daf
[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?

[p. 328]

Section A -- HOUSING AND LONG-TERM CARE SERVICES

ITEM A1
Status of Sample Person (SP).

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

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

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

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

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

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?

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?

[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?

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

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

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

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

ITEM A2
Status of SP.

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?

[p. 330]

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

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

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

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?

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

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

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?

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

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?

[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.

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.

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.

[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 --

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?

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

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.

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.

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.

[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.

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

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

[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.

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

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

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

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

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

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?

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

[p. 336]

Section B -- TRANSPORTATION -- Continued

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

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

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

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

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.

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

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.

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

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

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?

[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.

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

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

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

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

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

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

[p. 338]

Section B -- TRANSPORTATION -- Continued

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

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

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

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

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

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

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

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

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

[p. 339]

Section C -- SOCIAL ACTIVITY

ITEM C1
Status of SP.

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 --

Ask 2 for each "Yes" in 1.

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

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

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.

[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?

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

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

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

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?

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

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

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

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

[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 --

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

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

[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?

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

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

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

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

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

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

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

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

b. Would you say very difficult or somewhat difficult?

[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?

b. Would you say very difficult or somewhat difficult?

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 --

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

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?

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

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

[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.

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

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?

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

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

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

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

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

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

b. Would you say very difficult or somewhat difficult?

[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?

b. Would you say very difficult or somewhat difficult?

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 --

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

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?

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

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

[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.

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

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?

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

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

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

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

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

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

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

[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 --

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

[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?

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

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

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?

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

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

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

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

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

[p. 349]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

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

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?

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

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

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

54a. Have you retired on disability?

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

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

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

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

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

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

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

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

[p. 350]

Section D -- WORK HISTORY/EMPLOYMENT -- Continued

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

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

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

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

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

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 --

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

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

[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?

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

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

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?

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

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

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

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

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

[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?

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

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 --

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

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

[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?

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

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

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?

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

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

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

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

[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?

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

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

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

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?

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

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

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

[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?

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

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

2. In what year did you LAST receive vocational rehabilitation services?

3. Have the vocational rehabilitation services you received --

[p. 356]

Section E -- VOCATIONAL REHABILITATION -- Continued

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

ITEM E2
Refer to SP's age.

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?

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

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

[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?

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

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

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.

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

[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?

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

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)?

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

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.

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?

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.

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

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

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.

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.

[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 --

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

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

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?

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

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

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

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

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

[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.

ITEM H1

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?

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

ITEM H2

7a. Do you use any special equipment or aids in (activity)?

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

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

[p.362]

Section H -- ASSISTANCE WITH KEY ACTIVITIES -- Continued

ITEM H3

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

b. Is this hands-on help?

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

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

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

ITEM H4

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)?

b. Does this person provide --

10. How often do you have supervision or standby help when you are (activity)? Would you say always, sometimes, or rarely?

11. Do you need (more) supervision or standby help with (activity)?

[p. 364]

Section H -- ASSISTANCE WITH KEY ACTIVITIES -- Continued

ITEM H5

(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)

b. How often do you have a partial bath? Would you say --
(Read categories)

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.

b. During the past month, did you experience a burn or scald caused by bathing with water that was too hot?

(B) Dressing
12a. Do you get dressed for the day --
(Read categories)

b. How often do you change your night clothes? Would you say --
(Read categories)

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?

(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?

b. During the past month, have you --

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?

b. Because of a health or physical problem, do you usually stay in a chair all or most of the time?

c. How often do you get out of bed? Would you say --
(Read categories)

(E) Walking
12a. How often do you move around your (house/apartment/room)? Would you say -- (Read categories)

(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.

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?

c. During the past month, did you experience skin problems such as a rash or irritation because of this?

d. During the past month, did you use a commode or bed pan because no help was available?

[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.

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.

b. Besides (condition), is there any other condition which causes this trouble in (activities)?

c. Is this trouble in (activities) caused by any specific condition?

