[] DK

9. Are you planning a move in order to receive any (additional) personal help, assistance or services?

1[] Yes
2[] No
9[] DK

Mark "Yes" if SP is currently living in a nursing home; otherwise ask:
10a. Have you EVER been a resident or patient in a nursing home?

1[] Yes (Go to 10b)
2[] No (Skip to 12 on page 7)
9[] DK (Skip to 12 on page 7)

b. How many DIFFERENT TIMES have you been a resident or patient in a nursing home (including the current time)?

____ (Number) Times
99[] DK

c. On what date were you admitted (the FIRST time)?
If date not known, ask: Was it within the past 12 months?

0000[] Now in nursing home

____ Month/19____ year

0001[] In past 12 months
0002[] Not in past 12 months
9999[] DK

Mark box if "Now in nursing home"; otherwise ask:
d. On what date were you discharged (the LAST time)?
If date not known, ask: Was it within the past 12 months?

0000[] Now in nursing home

____ Month/19____ year

0001[] In past 12 months
0002[] Not in past 12 months
9999[] DK

e. How long [were you/have you been] in the nursing home (the LAST time/THIS time)?

00[] Less than 1 month

____ (Number) Months

99[] DK

Ask if date in 10d is within the past 12 months, including "Now in". If not within the past 12 months, skip to 12 on page 7.
f. How many weeks in the past 12 months [were you/have you been] in a nursing home?

00[] Less than 1 week

____ (Number) Weeks

99[] DK

[p.419]

Section A - HOUSING AND LONG-TERM CARE SERVICES - Continued

HAND CARD A1. Read categories if telephone interview.

(card A1 not found)

11a. Who paid or will pay for your nursing home stays in the past 12 months?
(Anyone else?)
Mark (X) all that apply.

01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 12)
99[] DK (Skip to 12)

Ask if more than one source in 11a. If only one source in 11a, transcribe the number of the box marked without asking.
b. Who paid or will pay the most for your nursing home stays in the past12 months?
Record number of the main source.

___ ___ (Number) Paid most
99[] DK

Ask only if box 01 marked in 11a; otherwise, skip to 12.
c. During the past 12 months, about how much did you or your family pay for your nursing home stays? Do not count any money that has been or will be reimbursed by insurance or any other source.

000000[] None

$____ . [00]

999999[] DK

If "Now in nursing home" marked in 10d, skip to Section D on page 10; otherwise, ask:
12. Are you currently on a waiting list to go into a nursing home?

1[] Yes
2[] No
9[] DK

[p.420]

Section B - TRANSPORTATION

ITEM B1
Status of SP

1[] Institutionalized (Skip to Section D on page 10)
2[] All others (Go to 1)

These next questions are about getting around outside your home.
1. How frequently do you drive a car or other motor vehicle? Would you say -- (Read all categories)
Mark (X) only one.

1[] Every day or almost everyday, (Skip to 3)
2[] Occasionally, (Skip to 3)
3[] Seldom, or (Skip to 3)
4[] Never (Go to 2)
9[] DK (Skip to 3)

2. Is this because of an impairment or health problem?

1[] Yes
2[] No
9[] DK

3a. During the past 12 months, have you used local public transportation, such as a regular bus line, rapid transit, subway, or street car?
Mark (X) only one.

0[] No public transit system available (Skip to Section C on page 9)
1[] Yes (Skip to 3c)
2[] No (Skip to 3b)
9[] DK (Skip to 3b)

b. Does an impairment or health problem prevent or limit your use of the public transportation service?
Mark (X) only one.

0[] No public system available (Skip to Section C on page 9)
1[] Yes (Skip to Section C on page 9)
2[] No (Skip to Section C on page 9)
9[] DK (Skip to Section C on page 9)

c. During the past 12 months, how often did you use the local public transportation service? Would you say -- (Read all categories)
Mark (X) only one.

1[] Every day or almost everyday,
2[] Occasionally, or
3[] Seldom?
9[] DK

d. Because of an impairment or health problem, during the past 12 months, did you have any difficulty using the local public transportation service?

1[] Yes
2[] No
9[] DK

[p.421]

Section C - SOCIAL ACTIVITY

Reminder - If SP is institutionalized, skip to Section D on page 10.

These next questions are about various activities you many have participated in.
1. DURING THE PAST 2 WEEKS, did you --

a. Get together with friends or neighbors?
1[] Yes
2[] No
9[] DK


b. Talk with friends or neighbors on the telephone?
1[] Yes
2[] No
9[] DK


c. Get together with ANY relatives not including those living with you?
1[] Yes
2[] No
9[] DK


d. Talk with ANY relatives on the telephone not including those living with you?
1[] Yes
2[] No
9[] DK


e. Go to church, temple, or another place of worship for services or other activities?
1[] Yes
2[] No
9[] DK


f. Go to a show or movie, sports event, club meeting, class, or other group even?
1[] Yes
2[] No
9[] DK


g. Go out to eat at a restaurant?
1[] Yes
2[] No
9[] DK

2. How many days in the past two weeks did you leave your home for any reason?

14[] Every day
00[] None

____ (Number) Days

99[] DK

If proxy respondent, skip to Section D on page 10; otherwise ask:
3. Regarding your present social activities, do you feel that you are doing about enough, too much, or would you like to be doing more?
Mark (X) only one.

1[] About enough
2[] Too much
3[] Would like to be doing more
9[] DK

[p.422]

Section D - WORK HISTORY/EMPLOYMENT

These next questions are about working for pay or profit, and about unpaid volunteer work.
1. Have you EVER worked at a job or business?

1[] Yes (Go to 2)
2[] No (Skip to 7)
9[] DK (Skip to 7)

2. Do you NOW work at a job or business?

1[] Yes (Go to 3)
2[] No (Skip to 4)
9[] DK (Skip to 4)

3. About how many hours a week do you usually work at your current job?
(Note: If more than one job, include all jobs)

___ (Number) Hours per week (Skip to 5)
99[] DK (Skip to 5)

4. In what year did you stop working at your last job?

19___ year
99[] DK

5a. Have you retired from a job or business?

1[] Yes (Go to 5b)
2[] No (Skip to 7)
9[] DK (Skip to 7)

b. How old were you when you retired the last time?

___ Age
99[] DK

6. Did you retire because of an ongoing health problem, impairment, or disability?

1[] Yes
2[] No
9[] DK

7. DURING THE PAST 12 MONTHS, were you involved in unpaid volunteer work such as teaching or coaching, office work, or providing care?

1[] Yes (Go to 8)
2[] No (Skip to Section E on page 11)
9[] DK (Skip to Section E on page 11)

8. How many days did you do volunteer work in the past 12 months

____ (Days)
1[] Per week
2[] Per month
3[] Per year

9999[] DK

[p.423]

Section E - ASSISTIVE DEVICES AND TECHNOLOGY

The next questions are about medical devices and implants.

Ask all of 1a-o before going to 2.
1. During the past 12 months, did you use any of the following medical devices or supplies?

a. A tracheotomy tube?
1[] Yes
2[] No
9[] DK


b. A respirator?
1[] Yes
2[] No
9[] DK


c. An ostomy bag?
1[] Yes
2[] No
9[] DK


d. Catheterization equipment?
1[] Yes
2[] No
9[] DK


e. A glucose monitor?
1[] Yes
2[] No
9[] DK


f. Diabetic equipment or supplies?
1[] Yes
2[] No
9[] DK


g. An inhaler?
1[] Yes
2[] No
9[] DK


h. A nebulizer?
1[] Yes
2[] No
9[] DK


i. A hearing aid?
1[] Yes
2[] No
9[] DK


j. Crutches?
1[] Yes
2[] No
9[] DK


k. A cane?
1[] Yes
2[] No
9[] DK


l. A walker?
1[] Yes
2[] No
9[] DK


m. A wheelchair?
1[] Yes
2[] No
9[] DK


n. A scooter?
1[] Yes
2[] No
9[] DK


o. A feeding tube?
1[] Yes
2[] No
9[] DK

Ask for each "Yes" in 1.
2. Did you use (device) in the past two weeks?

a. [A tracheotomy tube]
1[] Yes
2[] No
9[] DK


b. [A respirator]
1[] Yes
2[] No
9[] DK


c. [An ostomy bag]
1[] Yes
2[] No
9[] DK


d. [Catheterization equipment]
1[] Yes
2[] No
9[] DK


e. [A glucose monitor]
1[] Yes
2[] No
9[] DK


f. [Diabetic equipment or supplies]
1[] Yes
2[] No
9[] DK


g. [An inhaler]
1[] Yes
2[] No
9[] DK


h. [A nebulizer]
1[] Yes
2[] No
9[] DK


i. [A hearing aid]
1[] Yes
2[] No
9[] DK


j. [Crutches]
1[] Yes
2[] No
9[] DK


k. [A cane]
1[] Yes
2[] No
9[] DK


l. [A walker]
1[] Yes
2[] No
9[] DK


m. [A wheelchair]
1[] Yes
2[] No
9[] DK


n. [A scooter]
1[] Yes
2[] No
9[] DK


o. [A feeding tube]
1[] Yes
2[] No
9[] DK

3. Do you now have any of the following implants?

a. Any shunt that drains away fluid?
1[] Yes
2[] No
9[] DK


b. An artificial joint?
1[] Yes
2[] No
9[] DK


c. Implanted lens?
1[] Yes
2[] No
9[] DK


d. Implanted pin, screw, nail, wire, rod, or plate?
1[] Yes
2[] No
9[] DK


e. An artificial heart valve?
1[] Yes
2[] No
9[] DK


f. A pacemaker?
1[] Yes
2[] No
9[] DK


g. Silicone implant?
1[] Yes
2[] No
9[] DK


h. Infusion pump?
1[] Yes
2[] No
9[] DK


i. Implanted catheter?
1[] Yes
2[] No
9[] DK


j. An organ implant?
1[] Yes
2[] No
9[] DK


k. A cochlear implant?
1[] Yes
2[] No
9[] DK

[p.424]

Section F - HEALTH INSURANCE

The next questions are about health insurance coverage.

There are several government programs that provide medical care or help pay medical bills.
People covered by Medicare have a card that looks like this.
SHOW MEDICARE CARD.
1a. In (month), were you covered by Medicare?

1[] Yes (Go to 1b)
2[] No (Skip to 2)
9[] DK (Skip to 2)

b. How long have you been covered by Medicare?
Read categories if necessary.
Mark (X) only one.

1[] Less than 6 months
2[] 6 months, but less than 1 year
3[] 1 year, but less than 2 years
4[] 2 years or more
9[] DK

There is a program called MEDICAID that pays for health care for persons in need. In this state, it is also called (state name).
2a. In (month), were you covered by Medicaid or (state name)?

1[] Yes (Go to 2b)
2[] No (Skip to 3)
9[] DK (Skip to 3)

b. How long have you had MEDICAID or (state name) coverage?
Read categories if necessary.
Mark (X) only one.

1[] Less than 6 months
2[] 6 months, but less than 1 year
3[] 1 year, but less than 2 years
4[] 2 years, but less than 5 years
5[] 5 years or more
6[] On and off for less than 2 years
7[] On and off for 2 years, but less than 5 years
8[] On and off for 5 years or more
9[] DK

3. In (month), were you covered by any other public assistance program (other than Medicaid) that pays for health care? Do not include use of public or free clinics if that is your only source of care.

1[] Yes
2[] No
9[] DK


4a. In (month), were you covered by military health care, including armed forces retirement benefits, the VA (Department of Veterans' Affairs), CHAMPUS, or CHAMP-VA?

1[] Yes (Go to 4b)
2[] No (Skip to 5)
9[] DK (Skip to 5)

b. Was this CHAMPUS, or CHAMP-VA
Read if necessary: CHAMPUS is a program of medical care for dependents of active duty or retired military personnel. CHAMP-VA is medical insurance for dependents or survivors of disabled veterans.

1[] Yes
2[] No
9[] DK

c. In (month), were you covered by any other military health care, including armed forces retirement benefits, or the VA (Department of Veterans' Affairs)?

1[] Yes
2[] No
9[] DK

5. In (month), were you covered by the Indian Health Service>

1[] Yes
2[] No
9[] DK

6a. (Not counting the government health programs we just mentioned), in (month), were you covered by a private health insurance plan?
Read if necessary: Besides government programs, people also get health insurance through their jobs or union, through other private groups, or directly from an insurance company. A variety of types of plans are available including Health Maintenance Organizations or HMOs.

1[] Yes (Go to 6b)
2[] No (Skip to Section G on page 13)
9[] DK (Skip to Section G on page 13)

b. Was any of this private health insurance obtained originally through the workplace, that is through a present or former employer or union?
Mark (X) only one.

1[] Employer
2[] Union
3[] Through workplace, DK which
4[] No
9[] DK

[p.425]

Section G - ASSISTANCE WITH KEY ACTIVITIES

Read to Respondent: The next questions are about how well you are able to do certain activities. Please tell me if you have any difficulty when you do the following.

Ask 1a-j before asking 2 and 3.
1. By yourself and not using aids, do you have any difficulty --

a. Walking for a quarter of a mile, (that is about 2 or 3 blocks)?
1[] Yes
2[] No
9[] NA/DK


b. Walking up 10 steps without resting?
1[] Yes
2[] No
9[] NA/DK


c. Standing or being on your feet for about 2 hours?
1[] Yes
2[] No
9[] NA/DK


d. Sitting for about 2 hours?
1[] Yes
2[] No
9[] NA/DK


By yourself and not using aids, do you have any difficulty --
e. Stooping, crouching, or kneeling?
1[] Yes
2[] No
9[] NA/DK


f. Reaching up over your head?
1[] Yes
2[] No
9[] NA/DK


g. Reaching out (as if to shake someone's hand)?
1[] Yes
2[] No
9[] NA/DK


h. Using your fingers to grasp or handle?
1[] Yes
2[] No
9[] NA/DK


By yourself and not using aids, do you have any difficulty --
i. Lifting or carrying something heavy as 25 pounds, (such as two full bags of groceries)?
1[] Yes
2[] No
9[] NA/DK


j. Lifting or carrying something as heavy as 10 pounds?
1[] Yes
2[] No
9[] NA/DK

Ask 2 and 3 for each "Yes" in 1a-j.

2. How much difficulty do you have (activity), some, a lot, or are you unable to do it?

[a. Walking for a quarter of a mile]
1[] Some
2[] A lot
3[] Unable
9[] DK


[b. Walking up 10 steps without resting]
1[] Some
2[] A lot
3[] Unable
9[] DK


[c. Standing or being on your feet for about 2 hours]
1[] Some
2[] A lot
3[] Unable
9[] DK


[d. Sitting for about 2 hours]
1[] Some
2[] A lot
3[] Unable
9[] DK


[e. Stooping, crouching, or kneeling]
1[] Some
2[] A lot
3[] Unable
9[] DK


[f. Reaching up over your head]
1[] Some
2[] A lot
3[] Unable
9[] DK


[g. Reaching out]
1[] Some
2[] A lot
3[] Unable
9[] DK


[h. Using your fingers to grasp or handle]
1[] Some
2[] A lot
3[] Unable
9[] DK


[i. Lifting or carrying something heavy as 25 pounds]
1[] Some
2[] A lot
3[] Unable
9[] DK


[j. Lifting or carrying something as heavy as 10 pounds]
1[] Some
2[] A lot
3[] Unable
9[] DK

3. For how long have you [had some difficulty/had a lot of difficulty/been unable to do] (activity)?

[a. Walking for a quarter of a mile]
00[] Less than 1 year
99[] DK
____ Number of years


[b. Walking up 10 steps without resting]
00[] Less than 1 year
99[] DK
____ Number of years


[c. Standing or being on your feet for about 2 hours]
00[] Less than 1 year
99[] DK
____ Number of years


[d. Sitting for about 2 hours]
00[] Less than 1 year
99[] DK
____ Number of years


[e. Stooping, crouching, or kneeling]
00[] Less than 1 year
99[] DK
____ Number of years


[f. Reaching up over your head]
00[] Less than 1 year
99[] DK
____ Number of years


[g. Reaching out]
00[] Less than 1 year
99[] DK
____ Number of years


[h. Using your fingers to grasp or handle]
00[] Less than 1 year
99[] DK
____ Number of years


[i. Lifting or carrying something heavy as 25 pounds]
00[] Less than 1 year
99[] DK
____ Number of years


[j. Lifting or carrying something as heavy as 10 pounds]
00[] Less than 1 year
99[] DK
____ Number of years

[p.426-427]

Section G - ASSISTANCE WITH KEY ACTIVITUES - Continued

READ TO RESPONDENT: These questions are about some other activities and how well you are able to do them by yourself and without using special equipment.

Ask questions 4A-G before continuing to Item G1.
4. Because of a health or physical problem, do you have any difficulty --
Ask if "Doesn't do": Is this because of a HEALTH or PHYSICAL problem? If "Yes", mark box 1; if "No" mark box 3.

(A) Bathing or showering
1[] "Yes
2[] No
3[] Doesn't do for other reason
9[] DK


(B) Dressing?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK


(C) Eating?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK


(D) Getting in and out of bed or chairs?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK


(E) Walking?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK


(F) Getting outside?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK


(G) Using the toilet, including getting to the toilet?
1[] Yes
2[] No
3[] Doesn't do for other reason
9[] DK

ITEM G1
(A) Bathing or showering
Refer to question 4.

1[] "Yes" marked (Go to 5)
2[] All other (Go to G1 for next activity)

(B) Dressing
Refer to question 4.

1[] "Yes" marked (Go to 5)
2[] All other (Go to G1 for next activity)

(C) Eating
Refer to question 4.

1[] "Yes" marked (Go to 5)
2[] All other (Go to G1 for next activity)

(D) Getting in and out of bed or chairs
Refer to question 4.

1[] "Yes" marked (Go to 5)
2[] All other (Go to G1 for next activity)

(E) Walking
Refer to question 4.

1[] "Yes" marked (Go to 5)
2[] All other (Go to G1 for next activity)

(F) Getting outside
Refer to question 4.

1[] "Yes" marked (Go to 5)
2[] All other (Go to G1 for next activity)

(G) Using the toilet, including getting to the toilet
Refer to question 4.

1[] "Yes" marked (Go to 5)
2[] All other (Skip to G2 for activity (A))

5. By yourself and without using any special equipment, how much difficulty do you have (activity), some, a lot or are you unable to do it?

(A) Bathing or showering
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (G1 for next activity)
9[] DK (Go to 6)


(B) Dressing
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (G1 for next activity)
9[] DK (Go to 6)


(C) Eating
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (G1 for next activity)
9[] DK (Go to 6)


(D) Getting in and out of bed or chairs
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (G1 for next activity)
9[] DK (Go to 6)


(E) Walking
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (G1 for next activity)
9[] DK (Go to 6)


(F) Getting outside
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (G1 for next activity)
9[] DK (Go to 6)


(G) Using the toilet, including getting to the toilet
1[] Some (Go to 6)
2[] A lot (Go to 6)
3[] Unable (G1 for activity (A))
9[] DK (Go to 6)

6. When you DO NOT HAVE HELP OR USE SPECIAL EQUIPMENT, is (activity) by yourself --

(A) Bathing or showering
0[] Never do without help or special equipment (Go to G1 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G1 for next activity)

(B) Dressing
0[] Never do without help or special equipment (Go to G1 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G1 for next activity)

(C) Eating
0[] Never do without help or special equipment (Go to G1 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G1 for next activity)

(D) Getting in and out of bed or chairs
0[] Never do without help or special equipment (Go to G1 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G1 for next activity)

(E) Walking
0[] Never do without help or special equipment (Go to G1 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G1 for next activity)

(F) Getting outside
0[] Never do without help or special equipment (Go to G1 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G1 for next activity)

(G) Using the toilet, including getting to the toilet
0[] Never do without help or special equipment (Go to G2 for activity (A))
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G2 for activity (A))

ITEM G2
(A) Bathing or showering
Refer to question 4

1[] Box 3 marked (Go to G2 for next activity)
2[] All other (Go to 7)

(B) Dressing
Refer to question 4

1[] Box 3 marked (Go to G2 for next activity)
2[] All other (Go to 7)

(C) Eating
Refer to question 4

1[] Box 3 marked (Go to G2 for next activity)
2[] All other (Go to 7)

(D) Getting in and out of bed or chairs
Refer to question 4

1[] Box 3 marked (Go to G2 for next activity)
2[] All other (Go to 7)

(E) Walking
Refer to question 4

1[] Box 3 marked (Go to G2 for next activity)
2[] All other (Go to 7)

(F) Getting outside
Refer to question 4

1[] Box 3 marked (Go to G2 for next activity)
2[] All other (Go to 7)

(G) Using the toilet, including getting to the toilet
Refer to question 4

1[] Box 3 marked (Skip to G3 on page 16)
2[] All other (Go to 7)

7a. Do you use any special equipment or aids in (activity)?

(A) Bathing or showering
1[] Yes (Go to 7b)
2[] No (Go to G2 for next activity)


(B) Dressing
1[] Yes (Go to 7b)
2[] No (Go to G2 for next activity)


(C) Eating
1[] Yes (Go to 7b)
2[] No (Go to G2 for next activity)


(D) Getting in and out of bed or chairs
1[] Yes (Go to 7b)
2[] No (Go to G2 for next activity)


(E) Walking
1[] Yes (Go to 7b)
2[] No (Go to G2 for next activity)


(F) Getting outside
1[] Yes (Go to 7b)
2[] No (Go to G2 for next activity)


(G) Using the toilet, including getting to the toilet
1[] Yes (Go to 7b)
2[] No (Skip to G3 on page 16)

b. What special equipment or aids do you use?
Anything else?
Mark (X) all that apply

(A) Bathing or showering
1[] Stool, seat or chair
2[] Handbar or rail
3[] Other
9[] DK


(B) Dressing
1[] Special clothes
2[] Special fasteners
3[] Cord, string, zipper pull
4[] Orthopedic shoes
5[] Other
9[] DK


(C) Eating
1[] Oversized eating equipment
2[] Bed or lap tray
3[] Covered cup/modified bowl
4[] Other
9[] DK


(D) Getting in and out of bed or chairs
1[] Cane or walking stick
2[] Walker
3[] Extra/special cushions
4[] Special "raising seat" chair/lift chair
5[] Hospital bed
6[] Trapeze/sling
7[] Ramp
8[] Other
9[] DK


(E) Walking
01[] Cane or walking stick
02[] Walker
03[] Crutch or crutches
04[] Wheelchair
05[] Artificial leg
06[] Brace
07[] Guide dog
08[] Oxygen/special breathing equipment
09[] Other
99[] DK


(F) Getting outside
01[] Cane or walking stick
02[] Walker
03[] Crutch or crutches
04[] Wheelchair
05[] Artificial leg
06[] Brace
07[] Guide dog
08[] Oxygen/special breathing equipment
09[] Other
99[] DK


(G) Using the toilet, including getting to the toilet
01[] Cane or walking stick
02[] Walker
03[] Crutch or crutches
04[] Wheelchair
05[] Artificial leg
06[] Brace
07[] Guide dog
08[] Bed pan
09[] Raised toilet seat
10[] Special toilet/portable toilet
11[] Hand holds/rails near toilet
12[] Other
99[] DK

c. When you USE SPECIAL EQUIPMENT AND DO NOT HAVE HELP is (activity) --

(A) Bathing or showering
0[] Never do without help or special equipment (Go to G2 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G2 for next activity)

(B) Dressing
0[] Never do without help or special equipment (Go to G2 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G2 for next activity)

(C) Eating
0[] Never do without help or special equipment (Go to G2 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G2 for next activity)

(D) Getting in and out of bed or chairs
0[] Never do without help or special equipment (Go to G2 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G2 for next activity)

(E) Walking
0[] Never do without help or special equipment (Go to G2 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G2 for next activity)

(F) Getting outside
0[] Never do without help or special equipment (Go to G2 for next activity)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G2 for next activity)

(G) Using the toilet, including getting to the toilet
0[] Never do without help (Go to G3 on page 16)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G3 on page 16)

[p.428-429]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM G3
(A) Bathing or showering
Refer to question 4 on page 14

1[] Box 3 marked (Go to G3 for next activity)
2[] All other (Go to 8)

(B) Dressing
Refer to question 4 on page 14

1[] Box 3 marked (Go to G3 for next activity)
2[] All other (Go to 8)

(C) Eating
Refer to question 4 on page 14

1[] Box 3 marked (Go to G3 for next activity)
2[] All other (Go to 8)

(D)
Getting in and out of bed or chairs
Refer to question 4 on page 14

1[] Box 3 marked (Go to G3 for next activity)
2[] All other (Go to 8)

(E) Walking
Refer to question 4

1[] Box 3 marked (Go to G3 for next activity)
2[] All other (Go to 8)

(F) Getting outside
Refer to question 4

1[] Box 3 marked (Go to G3 for next activity)
2[] All other (Go to 8)

(G) Using the toilet, including getting to the toilet
Refer to question 4 on page 14

1[] Box 3 marked (Skip to G4 for activity (A))
2[] All other (Go to 8)

8a. Do you receive help from another person in (activity)?