15. (Was this/were any of these) condition(s) a result of a motor vehicle accident?

16. During the past 12 months, did you receive training to increase your independence in daily living skills such as bathing, eating, or toileting?

17a. Do you have difficulty controlling your bowels?

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.

c. Do you have a colostomy or a device to help control bowel movements?

d. Do you need help from another person in taking care of this device?

[p. 367]

Section H -- ASSISTANCE WITH KEY ACTIVITES -- Continued

18a. Do you have difficulty controlling urination?

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.

c. Do you have a urinary catheter or a device to help control urination?

d. Do you need help from another person in taking care of this device?

ITEM H8
Status of SP.

[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.

ITEM H9
(H) Preparing your own meals
Refer to 19.

(I) Shopping for groceries and personal items
Refer to 19.

(J) Managing your money
Refer to 19.

(K) Using the telephone
Refer to 19.

(L) Doing heavy housework
Refer to 19.

(M) Doing light housework
Refer to 19.

(N) Getting to places outside of walking distance
Refer to 19.

(O) Managing your medication
Refer to 19.

20. By yourself, how much difficulty do you have (activity), -- some, a lot, or are you unable to do it?

21. When you DO NOT HAVE HELP, is (activity) by yourself --

[p.370-371]

Section H - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM H10
(H) Preparing your own meals
Refer to 19 on page 44.

(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

22a. Do you receive help from another person in (activity)?

b. Is this hands-on help?

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

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

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

ITEM H11
(H) Preparing your own meals
Refer to h10 and 22b:

(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 pf walking distance

(O) Managing your medication

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)?

b. Does this person provide --
Supervisory help, such as making sure this activity is performed correctly when you are (activity)?

c. Stand-by help, such as observing to see if any help is needed when you are (activity)?

24. How often do you have supervision or standby help when you are (activity)? Would you say always, sometimes, or rarely?

25. Do you need (more) supervision or standby help with (activity)?

[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.

(I) Shopping for groceries and personal items
Refer to 22a, 22e, 23a, and 25 on page 46.

(L) Doing heavy housework
Refer to 22a, 22e, 23a, and 25 on page 47.

(M) Doing light housework
Refer to 22a, 22e, 23a, and 25 on page 47.

(N) Getting to places outside of walking distance
Refer to 22a, 22e, 23a, and 25 on page 47.

(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?

b. During the past month, were you unable to follow a special diet because you needed help cooking?

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?

(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?

b. During the past month, did you miss a meal because you were unable to shop?

(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?

(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?

(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?

b. During the past month, were you unable to go places you wanted to for fun or recreation because you did not have transportation?

c. During the past month, did you run out of food because you were unable to get to the store?

ITEM H13
(H) Prepare your own meals
Refer to 19 on page 44

(I) Shop for groceries and personal items
Refer to 19 on page 44

(J) Manage your money
Refer to 19 on page 44

(L) Doing heavy housework
Refer to 19 on page 45

(M) Doing light housework
Refer to 19 on page 45

27. In your household, how often do YOU (activity)? Would you say always, sometimes, rarely, or never?

[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.

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

b. Besides (condition), Is there any other condition which causes this trouble in (activities)?

c. Is this trouble in (activities) caused by any specific condition?

29. [Was this/Were any of these] condition(s) a result of a motor vehicle accident?

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?

31a. During the past 12 months, that is, since (today's date) a year ago, have you fallen?

b. Have you fallen more than once in the past 12 months?

c. Were you injured as a result of the fall(s)?

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.

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?

f. [Did you fall/Were any of these falls] because you felt dizzy?

[p.375]
Section H - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM H16
Status of SP

32a. During the past three months, did you experience bedsores or pressure sores?

b. Were any of these NEW bedsores or pressure sores?

33a. During the past three months, did you experience contractures, that is, joints that won't straighten out?

b. Were any of these NEW contractures?