(A) Bathing or showering
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(B) Dressing
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(C) Eating
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(D) Getting in and out of bed or chairs
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(E) Walking
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(F) Getting outside
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(G) Using the toilet, including getting to the toilet
1[] Yes (Go to 8b)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)

b. Is this hands-on help?

(A) Bathing or showering
1[] Yes (Go to 8c)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(B) Dressing
1[] Yes (Go to 8c)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(C) Eating
1[] Yes (Go to 8c)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(D) Getting in and out of bed or chairs
1[] Yes (Go to 8c)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(E) Walking
1[] Yes (Go to 8c)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(F) Getting outside
1[] Yes (Go to 8c)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)


(G) Using the toilet, including getting to the toilet
1[] Yes (Go to 8c)
2[] No (Skip to 8e)
9[] DK (Skip to 8e)

c. When you HAVE HANDS-ON HELP FROM ANOTHER PERSON, is (activity) --

(A) Bathing or showering
0[] Never does activity (Skip to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(B) Dressing
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(C) Eating
0[] Never does activity (Skip to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(D) Getting in and out of bed or chairs
0[] Never does activity (Skip to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(E) Walking
0[] Never does activity (Skip to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(F) Getting outside
0[] Never does activity (Skip to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(G) Using the toilet, including getting to the toilet
0[] Never does activity (Skip to 8e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK


(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK


(3) Is it very painful?
1[] Yes
2[] No
9[] DK

d. How often do you have hands-on help with (activity)? Would you say always, sometimes, or rarely?

(A) Bathing or showering
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(B) Dressing
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(C) Eating
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(D) Getting in and out of bed or chairs
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(E) Walking
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(F) Getting outside
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(G) Using the toilet, including getting to the toilet
1[] Always
2[] Sometimes
3[] Rarely
9[] DK

e. Do you need (more) hands-on help with (activity)?

(A) Bathing or showering
1[] Yes (Go to G3 for next activity)
2[] No (Go to G3 for next activity)
9[] DK (Go to G3 for next activity)


(B) Dressing
1[] Yes (Go to G3 for next activity)
2[] No (Go to G3 for next activity)
9[] DK (Go to G3 for next activity)


(C) Eating
1[] Yes (Go to G3 for next activity)
2[] No (Go to G3 for next activity)
9[] DK (Go to G3 for next activity)


(D) Getting in and out of bed or chairs
1[] Yes (Go to G3 for next activity)
2[] No (Go to G3 for next activity)
9[] DK (Go to G3 for next activity)


(E) Walking
1[] Yes (Go to G3 for next activity)
2[] No (Go to G3 for next activity)
9[] DK (Go to G3 for next activity)


(F) Getting outside
1[] Yes (Go to G3 for next activity)
2[] No (Go to G3 for next activity)
9[] DK (Go to G3 for next activity)


(G) Using the toilet, including getting to the toilet
1[] Yes (Go to G4 for activity (A))
2[] No (Go to G4 for activity (A))
9[] DK (Go to G4 for activity (A))

ITEM G4
(A) Bathing or showering
Refer to G3 and 8b above

1[] Box 1 marked in G3 (Go to G4 for next activity)
2[] "Yes" in 8b (Go to G4 for next activity)
3[] All other (Go to 9)

(B) Dressing
Refer to G3 and 8b above

1[] Box 1 marked in G3 (Go to G4 for next activity)
2[] "Yes" in 8b (Go to G4 for next activity)
3[] All other (Go to 9)

(C) Eating
Refer to G3 and 8b above

1[] Box 1 marked in G3 (Go to G4 for next activity)
2[] "Yes" in 8b (Go to G4 for next activity)
3[] All other (Go to 9)

(D) Getting in and out of bed or chairs
Refer to G3 and 8b above

1[] Box 1 marked in G3 (Go to G4 for next activity)
2[] "Yes" in 8b (Go to G4 for next activity)
3[] All other (Go to 9)

(E) Walking
Refer to G3 and 8b above

1[] Box 1 marked in G3 (Go to G4 for next activity)
2[] "Yes" in 8b (Go to G4 for next activity)
3[] All other (Go to 9)

(F) Getting outside
Refer to G3 and 8b above

1[] Box 1 marked in G3 (Go to G4 for next activity)
2[] "Yes" in 8b (Go to G4 for next activity)
3[] All other (Go to 9)

(G) Using the toilet, including getting to the toilet
Refer to G3 and 8b above

1[] Box 1 marked in G3 (Skip to G5 on page 18 )
2[] "Yes" in 8b (Skip to G5 on page 18 )
3[] All other (Go to 9)

READ ONCE - Sometimes people just need to have someone supervise them or stay nearby in case any help is needed.
9a. Do you have someone who supervises you or stays nearby when you are (activity)?

(A) Bathing or showering
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)


(B) Dressing
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)


(C) Eating
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)


(D) Getting in and out of bed or chairs
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)


(E) Walking
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)


(F) Getting outside
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)


(G) Using the toilet, including getting to the toilet
1[] Yes (Go to 9b)
2[] No (Skip to 11)
9[] DK (Skip to 11)

b. Does this person provide --

(A) Bathing or showering
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(B) Dressing
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(C) Eating
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(D) Getting in and out of bed or chairs
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(E) Walking
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(F) Getting outside
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(G) Using the toilet, including getting to the toilet
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK

10. How often do you have supervision or standby help when you are (activity)? Would you say always, sometimes, or rarely?

(A) Bathing or showering
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(B) Dressing
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(C) Eating
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(D) Getting in and out of bed or chairs
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(E) Walking
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(F) Getting outside
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(G) Using the toilet, including getting to the toilet
1[] Always
2[] Sometimes
3[] Rarely
9[] DK

11. Do you need (more) supervision or standby help with (activity)?

(A) Bathing or showering
1[] Yes (Go to G4 for next activity)
2[] No (Go to G4 for next activity)
9[] DK (Go to G4 for next activity)


(B) Dressing
1[] Yes (Go to G4 for next activity)
2[] No (Go to G4 for next activity)
9[] DK (Go to G4 for next activity)


(C) Eating
1[] Yes (Go to G4 for next activity)
2[] No (Go to G4 for next activity)
9[] DK (Go to G4 for next activity)


(D) Getting in and out of bed or chairs
1[] Yes (Go to G4 for next activity)
2[] No (Go to G4 for next activity)
9[] DK (Go to G4 for next activity)


(E) Walking
1[] Yes (Go to G4 for next activity)
2[] No (Go to G4 for next activity)
9[] DK (Go to G4 for next activity)


(F) Getting outside
1[] Yes (Go to G4 for next activity)
2[] No (Go to G4 for next activity)
9[] DK (Go to G4 for next activity)


(G) Using the toilet, including getting to the toilet
1[] Yes (Go to G5 on page 18)
2[] No (Go to G5 on page 18)
9[] DK (Go to G5 on page 18)

[p.430]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

(A) Bathing or showering
ITEM G5
Refer to 8a, 8e, 9a and 11 on page 16

1[] Any "Yes" (Go to 12)
2[] All other (Go to G5 for activity (B))
12a. How often do you have a complete bath? This could be a tub bath, shower, sink bath or bed bath. Would you say (read categories)

1[] Everyday
2[] 2-3 times per week,
3[] Once a week, or
4[] Less than once a week?
9[] DK

b. How often do you have a partial bath? Would you say -- (Read categories)

1[] Everyday
2[] 2-3 times per week,
3[] Once a week, or
4[] Less than once a week?
9[] DK

13a. During the past month, did you experience discomfort because you were not able to bathe as often as you would have liked?
If necessary: That can be either physical or emotional discomfort.

1[] Yes
2[] No
9[] DK

b. During the past month, did you experience a burn or scald caused by bathing with water that was too hot?

1[] Yes (Go to G5 for activity (B))
2[] No (Go to G5 for activity (B))
9[] DK (Go to G5 for activity (B))

(B) Dressing
ITEM G5

Refer to 8a, 8e, 9a and 11 on page 16

1[] Any "Yes" (Go to 12)
2[] All other (Go to G5 for activity (C))
12a. Do you get dressed for the day -- (Read categories)

1[] Everyday (Skip to 13)
2[] 2-3 times per week, (Go to 12b)
3[] Once a week, or (Go to 12b)
4[] Do you stay in night clothes? (Go to 12b)
9[] DK (Go to 12b)

b. How often do you change your night clothes? Would you say -- (Read categories)

1[] Everyday
2[] 2-3 times per week,
3[] Once a week, or
4[] Less than once a week?
9[] DK

13. During the past month, did you experience discomfort because you were not able to change your clothes as often as you would have liked because you did not have help?

1[] Yes (Go to G5 for activity (C))
2[] No (Go to G5 for activity (C))
9[] DK (Go to G5 for activity (C))

(C) Eating
ITEM G5

Refer to 8a, 8e, 9a and 11 on page 16

1[] Any "Yes" (Go to 12)
2[] All other (Go to G5 for activity (D))
12a. During the past month, were there times you were unable to eat when you were hungry because no one was available to help you eat?

1[] Yes
2[] No
9[] DK

b. During the past month have you --

(1) Lost any weight because you were on a diet?
1[] Yes
2[] No
9[] DK


(2) Lost weight even though you were not on a diet?
1[] Yes
2[] No
9[] DK


(3) Been dehydrated, that is not had enough liquid in your diet?
1[] Yes (Go to G5 for activity (D))
2[] No (Go to G5 for activity (D))
9[] DK (Go to G5 for activity (D))

If necessary: If you were dehydrated you might have been thirsty or lost body fluids.

[p.431]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

(D) Getting in and out of bed or chairs
ITEM G5

Refer to 8a, 8e, 9a and 11 on page 17

1[] Any "Yes" (Go to 12)
2[] All other (Go to G5 for activity (E))
12a. Because of a health or physical problem, do you usually stay in bed all or most of the time?

1[] Yes (Skip to G5 for activity (E))
2[] No (Go to 12b)
9[] DK (Go to 12b)

b. Because of a health or physical problem, do you usually stay in a chair all or most of the time?

1[] Yes
2[] No
9[] DK

c. How often do you get out of bed? Would you say -- (Read categories)

1[] Everyday
2[] 2-3 times per week,
3[] Once a week, or
4[] Less than once a week?
9[] DK
(Go to G5 for activity (E))

(E) Walking
ITEM G5

Refer to 8a, 8e, 9a and 11 on page 17

1[] Any "Yes" (Go to 12)
2[] All other (Go to G5 for activity (G))
12a. How often do you move around your [house/apartment/room]? Would you say -- (Read categories)

1[] Whenever you want,
2[] Often enough to stretch and have a change of scenery now and then,
3[] Often enough to take care of toileting needs but not much more than that, or
4[] Not often enough even to use the bathroom?
9[] DK
(Go to G5 for activity (G))

(G) Using the toilet, including getting to the toilet
ITEM G5

Refer to 8a, 8e, 9a and 11 on page 17

1[] Any "Yes" (Go to 12)
2[] All other (Skip to G6 on page 20)
12a. During the past month, did you experience discomfort because you did not have help getting to the bathroom or changing soiled clothing as often as you needed to?
If necessary: That can be either physical or emotional discomfort.

1[] Yes
2[] No
9[] DK

b. During the past month, did you wet or soil yourself because you did not have help getting to the bathroom, using a bed pan or using a commode?

1[] Yes (Go to 12c)
2[] No (Skip to 12d)
9[] DK (Skip to 12d)

c. During the past month, did you experience skin problems such as a rash or irritation because of this?

1[] Yes
2[] No
9[] DK

d. During the past month, did you use a commode or bed pan because no help was available?

1[] Yes
2[] No
9[] DK
(Go to G6 on page 20)

[p.432]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM G6
Refer to question 4 for activities A-G on pages 14 and 15. Indicate the activities marked "Yes".
Insert these marked activities when asking 14.

[] A. Bathing or showering
[] B. Dressing
[] C. Eating
[] D. Getting in and out of bed or chairs
[] E. Walking
[] F. Getting outside
[] G. Using the toilet, including getting to the toilet
[] No activities marked (Skip to 15)

Insert activities marked in G6.
14a. What (other) condition causes the trouble in (activities)?
Record conditions and ask 14b.
Ask if operation:
For what condition did you have the operation?
Record up to 5 conditions.

00[] No condition (Skip to 15)
01[] Old age (Go to 14c)

(a) ____
(b) ____
(c) ____
(d) ____
(e) ____

b. Besides (condition), is there any other condition which causes this trouble in (activities)?

1[] Yes (Reask 14a and 14b)
2[] No (Go to 15)
9[] DK (Go to 15)

c. Is this trouble in (activities) cause by any specific condition?

1[] Yes (Reask 14a and 14b)
2[] No (Go to 15)
9[] DK (Go to 15)

15a. Do you have difficulty controlling your bowels?

1[] Yes (Go to 15b)
2[] No (Skip to 15c)
9[] DK (Skip to 15c)

b. How frequently do you have this difficulty -- daily, several times a week, once a week, or less than once a week?
Mark (X) only one.

1[] Daily
2[] Several times a week
3[] Once a week
4[] Less than once a week
9[] DK

c. Do you have a colostomy or a device to help control bowel movements?

1[] Yes (Go to 15d)
2[] No (Skip to 16a on page 21)
9[] DK (Skip to 16a on page 21)

d. Do you need help from another person in taking care of this device?

1[] Yes
2[] No
9[] DK

[p.433]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

16a. Do you have difficulty controlling urination?

1[] Yes (Go to 16b)
2[] No (Skip to 16c)
9[] DK (Skip to 16c)

b. How frequently do you have this difficulty -- daily, several times a week, once a week, or less than once a week?
Mark (X) only one.

1[] Daily
2[] Several times a week
3[] Once a week
4[] Less than once a week
9[] DK

c. Do you have a urinary catheter or a device to help control urination?

1[] Yes (Go to 16d)
2[] No (Skip to Item G7)
9[] DK (Skip to Item G7)

d. Do you need help from another person in taking care of this device?

1[] Yes
2[] No
9[] DK

ITEM G7
Status of SP

1[] Institutionalized (Skip to 27 on page 28)
2[] All others (Go to 17 on page 22)

[p.434-435]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

READ TO RESPONDENT: These questions are about some other activities. Please tell me about doing them by yourself.

Ask questions 17(H)-(O) before continuing to item G8.
17. Because of a health or physical problem, do you have ANY difficulty --
Ask if "Doesn't do": Is this because of a HEALTH or PHYSICAL problem?
If "Yes", mark box 1; if "No" mark box 3.

(H) Preparing your own meals?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(I) Shopping for groceries and personal items, such as toilet items or medicines?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(J) Managing your money, such as keeping track of expenses or paying bills?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(K) Using the telephone?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(L) Doing heavy housework, like scrubbing wood floors, or washing windows?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(M) Doing light housework, like doing dishes, straightening up, or light cleaning?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(N) Getting to places outside of walking distance?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No


(O) Managing your medication?
1[] Yes
2[] No
3[] Doesn't do for other reason
Does someone else regularly do this for you?
4[] Yes
5[] No

ITEM G8
(H) Preparing your own meals
Refer to question 17.

1[] Box 1 "Yes" marked (Go to 18)
2[] All other (Go to G8 for next activity)

(I) Shopping for groceries and personal items
Refer to question 17.

1[] Box 1 "Yes" marked (Go to 18)
2[] All other (Go to G8 for next activity)

(J) Managing your money
Refer to question 17.

1[] Box 1 "Yes" marked (Go to 18)
2[] All other (Go to G8 for next activity)

(K) Using the telephone
Refer to question 17.

1[] Box 1 "Yes" marked (Go to 18)
2[] All other (Go to G8 for next activity)

(L) Doing heavy housework
Refer to question 17.

1[] Box 1 "Yes" marked (Go to 18)
2[] All other (Go to G8 for next activity)

(M) Doing light housework
Refer to question 17.

1[] Box 1 "Yes" marked (Go to 18)
2[] All other (Go to G8 for next activity)

(N) Getting to places outside of walking distance
Refer to question 17.

1[] Box 1 "Yes" marked (Go to 18)
2[] All other (Go to G8 for next activity)

(O) Managing your medication
Refer to question 17.

1[] Box 1 "Yes" marked (Go to 18)
2[] All other (Skip to G9 on page 24)

18. By yourself, how much difficulty do you have (activity), -- some, a lot, or are you unable to do it?

(H) Preparing your own meals
1[] Some (Go to 19)
2[] A lot (Go to 19)
3[] Unable (Go to G8 for next activity)
9[] DK (Go to 19)


(I) Shopping for groceries and personal items
1[] Some (Go to 19)
2[] A lot (Go to 19)
3[] Unable (Go to G8 for next activity)
9[] DK (Go to 19)


(J) Managing your money
1[] Some (Go to 19)
2[] A lot (Go to 19)
3[] Unable (Go to G8 for next activity)
9[] DK (Go to 19)


(K) Using the telephone
1[] Some (Go to 19)
2[] A lot (Go to 19)
3[] Unable (Go to G8 for next activity)
9[] DK (Go to 19)


(L) Doing heavy housework
1[] Some (Go to 19)
2[] A lot (Go to 19)
3[] Unable (Go to G8 for next activity)
9[] DK (Go to 19)


(M) Doing light housework
1[] Some (Go to 19)
2[] A lot (Go to 19)
3[] Unable (Go to G8 for next activity)
9[] DK (Go to 19)


(N) Getting to places outside of walking distance
1[] Some (Go to 19)
2[] A lot (Go to 19)
3[] Unable (Go to G8 for next activity)
9[] DK (Go to 19)


(O) Managing your medication
1[] Some (Go to 19)
2[] A lot (Go to 19)
3[] Unable (Go to G8 for next activity)
9[] DK (Go to 19)

19. When you DO NOT HAVE HELP, is (activity) by yourself --

(H) Preparing your own meals
0[] Never do without help (Go to G8 for next activity)
a. Very tiring?
1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

c. Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G8 for next activity)

(I) Shopping for groceries and personal items
0[] Never do without help (Go to G8 for next activity)
a. Very tiring?
1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

c. Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G8 for next activity)

(J) Managing your money
0[] Never do without help (Go to G8 for next activity)
a. Very tiring?
1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

c. Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G8 for next activity)

(K) Using the telephone
0[] Never do without help (Go to G8 for next activity)
a. Very tiring?
1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

c. Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G8 for next activity)

(L) Doing heavy housework
0[] Never do without help (Go to G8 for next activity)
a. Very tiring?
1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

c. Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G8 for next activity)

(M) Doing light housework
0[] Never do without help (Go to G8 for next activity)
a. Very tiring?
1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

c. Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G8 for next activity)

(N) Getting to places outside of walking distance
0[] Never do without help (Go to G8 for next activity)
a. Very tiring?
1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

c. Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G8 for next activity)

(O) Managing your medication
0[] Never do without help (Skip to G9 for activity (H))
a. Very tiring?
1[] Yes
2[] No
9[] DK

b. Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

c. Is it very painful?
1[] Yes
2[] No
9[] DK

(Go to G9 on page 24)

[p.436-437]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM G9
(H) Preparing your own meals
Refer to question 17 on page 22.

1[] Box 3 marked (Go to G9 for next activity)
2[] All others (Go to 20)

(I) Shopping for groceries and personal items
Refer to question 17 on page 22.

1[] Box 3 marked (Go to G9 for next activity)
2[] All others (Go to 20)

(J) Managing your money
Refer to question 17 on page 22.

1[] Box 3 marked (Go to G9 for next activity)
2[] All others (Go to 20)

(K) Using the telephone
Refer to question 17 on page 22.

1[] Box 3 marked (Go to G9 for next activity)
2[] All others (Go to 20)

(L) Doing heavy housework
Refer to question 17 on page 22.

1[] Box 3 marked (Go to G9 for next activity)
2[] All others (Go to 20)

(M) Doing light housework
Refer to question 17 on page 22.

1[] Box 3 marked (Go to G9 for next activity)
2[] All others (Go to 20)

(N) Getting to places outside of walking distance
Refer to question 17 on page 22.

1[] Box 3 marked (Go to G9 for next activity)
2[] All others (Go to 20)

(O) Managing your medication
Refer to question 17 on page 22.

1[] Box 3 marked (Go to G10 for activity (H))
2[] All others (Go to 20)

20a. Do you receive help from another person in (activity)?

(H) Preparing your own meals
1[] Yes (Go to 20b)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(I) Shopping for groceries and personal items
1[] Yes (Go to 20b)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(J) Managing your money
1[] Yes (Go to 20b)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(K) Using the telephone
1[] Yes (Go to 20b)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(L) Doing heavy housework
1[] Yes (Go to 20b)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(M) Doing light housework
1[] Yes (Go to 20b)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(N) Getting to places outside of walking distance
1[] Yes (Go to 20b)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(O) Managing your medication
1[] Yes (Go to 20b)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)

b. Is this hands-on help?

(H) Preparing your own meals
1[] Yes (Go to 20c)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(I) Shopping for groceries and personal items
1[] Yes (Go to 20c)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(J) Managing your money
1[] Yes (Go to 20c)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(K) Using the telephone
1[] Yes (Go to 20c)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(L) Doing heavy housework
1[] Yes (Go to 20c)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(M) Doing light housework
1[] Yes (Go to 20c)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(N) Getting to places outside of walking distance
1[] Yes (Go to 20c)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)


(O) Managing your medication
1[] Yes (Go to 20c)
2[] No (Skip to 20e)
9[] DK (Skip to 20e)

c. When you HAVE HANDS-ON HELP FROM ANOTHER PERSON, is (activity):

(H) Preparing your own meals
0 [] Never does activity (Skip to 20e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK

(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(I) Shopping for groceries and personal items
0 [] Never does activity (Skip to 20e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK

(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(J) Managing your money
0 [] Never does activity (Skip to 20e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK

(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(K) Using the telephone
0 [] Never does activity (Skip to 20e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK

(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(L) Doing heavy housework
0 [] Never does activity (Skip to 20e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK

(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(M) Doing light housework
0 [] Never does activity (Skip to 20e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK

(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(N) Getting to places outside of walking distance
0 [] Never does activity (Skip to 20e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK

(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

(3) Is it very painful?
1[] Yes
2[] No
9[] DK


(O) Managing your medication
0 [] Never does activity (Skip to 20e)
(1) Very tiring?
1[] Yes
2[] No
9[] DK

(2) Does (activity) take a long time?
1[] Yes
2[] No
9[] DK

(3) Is it very painful?
1[] Yes
2[] No
9[] DK

d. How often do you have hands-on help with (activity)? Would you say always, sometimes, or rarely?

(H) Preparing your own meals
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(I) Shopping for groceries and personal items
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(J) Managing your money
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(K) Using the telephone
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(L) Doing heavy housework
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(M) Doing light housework
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(N) Getting to places outside of walking distance
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(O) Managing your medication
1[] Always
2[] Sometimes
3[] Rarely
9[] DK

e. Do you need (more) hands-on help with (activity)?

(H) Preparing your own meals
1[] Yes (Go to G9 for next activity)
2[] No (Go to G9 for next activity)
9[] DK (Go to G9 for next activity)


(I) Shopping for groceries and personal items
1[] Yes (Go to G9 for next activity)
2[] No (Go to G9 for next activity)
9[] DK (Go to G9 for next activity)


(J) Managing your money
1[] Yes (Go to G9 for next activity)
2[] No (Go to G9 for next activity)
9[] DK (Go to G9 for next activity)


(K) Using the telephone
1[] Yes (Go to G9 for next activity)
2[] No (Go to G9 for next activity)
9[] DK (Go to G9 for next activity)


(L) Doing heavy housework
1[] Yes (Go to G9 for next activity)
2[] No (Go to G9 for next activity)
9[] DK (Go to G9 for next activity)


(M) Doing light housework, like doing dishes
1[] Yes (Go to G9 for next activity)
2[] No (Go to G9 for next activity)
9[] DK (Go to G9 for next activity)


(N) Getting to places outside of walking distance
1[] Yes (Go to G9 for next activity)
2[] No (Go to G9 for next activity)
9[] DK (Go to G9 for next activity)


(O) Managing your medication
1[] Yes (Go to G10 for activity (H))
2[] No (Go to G10 for activity (H))
9[] DK (Go to G10 for activity (H))

ITEM G10
(H) Preparing your own meals
Refer to G9 and 20b

1[] Box 1 marked in G9 (Go to G10 for next activity)
2[] "Yes" marked in 20b (Go to G10 for next activity)
3[] Other (Go to 21)

(I) Shopping for groceries and personal items
Refer to G9 and 20b

1[] Box 1 marked in G9 (Go to G10 for next activity)
2[] "Yes" marked in 20b (Go to G10 for next activity)
3[] Other (Go to 21)

(J) Managing your money
Refer to G9 and 20b

1[] Box 1 marked in G9 (Go to G10 for next activity)
2[] "Yes" marked in 20b (Go to G10 for next activity)
3[] Other (Go to 21)

(K) Using the telephone
Refer to G9 and 20b

1[] Box 1 marked in G9 (Go to G10 for next activity)
2[] "Yes" marked in 20b (Go to G10 for next activity)
3[] Other (Go to 21)

(L) Doing heavy housework
Refer to G9 and 20b

1[] Box 1 marked in G9 (Go to G10 for next activity)
2[] "Yes" marked in 20b (Go to G10 for next activity)
3[] Other (Go to 21)

(M) Doing light housework
Refer to G9 and 20b

1[] Box 1 marked in G9 (Go to G10 for next activity)
2[] "Yes" marked in 20b (Go to G10 for next activity)
3[] Other (Go to 21)

(N) Getting to places outside of walking distance
Refer to G9 and 20b

1[] Box 1 marked in G9 (Go to G10 for next activity)
2[] "Yes" marked in 20b (Go to G10 for next activity)
3[] Other (Go to 21)

(O) Managing your medication
Refer to G9 and 20b

1[] Box 1 marked in G9 (Skip to G11 on page 26)
2[] "Yes" marked in 20b (Skip to G11 on page 26)
3[] Other (Go to 21)

READ ONCE: Sometimes people just need to have someone supervise them or stay nearby in case any help is needed.
21a. Do you have someone who supervises you or stays nearby when you are (activity)?

(H) Preparing your own meals
1[] Yes (Go to 21b)
2[] No (Skip to 23)
9[] DK (Skip to 23)


(I) Shopping for groceries and personal items
1[] Yes (Go to 21b)
2[] No (Skip to 23)
9[] DK (Skip to 23)


(J) Managing your money
1[] Yes (Go to 21b)
2[] No (Skip to 23)
9[] DK (Skip to 23)


(K) Using the telephone
1[] Yes (Go to 21b)
2[] No (Skip to 23)
9[] DK (Skip to 23)


(L)
Doing heavy housework
1[] Yes (Go to 21b)
2[] No (Skip to 23)
9[] DK (Skip to 23)


(M) Doing light housework
1[] Yes (Go to 21b)
2[] No (Skip to 23)
9[] DK (Skip to 23)


(N) Getting to places outside of walking distance
1[] Yes (Go to 21b)
2[] No (Skip to 23)
9[] DK (Skip to 23)


(O) Managing your medication
1[] Yes (Go to 21b)
2[] No (Skip to 23)
9[] DK (Skip to 23)

b. Does this person provide --

(H) Preparing your own meals
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(I) Shopping for groceries and personal items
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(J) Managing your money
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(K) Using the telephone
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(L) Doing heavy housework
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(M) Doing light housework
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(N) Getting to places outside of walking distance
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK


(O) Managing your medication
(1) Supervisory help, such as making sure the activity is performed correctly when you are (activity)?
1[] Yes
2[] No
9[] DK


(2) Standby help, such as observing to see if any help is needed when you are (activity)?
1[] Yes
2[] No
9[] DK

22. How often do you have supervision or standby help when you are (activity)? Would you say always, sometimes, or rarely?

(H) Preparing your own meals
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(I) Shopping for groceries and personal items
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(J) Managing your money
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(K) Using the telephone
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(L) Doing heavy housework
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(M) Doing light housework
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(N) Getting to places outside of walking distance
1[] Always
2[] Sometimes
3[] Rarely
9[] DK


(O) Managing your medication
1[] Always
2[] Sometimes
3[] Rarely
9[] DK

23. Do you need (more) supervision or standby help with (activity)?

(H) Preparing your own meals
1[] Yes (Go to G10 for next activity)
2[] No (Go to G10 for next activity)
9[] DK (Go to G10 for next activity)


(I) Shopping for groceries and personal items
1[] Yes (Go to G10 for next activity)
2[] No (Go to G10 for next activity)
9[] DK (Go to G10 for next activity)


(J) Managing your money
1[] Yes (Go to G10 for next activity)
2[] No (Go to G10 for next activity)
9[] DK (Go to G10 for next activity)


(K) Using the telephone
1[] Yes (Go to G10 for next activity)
2[] No (Go to G10 for next activity)
9[] DK (Go to G10 for next activity)


(L) Doing heavy housework
1[] Yes (Go to G10 for next activity)
2[] No (Go to G10 for next activity)
9[] DK (Go to G10 for next activity)


(M) Doing light housework
1[] Yes (Go to G10 for next activity)
2[] No (Go to G10 for next activity)
9[] DK (Go to G10 for next activity)


(N) Getting to places outside of walking distance
1[] Yes (Go to G10 for next activity)
2[] No (Go to G10 for next activity)
9[] DK (Go to G10 for next activity)


(O) Managing your medication
1[] Yes (Go to G11 on page 26 for activity (H))
2[] No (Go to G11 on page 26 for activity (H))
9[] DK (Go to G11 on page 26 for activity (H))

[p.438-439]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

(H) Preparing your own meals
ITEM G11

Refer to 20a, 20e, 21a, and 23 on page 24

1[] Any "Yes" (Go to 24)
2[] All other (Go to G11 for activity (I))
24a. During the past month, did you experience discomfort because you were unable to eat when you were hungry because no one was available to prepare food?

1[] Yes
2[] No
9[] DK

b. During the past month, were you unable to follow a special diet because you needed help cooking?

1[] Yes
2[] No
9[] DK

c. During the past month, were you unable to eat the kind of food you are used to and you prefer because you needed help cooking?

1[] Yes (Go to G11 for activity (I))
2[] No (Go to G11 for activity (I))
9[] DK (Go to G11 for activity (I))

(I) Shopping for groceries and personal items
ITEM G11

Refer to 20a, 20e, 21a, and 23 on page 24

1[] Any "Yes" (Go to 24)
2[] All other (Go to G11 for activity (L))
24a. During the past month, were you unable to follow a special diet because you needed help shopping?

1[] Yes
2[] No
9[] DK

b. During the past month, did you miss a meal because you were unable to shop?

1[] Yes (Go to G11 for activity (L))
2[] No (Go to G11 for activity (L))
9[] DK (Go to G11 for activity (L))

(L) Doing heavy housework
ITEM G11

Refer to 20a, 20e, 21a, and 23 on page 25

1[] Any "Yes" (Go to 24)
2[] All other (Go to G11 for activity (M))
24. During the past month, did you experience distress because you were not able to wash clothes or clean up around the house?

1[] Yes (Go to G11 for activity (M))
2[] No (Go to G11 for activity (M))
9[] DK (Go to G11 for activity (M))

(M) Doing light housework
ITEM G11

Refer to 20a, 20e, 21a, and 23 on page 25

1[] Any "Yes" (Go to 24)
2[] All other (Go to G11 for activity (N))
24. During the past month, did you experience distress because you were not able to do dishes or straighten up around the house?

1[] Yes (Go to G11 for activity (N))
2[] No (Go to G11 for activity (N))
9[] DK (Go to G11 for activity (N))

(N) Getting to places outside of walking distance
ITEM G11

Refer to 20a, 20e, 21a, and 23 on page 25

1[] Any "Yes" (Go to 24)
2[] All other (Skip to G12 for activity (H))
24a. During the past month, did you miss a doctor's or other medical appointment because you were unable to get there?

1[] Yes
2[] No
9[] DK

b. During the past month, were you unable to go places you wanted to for fun or recreation because you did not have transportation?

1[] Yes
2[] No
9[] DK

c. During the past month, did you run out of food because you were unable to get to the store?

1[] Yes (Go to G12 for activity (H))
2[] No (Go to G12 for activity (H))
9[] DK (Go to G12 for activity (H))

ITEM G12
(H) Prepare your own meals
Refer to 17 on page 22.

1[] Box 3 marked (Go to G12 for next activity)
2[] All other (Go to 25)

(I) Shop for groceries and personal items
Refer to 17 on page 22.

1[] Box 3 marked (Go to G12 for next activity)
2[] All other (Go to 25)

(J) Manage your money
Refer to 17 on page 22.

1[] Box 3 marked (Go to G12 for next activity)
2[] All other (Go to 25)

(L) Do heavy housework
Refer to 17 on page 23.

1[] Box 3 marked (Go to G12 for next activity)
2[] All other (Go to 25)

(M) Do light housework
Refer to 17 on page 23.

1[] Box 3 marked (Go to G12 for next activity)
2[] All other (Go to 25)

25. In your household, how often do YOU (activity)? Would you say always, sometimes, rarely, or never?

(H) Prepare your own meals
1[] Always (Go to G12 for next activity)
2[] Sometimes (Go to G12 for next activity)
3[] Rarely (Go to G12 for next activity)
4[] Never (Go to G12 for next activity)
9[] DK (Go to G12 for next activity)


(I) Shop for groceries and personal items
1[] Always (Go to G12 for next activity)
2[] Sometimes (Go to G12 for next activity)
3[] Rarely (Go to G12 for next activity)
4[] Never (Go to G12 for next activity)
9[] DK (Go to G12 for next activity)


(J) Manage your money
1[] Always (Go to G12 for activity (L))
2[] Sometimes (Go to G12 for activity (L))
3[] Rarely (Go to G12 for activity (L))
4[] Never (Go to G12 for activity (L))
9[] DK (Go to G12 for activity (L))


(L) Do heavy housework
1[] Always (Go to G12 for next activity)
2[] Sometimes (Go to G12 for next activity)
3[] Rarely (Go to G12 for next activity)
4[] Never (Go to G12 for next activity)
9[] DK (Go to G12 for next activity)


(M) Do light housework
1[] Always (Skip to G13 on page 28)
2[] Sometimes (Skip to G13 on page 28)
3[] Rarely (Skip to G13 on page 28)
4[] Never (Skip to G13 on page 28)
9[] DK (Skip to G13 on page 28)

[p.440]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM G13
Refer to question 17 for activities H-O on pages 22 and 23. Indicated the activities marked "Yes".
Insert these marked activities when asking 26.

[] H. Preparing your own meals
[] I. Shopping for groceries and personal items
[] J. Managing your money
[] K. Using the telephone
[] L. Doing heavy housework
[] M. Doing light house work
[] N. Getting to places outside of walking distance
[] O. Managing your medication
[] No activities marked (Skip to 27)

Insert activities marked in G13.
26a. What (other) condition causes the trouble in (activities)?
Record conditions and ask 26b.
Ask if operation:
For what condition did you have the operation?
Record up to 5 conditions

00[] No condition (Skip to 27)
01[] Old age (Skip to 26c)
(a) ____
(b) ____
(c) ____
(d) ____
(e) ____

b. Besides (condition), is there any other condition which causes this trouble in (activities)?

1[] Yes (Reask 26a and b)
2[] No (Skip to 27)
9[] DK (Skip to 27)

c. Is this trouble in (activities) caused by any specific condition?

1[] Yes (Reask 26a and b)
2[] No (Go to 27)
9[] DK (Go to 27)

27a. During the past 12 months, that is since (today's date) a year ago, have you fallen?

1[] Yes (Go to 27b)
2[] No (Skip to Item G14 on page 29)
9[] DK (Skip to Item G14 on page 29)

b. Have you fallen more than once during the past 12 months?

1[] Yes
2[] No
9[] DK

c. Were you injured as a result of the fall(s)?

1[] Yes (Go to 27d)
2[] No (Skip to 27e)
9[] DK (Skip to 27e)

d. What kind of injuries did you have -- a fracture, bruise, scrape or cut; did you lose consciousness, or did you have some other injury?
Mark (X) all that apply.

1[] Fracture
2[] Bruise, cut, or scrape
3[] Lost consciousness
4[] Other
9[] DK

e. [Did you fall/Were any of these falls] because you did not have help getting around or because your helper could not prevent you from falling?

1[] Yes
2[] No
9[] DK

f. [Did you fall/Were any of these falls] because you felt dizzy?

1[] Yes
2[] No
9[] DK

[p.441]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM G14
Status of SP

1[] Institutionalized (Skip to 40 on page 33)
2[] All others (Go to Item G15)
ITEM G15
Refer to questions 8a, columns A, D, and G on pages 16-17. [Receives help]
Mark (X) all that apply.

[] "Yes" in 8a for A. Bathing (Go to 28)
[] "Yes" in 8a for D. Getting in/out of bed/chairs (Go to 28)
[] "Yes" in 8a for G. Using the toilet (Go to 28)
[] All others (Skip to 29)
28. You said that you receive help with [bathing/(and) getting in or out of a bed or chair/(and) using the toilet]. Is the person who helps you most with [this/these activities] strong enough to give you the help you need or is helping physically difficult for him or her?

1[] Yes, strong enough
2[] No, physically difficult
9[] DK

If proxy respondent, ask; otherwise skip to item G16.
29. Does (sample person) need supervision to ensure [his/her] personal safety or the safety of others?

1[] Yes
2[] No
9[] DK

ITEM G16
Refer to questions 8a and 9a on pages 16-17 and questions 20a and 21a on pages 24-25. (Receives help and/or supervision)
Mark (X) all that apply.

[] "Yes" in 8a or 9a for A. Bathing (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 8a or 9a for B. Dressing (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 8a or 9a for C. Eating (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 8a or 9a for D. Getting in/out of bed/chairs (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 8a or 9a for E. Walking (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 8a or 9a for F. Getting outside (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 8a or 9a for G. Using the toilet (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 20a or 21a for H. Preparing your own meals (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 20a or 21a for I. Shopping (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 20a or 21a for J. Managing your money (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 20a or 21a for K. Using the telephone (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 20a or 21a for L. Doing heavy housework (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 20a or 21a for M. Doing light housework (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 20a or 21a for N. Getting places (Insert marked activities when asking question 30 on page 30)
[] "Yes" in 20a or 21a for O. Managing your medication (Insert marked activities when asking question 30 on page 30)
[] All others (Skip to 38 on page 32)
[p.442]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

30. Who usually helps you with (activities marked in G16)?
Anyone else? Enter the name or description of each helper in separate column.

(01) ____ First helper

Ask 31-35 for each helper in 30.
ASK OR VERIFY:
31. Which activities does (Helper) help you with?
Mark (X) all that apply.

01[] Bathing or showering
02[] Dressing
03[] Eating
04[] Getting in or out of bed/chairs
05[] Walking
06[] Getting outside
07[] Using or getting to the toilet
08[] Preparing your own meals
09[] Shopping for groceries
10[] Managing your money
11[] Using the telephone
12[] Doing heavy housework
13[] Doing light housework
14[] Getting to places
15[] Managing your medications
99[] DK

ASK OR VERIFY:
HAND CARD A5. Read answers if telephone interview.

(Card A5 not found)

32a. Which of these best describes (Helper)?
Mark (X) only one.

01[] Spouse (In household)
02[] Child (In household)
03[] Parent (In household)
04[] Spouse (Not in household)
05[] Child (Not in household)
06[] Parent (Not in household)
07[] Other HH relative
08[] Non-HH relative
09[] HH non-relative
10[] Friend/Neighbor
11[] Unpaid volunteer from organization/business
12[] Paid employee of organization/business
13[] Paid employee of yours
14[] Other
99[] DK

ASK OR VERIFY:
b. Is (Helper) male or female?

1[] Male
2[] Female
9[] DK

If parent, child, spouse, or unpaid volunteer in 32a, skip to 34; otherwise ask:
33a. Is (Helper) paid?

1[] Yes (Go to 33b)
2[] No (Skip to 34)

HAND CARD A1. Read answers if telephone interview.

(Card A1 not found)

b. Who pays for this help?
(Anyone else?)
Mark (X) all that apply.

01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free
99[] DK

34. DURING THE PAST 2 WEEKS, how many days did (Helper) help you?

00[] None in the past 2 weeks
____(number) Days
99[] DK

35. On the days you receive help from (Helper), about how many hours per day does [he/she] usually help you?

____(number) Hours/day (Go to 31 for next helper, or G17)
99[] DK (Go to 31 for next helper, or G17)

ITEM G17
Refer to 30 above.
(Number of helpers)

[] Only one helper (Skip to 37 on page 32)
[] More than one helper (Go to 36 on page 32)
[p.443]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

36. You said that (Read all helpers) assist you. Who helps you the most? If 2 or more equally, ask the respondent to specify who he/she considers the main helper.

Helper No. ____
Name: ____

Ask 37 about only helper listed in 30 or main helper in 36.
37. How satisfied are you with --

a. (Helper's) scheduled hours or availability when you need [him/her]? Would you say very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK


b. The amount of assistance (helper) provides? (Would you say -- (Read categories)?)
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK


c. (Helper's) willingness to do what you ask? (Would you say -- (Read categories)?)
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK


d. (Helper's) ability to do what you need [him/her] to do? (Would you say -- (Read categories)?)
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK

If helper is present or related to SP, skip to 38; otherwise, ask:
How satisfied are you with --

e. (Helper's) reliability? (Would you say -- (Read categories)?)
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK


f. (Helper's) trustworthiness? (Would you say -- (Read categories)?)
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK


g. How (helper) treats you? (Would you say -- (Read categories)?)
1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK

38a. Including other persons living here, is there a friend, relative, or neighbor who would take care of you for a few DAYS, if necessary?

1[] Yes (Go to 38b)
2[] No (Skip to 40 on page 33)
9[] DK (Skip to 40 on page 33)

b. Who is this person?
Probe for description if necessary
Mark (X) only one.

1[] HH member - Related
2[] HH member - Unrelated
3[] Non HH member - Related
4[] Non HH member - Unrelated
9[] DK

[p.444]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

39a. Again, including other persons living here, is there a friend, relative, or neighbor who would take care of you for a few WEEKS, if necessary?

1[] Yes (Go to 39b)
2[] No (Skip to 40)
9[] DK (Skip to 40)

b. Who is this person?
Probe for description if necessary
Mark (X) only one.

1[] HH member - Related
2[] HH member - Unrelated
3[] Non HH member - Related
4[] Non HH member - Unrelated
9[] DK

40a. [In the past 12 months/In the 12 months prior to moving to this (type of institution)], did you experience problems of any kind because you were home by yourself?

1[] Yes (Go to 40b)
2[] No (Skip to Item H1 on page 34)
9[] DK (Skip to Item H1 on page 34)

b. What kind of problems did you have?
Anything else?
Read categories if necessary
Mark (X) all that apply.

01[] Fall
02[] Other accident or injury
03[] Incontinence - no reminders
04[] Incontinence - unable to get to toilet
05[] Confinement to bed or chairs
06[] Hunger or thirst
07[] Fire on stove/left stove on
08[] Fell asleep while smoking
09[] Got lost/wandered off
10[] Forgot medications
11[] Took wrong dose of medication (too much/too little)
12[] Fear
13[] Other
99[] DK

[p.445]

Section H - OTHER SERVICES

ITEM H1
Status of SP.

1[] Institutionalized (Skip to Section I on page 39)
2[] All others (Go to 1)

Now I would like to ask about prescription medicines.
1. How many different prescription medicines are you supposed to use? Please count ones you should use each day and those that you use regularly but not every day. Include injections, eye drops, suppositories, creams, ointments, and skin patches, but not vitamins, oxygen, or medicines you get through an IV.
Mark (X) only one.

0[] None (Skip to 9 on page 35)
1[] One or two (Go to 2)
2[] Three - five (Go to 2)
3[] Six - nine (Go to 2)
4[] Ten or more (Go to 2)
9[] DK (Go to 2)

The next questions are about these prescription medicines.
2. Would you say that you use medicine(s) as prescribed by the doctor -- (Read all categories)
Mark (X) only one.

1[] All of the time, (Skip to 6)
2[] Most of the time (Go to 3)
3[] Some of the time, (Go to 3)
4[] Rarely, or, (Go to 3)
5[] Never? (Go to 3)
9[] DK (Go to 3)

3. Are there any prescription medicines that you are supposed to use, but --

a. did not get when first prescribed because of the cost?
1[] Yes
2[] No
9[] DK
b. did not get the entire prescription filled because of the cost?
1[] Yes
2[] No
9[] DK
c. did not refill when you ran out because of the cost?
1[] Yes
2[] No
9[] DK
d. use less often than prescribed in order to stretch them out because of the cost?
1[] Yes
2[] No
9[] DK
e. sometimes forget to use?
1[] Yes
2[] No
9[] DK
f. don't use as prescribed because of the side effects?
1[] Yes
2[] No
9[] DK
g. cannot pick up from the drug store or get delivered?
1[] Yes
2[] No
9[] DK
h. don't use because you think you don't need it?
1[] Yes
2[] No
9[] DK

4. Have you experienced any problems because you forgot to use your medicine or didn't use your medicine as prescribed?

1[] Yes (Go to 5)
2[] No (Skip to 6)
9[] DK (Skip to 6)

5. What problems did you experience?
Anything else?
Mark (X) all that apply.

01[] Pain/Discomfort
02[] Dizziness/Fainting
03[] Disorientation
04[] Overdose/Withdrawal
05[] Change in blood pressure, breathing, or other vital signs
06[] Condition for which medicine prescribed got worse
07[] Other condition(s) got worse
08[] Had to be admitted to hospital
09[] Had to go to doctor/emergency room
10[] Drug reaction
11[] Other
99[] DK

6. Do you receive help using your medications? This includes reminding you or measuring the medicines, and setting them up for you, OR do you use ALL of your medicine completely by yourself?
Mark (X) only one.

1[] Receive help
2[] All by self
9[] DK

7. Not counting financial help, do you NEED (more) help with your medicine?

1[] Yes (Go to 8)
2[] No (Skip to 9 on page 35)
9[] DK (Skip to 9 on page 35)

8. What do you NEED (more) help with?
Anything else?
Mark (X) all that apply.

1[] Ordering/Shopping for/Getting medicines from pharmacy
2[] Reminder/Monitoring/Measuring/Setting up/Taking medicines
3[] Other
9[] DK

[p.446]

Section H - OTHER SERVICES - Continued

These next questions are about your sources of medical care.
9. Do you have a general practitioner, internist, or family doctor whom you see regularly?

1[] Yes (Go to 10)
2[] No (Skip to 14 on page 36)
9[] DK (Skip to 14 on page 36)

10. Which do you see most often -- a general practitioner, an internist, or family doctor?
Mark (X) only one.

1[] General practitioner
2[] Internist
3[] Family doctor
4[] DK specialty/title
5[] DK which seen most often

11. Have you seen this [(provider in 10)/doctor] in the past 12 months?

1[] Yes (Go to 12)
2[] No (Skip to 13)
9[] DK (Skip to 13)

12. In the past 3 months, how many times have you seen this [(provider in 10)/doctor]?

00[] None

____(number) Times

99[] DK

13. How would you rate this [(provider in 10)/doctor] in terms of overall quality of care and service? Would you say excellent, good, fair, or poor?
Mark (X) only one.

1[] Excellent
2[] Good
3[] Fair
4[] Poor
9[] DK

[p.447-448]

Section H - OTHER SERVICES - Continued

The next questions are about other services you may have received.
14a. During the past 12 months, did you receive any services from ___ ?

(A) A visiting nurse
1[] Yes (Skip to 15)
2[] No (Go to 14b)
9[] DK (Go to 14b)


(B) A personal care attendant (other than family or a friend)
1[] Yes (Skip to 15)
2[] No (Go to 14b)
9[] DK (Go to 14b)


(C) An adult day care center or day activity center
1[] Yes (Skip to 15)
2[] No (Go to 14b)
9[] DK (Go to 14b)

b. Did you need the services of ___ in the past 12 months?

(A) A visiting nurse
1[] Yes (Skip to 18)
2[] No (Go to 14a for next service)
9[] DK (Go to 14a for next service)


(B) A personal care attendant (other than family or a friend)
1[] Yes (Skip to 18)
2[] No (Go to 14a for next service)
9[] DK (Go to 14a for next service)


(C) An adult day care center or day activity center
1[] Yes (Skip to 18)
2[] No (Skip to 19 on page 38)
9[] DK (Skip to 19 on page 38)

15a. During the past 12 months, in how many months did you receive services from?

(A) A visiting nurse
A visiting nurse
____ (Number) Months
99[] DK


(B) A personal care attendant (other than family or a friend)
A visiting nurse
____ (Number) Months
99[] DK


(C) An adult day care center or day activity center
A visiting nurse
____ (Number) Months
99[] DK

b. What was the total number of times you received services from ___ during [that/those] month(s)?

(A) A visiting nurse
A visiting nurse
____ (Number) Times
99[] DK


(B) A personal care attendant (other than family or a friend)
A visiting nurse
____ (Number) Times
99[] DK


(C) An adult day care center or day activity center
A visiting nurse
____ (Number) Times
99[] DK

HAND CARD A1. Read categories if telephone interview

(Card A1 not found)

16a. Who paid or will pay for the services received from ___ in the past 12 months?
(Anyone else?)
Mark (X) all that apply.

(A) A visiting nurse
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 17)
99[] DK (Skip to 17)


(B) A personal care attendant (other than family or a friend)
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 17)
99[] DK (Skip to 17)


(C) An adult day care center or day activity center
01[] Self or family in household
02[] Family NOT in household
03[] Private health insurance
04[] Medicare
05[] Medicaid
06[] Rehabilitation program
07[] Employer
08[] School system
09[] VA program
10[] Other military
11[] Other private source
12[] Other public source
13[] No one/Free (Skip to 17)
99[] DK (Skip to 17)

Ask if more than one source in 16a. If only one, transcribe number of box marked without asking.
b. Who paid most of the cost for the services received from ___ in the past 12 months? Record number of main source.

(A) A visiting nurse
__ __ (Number) Paid most
99[] DK


(B) A personal care attendant (other than family or a friend)
__ __ (Number) Paid most
99[] DK


(C) An adult day care center or day activity center
__ __ (Number) Paid most
99[] DK

17. During (month) did you receive services from ___ ?

(A) A visiting nurse
1[] Yes (Skip to 14a for next service)
2[] No (Go to 18)
9[] DK (Skip to 14a for next service)


(B) A personal care attendant (other than family or a friend)
1[] Yes (Skip to 14a for next service)
2[] No (Go to 18)
9[] DK (Skip to 14a for next service)


(C)
An adult day care center or day activity center
1[] Yes (Skip to 14a for next service)
2[] No (Go to 18)
9[] DK (Skip to 14a for next service)

Hand card A7. Read categories if telephone interview.

(Card A7 not found)

18. Why didn't you receive services from ____ [in (month)/ in the past 12 months]?
(Anything else)
Mark (X) all that apply.

(A) A visiting nurse
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(B) A personal care attendant (other than family or a friend)
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK


(C) An adult day care center or day activity center
00[] Didn't need services
01[] Provider thinks services no longer needed
02[] Too expensive/can't afford
03[] Insurance doesn't cover
04[] Insurance no longer covers
05[] No longer on Medicaid
06[] Provider not available
07[] Didn't like provider
08[] Transportation problems
09[] Could not take time off from work
10[] Other
99[] DK

[p.449]

Section H - OTHER SERVICES - Continued

19a. Are you currently on a waiting list for services from a visiting nurse, personal care attendant, or an adult day care or day activity center?

1[] Yes (Go to 19b)
2[] No (Skip to 20)
9[] DK (Skip to 20)

b. For which of these services are you on a waiting list?
Read list if necessary.
Mark (X) all that apply.

01[] A visiting nurse
02[] A personal care attendant, other than family or a friend
03[] An adult day care center or day activity center
09 DK

20a. Do you NEED help filling out insurance forms or benefit applications?
Mark (X) only one.

1[] Yes (Go to 20b)
2[] No (Go to 20b)
3[] Never filled forms/applications (Skip to Section I on page 39)
9[] DK (Go to 20b)

b. Who helps you fill out insurance forms or applications for public programs or benefits?
Mark (X) all that apply.

0[] No one
1[] Household member
2[] Friend/Other relative not in household
3[] Paid caregiver
4[] Volunteer from organization
5[] Other
9[] DK

[p.450]

Section I - FAMILY STRUCTURE, RELATIONSHIPS, AND LIVING ARRANGEMENTS

1. Are you now married, widowed, divorced, separated, or have you never been married?
If married, probe as necessary to determine if the spouse is a current household member.
Mark (X) only one.

1[] Married - spouse in HH (Go to 2a)
2[] Married - spouse not in HH (Go to 2a)
3[] Widowed (Go to 2b)
4[] Divorced (Go to 2b)
5[] Separated (Go to 2b)
6[] Never married (Skip to Item I1)
9[] DK (Skip to Item I1)

2a. How long have you been married to your current spouse?

00[] Less than 1 year (Skip to Item I1)

____(Number) Years (Skip to Item I1)

99[] DK (Skip to Item I1)

b. How long have you been [widowed/divorced/separated]?

00[] Less than 1 year

____(Number) Years

99[] DK

ITEM I1
Status of SP

1[] Institutionalized (Skip to 5 on page 40)
2[] All others (Go to 3)
3. Including yourself, how many people altogether live in this household?

01[] SP only (Skip to 5 on page 40)

____ (Number) Household members (Go to 4)

99[] DK (Go to 4a)

4a. What are the names of all persons living in your household?
Enter SP on line 1, all others on subsequent lines.
If more than 9 household members, continue listing in the Notes space.

Name (First/Middle initial/Last)
01 ____
02 ____
03 ____
04 ____
05 ____
06 ____
07 ____
08 ____
09 ____

b. If necessary, ask: What is (name's) sex?

01
1[] M
2[] F

02
1[] M
2[] F

03
1[] M
2[] F

04
1[] M
2[] F

05
1[] M
2[] F

06
1[] M
2[] F

07
1[] M
2[] F

08
1[] M
2[] F

09
1[] M
2[] F

c. If necessary ask: How is (name) related TO YOU? Record relationship to sample person

01 77[] SAMPLE PERSON
02 ____
03 ____
04 ____
05 ____
06 ____
07 ____
08 ____
09 ____

[p.451]

Section I - FAMILY STRUCTURE, RELATIONSHIPS, AND LIVING ARRANGEMENTS - Continued

5a. Including step and adopted children, how many LIVING SONS do you have?

00[] None

____ (Number) Sons

99[]DK

b. Including step and adopted children, how many LIVING DAUGHTERS do you have?

00[] None

____ (Number) Daughters

99[]DK

ITEM I2
Refer to 5a and 5b above.
(Living children)

1[] 1+ living children (Go to Item I3)
2[] All others (Skip to Item I4 on page 41)

ITEM I3
Refer to question 4 on page 39.
(Household composition)

1[] Any of SP's child(ren) in HH (Skip to 7)
2[] All others (Go to 6)
6a. How quickly can [any of your children/your son/your daughter] get here?
If asked, "Here" means where the SP resides.

____ (Number)
1[] Minutes
2[] Hours
3[] Days


999[] DK

b. How often do you see [any of your children/your son/your daughter]?

000[] Less than once a year/Never

____ (Times)
1[] Per day
2[] Per week
3[] Per month
4[] Per year


999[] DK

c. How often do you talk on the telephone with [any of your children/your son/your daughter]?

000[] Less than once a year/Never

____ (Times)
1[] Per day
2[] Per week
3[] Per month
4[] Per year


999[] DK

d. How often do you get mail from [any of your children/your son/your daughter]?

000[] Less than once a year/Never

____ (Times)
1[] Per day
2[] Per week
3[] Per month
4[] Per year


999[] DK

7. [Do your children/Does your son/Does your daughter] routinely give you money to help with your living expenses or pay your bills?

1[] Yes
2[] No
3[] DK

[p.452]

Section I - FAMILY STRUCTURE, RELATIONSHIPS, AND LIVING ARRANGEMENTS - Continued

ITEM I4
Refer to question 4 on page 39.
(Household composition)
Mark (X) first appropriate box.

1[] SP institutionalized (Skip to 11)
2[] SP lives alone (Skip to 11)
3[] SP lives w/spouse only (Skip to 11)
4[] Other (Go to 8)
8. (Other than your spouse) [is/are any of] the person(s) living with you 18 years of age or older?

1[] Yes (Go to 9)
2[] No (Skip to 11)
9[] DK (Skip to 11)

9. Do you live with [these people/this person] NOW because YOU need to share living expenses?

1[] Yes
2[] No
9[] DK

10. Do you live with [these people/this person] NOW because of a health or physical problem YOU have?

1[] Yes
2[] No
9[] DK

11. Including step and adopted brothers, how many LIVING brothers do you have?

00[] None

____ (Number) Brothers

99[]DK

12. Including step and adopted sisters, how many LIVING sisters do you have?

00[] None

____ (Number) Sisters

99[]DK

ASK OR VERIFY:
13a. Is your mother still living?

1[] Yes
2[] No
9[] DK

b. Is your father still living?

1[] Yes
2[] No
9[] DK

ITEM I5
Refer to Item I4.
(SP's living arrangements)

1[] Box 1, 2, or 3 marked (Go to 14)
2[] Box 4 marked (Skip to 15)

The next few questions are about contact you have with family members (other than your spouse or children).
14a. How quickly can any member of your family (other than your spouse or children) get here?
If asked, "Here" means where the SP resides.

000[] No other family (Skip to Section J on page 42)

____ (Number)
1[] Minutes
2[] Hours
3[] Days


999[] DK

b. How often do you see any member of your family (other than your spouse or children)?

000[] Less than once a year/Never

____ (Times)
1[] Per day
2[] Per week
3[] Per month
4[] Per year


999[] DK

c. How often do you talk on the telephone with any member of your family (other than your spouse or children?

000[] Less than once a year/Never

____ (Times)
1[] Per day
2[] Per week
3[] Per month
4[] Per year


999[] DK

d. How often do you get mail from any member of your family (other than your spouse or children)?

000[] Less than once a year/Never

____ (Times)
1[] Per day
2[] Per week
3[] Per month
4[] Per year


999[] DK

15. Do any members of your family (other than your spouse or children) routinely give you money to help with your living expenses or pay your bills?

1[] Yes
2[] No
9[] DK

[p.453]

Section J -CONDITIONS AND IMPAIRMENTS

Now I'm going to ask some questions about vision and hearing. Please tell me if you have any of the following conditions, even if you have mentioned them before.
1. Do you NOW have --

a. Cataracts?
1[] Yes
2[] No
9[] DK


b. Glaucoma?
1[] Yes
2[] No
9[] DK


c. Blindness in both eyes?
1[] Yes (Skip to 3)
2[] No
9[] DK


d. Blindness in one eye?
1[] Yes
2[] No
9[] DK


e. Any other trouble seeing with one or both eyes, EVEN when wearing glasses?
1[] Yes
2[] No
9[] DK

2a. Do you use eyeglasses? Include eyeglasses that just magnify.

1[] Yes (Go to 2b)
2[] No (Skip to 2c)
9[] DK (Skip to 2c)

b. Were these eyeglasses prescribed for you?

1[] Yes
2[] No
9[] DK

c. Do you use contact lenses?

1[] Yes
2[] No
9[] DK

3. Have you EVER had an operation for cataracts?

1[] Yes
2[] No
9[] DK

ITEM J1
Refer to 1c above.
(Blind in both eyes)

1[] "Yes" marked in 1c (Skip to 6)
2[] All others (Go to 4)
4. Do you have a lens implant?

1[] Yes
2[] No
9[] DK

5. Do you use a magnifying glass to read or to do other close work?

1[] Yes
2[] No
9[] DK

6. Do you NOW have --

a. Deafness in both ears?
1[] Yes (Skip to 7)
2[] No
9[] DK


b. Deafness in one ear?
1[] Yes
2[] No
9[] DK


c. Any other trouble hearing with one or both ears?
1[] Yes
2[] No
9[] DK

[p.454]

Section J - CONDITIONS AND IMPAIRMENTS - Continued

Now I'm going to ask about some other conditions. Again, please tell me if you ever had any of these conditions, even if you have mentioned them before.

Ask all of 7a(1)-(11) before going to 7b-d across.
7a. Have you EVER had --

(1) A broken hip?
1[] Yes
2[] No
9[] DK


(2) Osteoporosis?
1[] Yes
2[] No
9[] DK


(3) Diabetes?
1[] Yes
2[] No
9[] DK


(4) Arthritis?
1[] Yes
2[] No
9[] DK


(5) Chronic bronchitis or emphysema?
1[] Yes
2[] No
9[] DK


(6) Asthma?
1[] Yes
2[] No
9[] DK


(7) Hypertension, sometimes called high blood pressure?
1[] Yes
2[] No
9[] DK


(8) Heart disease, including coronary heart disease, angina, heart attack or myocardial infarction?
1[] Yes
2[] No
9[] DK


(9) Any other heart disease?
1[] Yes
2[] No
9[] DK


(10) A stroke or cerebrovascular accident?
1[] Yes
2[] No
9[] DK


(11) Cancer of any kind?
1[] Yes
2[] No
9[] DK

Ask 7b-d as appropriate for each "Yes" in 7a.
b. In what year [did/was] (condition) first [occur/noticed]?

(1) [A broken hip]
19___ Year
99[] DK


(2) [Osteoporosis]
19___ Year
99[] DK


(3) [Diabetes]
19___ Year
99[] DK


(4) [Arthritis]
19___ Year
99[] DK


(5) [Chronic bronchitis or emphysema]
19___ Year
99[] DK


(6) [Asthma]
19___ Year
99[] DK


(7) [Hypertension, sometimes called high blood pressure]
19___ Year
99[] DK


(8) [Heart disease, including coronary heart disease, angina, heart attack or myocardial infarction?]
19___ Year
99[] DK


(9) [Any other heart disease?]
19___ Year
99[] DK


(10) [A stroke or cerebrovascular accident?]
19___ Year
99[] DK


(11) [Cancer of any kind?]
19___ Year
99[] DK

c. Did a doctor ever tell you that you had (condition)?

(2) [Osteoporosis]
1[] Yes
2[] No
9[] DK


(3) [Diabetes]
1[] Yes
2[] No
9[] DK


(4) [Arthritis]
1[] Yes
2[] No
9[] DK


(5) [Chronic bronchitis or emphysema]
1[] Yes
2[] No
9[] DK


(6) [Asthma]
1[] Yes
2[] No
9[] DK


(7) [Hypertension, sometimes called high blood pressure]
1[] Yes
2[] No
9[] DK


(8) [Heart disease, including coronary heart disease, angina, heart attack or myocardial infarction?]
1[] Yes
2[] No
9[] DK


(9) [Any other heart disease?]
1[] Yes
2[] No
9[] DK


(10) [A stroke or cerebrovascular accident?]
1[] Yes
2[] No
9[] DK


(11) [Cancer of any kind?]
1[] Yes
2[] No
9[] DK

d. Do you still have (condition)?

(3) [Diabetes]
1[] Yes
2[] No
9[] DK


(5) [Chronic bronchitis or emphysema]
1[] Yes
2[] No
9[] DK


(6) [Asthma]
1[] Yes
2[] No
9[] DK


(7) [Hypertension, sometimes called high blood pressure]
1[] Yes
2[] No
9[] DK


(11) [Cancer of any kind?]
1[] Yes
2[] No
9[] DK

ITEM J2
Refer to 7a (11).
(Cancer of any kind)

1[] "Yes" marked in 7a (11) (Go to 8)
2[] All others (Skip to 9 on page 44)

HAND CARDA19. Read categories if telephone interview.

(Card A19 not found)

8. What kind of cancer [was/is] it?
(Anything else?)
Mark (X) all that apply.

01[] Colon/rectal/bowel
02[] Skin - melanoma
03[] Skin - nonmelanoma
04[] Skin - unknown type
05[] Uterine/ovarian
06[] Prostate
07[] Stomach
08[] Leukemia
09[] Breast
10[] Cervical
11[] Lung
12[] Other
99[] DK

[p.455]

Section J - CONDITIONS AND IMPAIRMENTS - Continued

9a. Do you sometimes have trouble with dizziness?

1[] Yes (Go to 9b)
2[] No (Skip to 10)
9[] DK (Skip to 10)

b. Does dizziness prevent you in any way from doing things you otherwise could do?

1[] Yes
2[] No
9[] DK

10. Do you have trouble biting or chewing any kinds of food, such as firm meat or apples?
If asked, this includes while wearing false teeth or dentures.

1[] Yes
2[] No
9[] DK

[p.456]

Section K - HEALTH OPINIONS AND BEHAVIORS

READ TO RESPONDENT - Now I'd like to ask your personal opinions about health related matters.
1. Would you say your health in general is excellent, very good, good, fair, or poor?

1[] Excellent
2[] Very good
3[] Good
4[] Fair
5[] Poor
9[] DK

If proxy respondent, skip to 3; otherwise ask.
2. In the past 12 months, how often did you feel sad or depressed? Would you say you were sad or depressed -- (Read all categories)
Mark (X) only one.

1[] All of the time,
2[] Some of the time,
3[] A little of the time, or
4[] None of the time?
9[] DK

3. Compared to your own level of physical activity 1 year ago, would you say you are now more active, less active, or about the same as you were then?
Mark (X) only one.

1[] More active
2[] Less active
3[] About the same
9[] DK

4. Do you follow a REGULAR routine of physical exercise?

1[] Yes
2[] No
9[] DK

5. About how tall are you without shoes?

____ Feet ____ Inches

999[] DK

6. About how much do you weight without shoes?

____ Pounds

999[] DK

If proxy respondent, skip to 8; otherwise ask.
7. What was your usual weight at the age of 50?

____ Pounds

999[] DK

8. Have you ever smoked at least 100 cigarettes in your entire life?
If asked: Approximately 5 packs.

1[] Yes (Go to 9)
2[] No (Skip to 11)
9[] DK (Skip to 11)

9. Do you NOW smoke cigarettes every day, some days, or not at all?

1[] Every day
2[] Some days
3[] Not at all
9[] DK

10. For how many years [have you smoked/did you smoke] cigarettes?

00[] Less than 1 year

____ (Number) Years

99[] DK

11. Now I would like to ask about drinking alcoholic beverages. By alcoholic beverages I mean beer, wine, or liquor. Have you had at least one drink of beer, wine, or liquor during the past year?

1[] Yes (Go to 12)
2[] No (Skip to Section L on page 46)
9[] DK (Skip to Section L on page 46)

12. During the past year, on the average, on how many days did you drink alcoholic beverages, that is beer, wine, or liquor?

0000[] Every day

____ (Number) Days
1[] Per week
2[] Per month
3[] Per year


9999[] DK

13. On [the/those] day(s) when you drank, about how many drinks would you say you had?

____ (Number) Drink(s)

99[] DK

[p.457]

Section L - COMMUNITY SERVICES

NOTE - Ask 2 immediately after a "Yes" in 1a-f.
READ TO RESPONDENT - The next questions are about community services

1. [In the past 12 months/In the 12 months prior to coming to this (type of institution)] , did you --

a. Use a senior center?
1[] Yes (Go to 2a)
2[] No (Go to 1b)
9[] DK (Go to 1b)


b. Use special transportation for the elderly?
1[] Yes (Go to 2b)
2[] No (Go to 1c)
9[] DK (Go to 1c)


c. Have meals delivered to your home by an agency or organization like Meals on Wheels?
1[] Yes (Go to 2c)
2[] No (Go to 1d)
9[] DK (Go to 1d)


d. Eat meals in a senior center or in some place with a special meal program for the elderly?
1[] Yes (Go to 2d)
2[] No (Go to 1e)
9[] DK (Go to 1e)


e. Use a homemaker service for the elderly that provides services like cleaning and cooking in the home?
1[] Yes (Go to 2e)
2[] No (Go to 1f)
9[] DK (Go to 1f)


f. Use information and referral services?
1[] Yes (Go to 2f)
2[] No (Go to Section M on page 47)
9[] DK (Go to Section M on page 47)

2. How often did you use it -- frequently, sometimes, or rarely?

a. [senior center]
1[] Frequently (Go to 1b)
2[] Sometimes (Go to 1b)
3[] Rarely (Go to 1b)
9[] DK (Go to 1b)


b. [special transportation for the elderly]
1[] Frequently (Go to 1c)
2[] Sometimes (Go to 1c)
3[] Rarely (Go to 1c)
9[] DK (Go to 1c)


c. [meals delivered to your home by an agency or organization like Meals on Wheels]
1[] Frequently (Go to 1d)
2[] Sometimes (Go to 1d)
3[] Rarely (Go to 1d)
9[] DK (Go to 1d)


d. [meals in a senior center or in some place with a special meal program for the elderly]
1[] Frequently (Go to 1e)
2[] Sometimes (Go to 1e)
3[] Rarely (Go to 1e)
9[] DK (Go to 1e)


e. [homemaker service for the elderly that provides services like cleaning and cooking in the home]
1[] Frequently (Go to 1f)
2[] Sometimes (Go to 1f)
3[] Rarely (Go to 1f)
9[] DK (Go to 1f)


f. [information and referral services]
1[] Frequently (Go to Section M on page 47)
2[] Sometimes (Go to Section M on page 47)
3[] Rarely (Go to Section M on page 47)
9[] DK (Go to Section M on page 47)

[p.458]

Section M - UPDATE CONTACT PERSON INFORMATION

The National Center for Health Statistics may wish to contact you again to obtain additional health related information

ITEM M1
Refer to CP on label.

1[] CP on label (Ask 1a)
2[] No CP on label (Ask 1b)
1a. The last time a Census Bureau interviewer talked to you or your family, we were told that (CP on label) will always know how to get in touch with you if we want to contact you again. Is (CP on label) still the best person to contact if we are unable to reach you?

1[] Yes (Verify CP's address and phone number. If incorrect, enter correct information in 2 below.)
2[] No (Go to 1b)

b. The National Center for Health Statistics would like the name, address, and telephone number of a relative or friend who would know where you could be reached in case we need additional health information in the future but cannot reach you. Please give me the name of someone who is not currently living in the household.
(Record information in 2.)

2. Contact Person Information

Last name _____
First name _____
MI _____
Number and street _____
City _____
State _____
ZIP Code _____

Telephone
Area code _____
Number _____
1[] None
7[] Refused
9[] DK

[p.459]

Section N - INTERVIEWER OBSERVATIONS

ITEM N1
Mark (X) the one that best represents this interview.

1[] Self response without assistance (Skip to 3)
2[] Self response with assistance (Go to 1a)
3[] Proxy (Skip to 1b)

ASK OR VERIFY:
1a. How is (assistant) related to you?
If more than one assistant, indicate the relationship of the one you consider to be the main assistant.

00[] Parent (Skip to 1c)
01[] Spouse (Skip to 1c)
02[] Son/Daughter (Skip to 1c)
03[] Son-in-law/Daughter-in-law (Skip to 1c)
04[] Grandchild/Great grandchild (Skip to 1c)
05[] Brother/Sister (Skip to 1c)
06[] Brother-in-law/Sister-in-law (Skip to 1c)
07[] Aunt/Uncle/Cousin (Skip to 1c)
08[] Niece/Nephew (Skip to 1c)
09[] Other relative (Skip to 1c)
10[] Roommate/Friend/Neighbor (Skip to 1c)
11[] Other non-relative (Skip to 1c)

b. How are you related to (sample person)?
If more than one proxy, direct this question to the one you consider to be the main proxy.

00[] Parent
01[] Spouse
02[] Son/Daughter
03[] Son-in-law/Daughter-in-law
04[] Grandchild/Great grandchild
05[] Brother/Sister
06[] Brother-in-law/Sister-in-law
07[] Aunt/Uncle/Cousin
08[] Niece/Nephew
09[] Other relative
10[] Roommate/Friend/Neighbor
11[] Other non-relative

ASK OR VERIFY:
c. Do(es) [you/(assistant)] live here?

1[] Yes
2[] No
9[] DK

Mark each to indicate why a proxy/assistant was needed.
2a. Sample person hospitalized

1[] Yes
2[] No

b. Sample person institutionalized

1[] Yes
2[] No

c. Sample person's hearing problem

1[] Yes
2[] No

d. Sample person's speech problem

1[] Yes
2[] No

e. Sample person's language problem

1[] Yes
2[] No

f. Sample person's poor memory, senility, or confusion

1[] Yes
2[] No

g. Sample person's Alzheimer's disease

1[] Yes
2[] No

h. Sample person's other mental condition

1[] Yes
2[] No

i. Sample person's other physical illness and/or disability

1[] Yes
2[] No

j. Other non-health related reason

1[] Yes
2[] No

The "respondent" in the following items refers to the sample person if he/she answered questions with or without assistance, or to the proxy if the sample person was not interviewed.
3. Do you feel the --

a. Respondent was intellectually capable of responding?
1[] Yes
2[] No


b. Respondent's answers were reasonably accurate?
1[] Yes
2[] No


c. Respondent understood the questions?
1[] Yes
2[] No

[p.460]

Section N - INTERVIEWER OBSERVATIONS - Continued

4a. Was there a section which seemed to be particularly upsetting or problematic to the respondent?

1[] Yes (Go to 4b)
2[] No (Skip to 5)

b. Which section(s)?
Mark (X) all that apply.

01[] A. Housing and long-term care services
02[] B. Transportation
03[] C. Social activity
04[] D. Work history/employment
05[] E. Assistive devices and technologies
06[] F. Health insurance
07[] G. Assistance with key activities
08[] H. Other services
09[] I. Family structure, relationships, and living arrangements
10[] J. Conditions and impairments
11[] K. Health opinions and behaviors
12[] L. Community services
13[] M. Contact person

5. How tiring did the interview seem to be for the respondent?

1[] Very tiring
2[] A little tiring
3[] Not tiring

6. Did the respondent have difficulty hearing you during the interview?

1[] Yes (Go to 7)
2[] No (END interview)
9[] DK (END interview)

7. Do you feel the respondent's hearing difficulty affected the interview?

1[] Yes
2[] No