ITEM H17
Refer to questions 8a on pages 38 and 39, columns A, D, and G. (Receives help)
Mark (X) all that apply.

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?

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?

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.

[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.

Ask 37-41 for each helper in 36.
ASK OR VERIFY:
37. Which activities does (Helper) help you with?
Mark (X) all that apply.

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.

ASK OR VERIFY:
b. Is (Helper) male or female?

If parent, child, spouse, or unpaid volunteer in 38a, skip to 40; otherwise ask:
39a. Is (Helper) paid?

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.

40. DURING THE PAST 2 WEEKS, how many days did (Helper) help you?

41. On the days you receive help from (Helper), about how many hours per day does [he/she] usually help you?

ITEM H19
Refer to 36 above.
(Number of helpers)

[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.

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?

b. How many days in the past 12 months?

Ask 44 about only helper in 36 or main helper in 42.
44. How satisfied are you with --

How satisfied are you with --

45. Are you EVER home alone for more than two hours at a time?

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?

47. If it could be arranged, would it be better if you did not have to stay alone for as long as two hours?

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?

b. Who is this person?
Probe for description if necessary
Mark (X) only one.

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?

b. Who is this person?
Probe for description if necessary
Mark (X) only one.

[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)

ITEM H21
Refer to questions 22e for activities H-O on pages 46 and 47. (Need [more] help)

ITEM H22
Refer to question 25 for activities H-O on pages 46 and 47. (Need [more] supervision)

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?

b. Why not?
Anything else?
Read categories if necessary.
Mark (X) all that apply.

51. What problems have you had in trying to find help?
Anything else?
Read categories if necessary.
Mark (X) all that apply.

52. Has any agency or organization tried to find someone to help you?

53. Have you ever hired someone or received help from a public agency or a non-profit agency?

54a. Did you stop getting help from the person or agency even though you still needed it?

b. Why did you stop getting help?
Any other reason?
Read categories if necessary.
Mark (X) all that apply.

[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?

b. What kind of problems did you have?
Anything else?
Read categories if necessary.
Mark (X) all that apply.

56. Because of YOUR health, did anyone in your family EVER --

[p.380]
Section I - OTHER SERVICES

ITEM I1
Status of SP

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?

2. Do you need more help or a different kind of help with your medical treatments at home?

3. Have you experienced any problems because you did not have enough help or the right kind of help with home medical treatments?

4. Do family members or friends help you with medical treatments at home?

5. Have these friends or family members been trained by a health care professional to administer these medical treatments?

6a. Do you receive any home medical treatments from friends or relatives that you feel should be administered by a health professional?

b. Why aren't you getting this help from a health professional?
Any other reason?
Mark (X) all that apply.

7. Are there any home medical treatments that have been prescribed for you but you are not getting?

8. Why aren't you getting this treatment?
Any other reason?
Mark (X) all that apply.

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.

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.

[p.381]
Section I - OTHER SERVICES - Continued

11. Are there any prescription medicines that you are supposed to use, but --

12. Have you experienced any problems because you forgot to use your medicine or didn't use your medicine as prescribed?

13. What problems did you experience?
Anything else?
Mark (X) all that apply.

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.

15. Not counting financial help, do you NEED (more) help with your medicine?

16. What do you NEED (more) help with?
Anything else?
Mark (X) all that apply.

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?

18. Which do you see most often -- a general practitioner, an internist, or family doctor?
Mark (X) only one.

19. Have you seen this [(provider in 18)/doctor] in the past 12 months?

20. In the past 3 months, how many times have you seen this [(provider in 18)/doctor]?

[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]?

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?

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.

ITEM I2
Refer to question 21.
(Additional visits recommended)

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.

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.

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.

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)

[p.383]
Section I - OTHER SERVICES - Continued

27. Have you seen this [(specialist in 26b)/doctor] in the past 12 months?

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.

29. Did this [(specialist in 26b)/doctor] ask to see you for more [than the (number in 28) visit(s)/visit]?

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?

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.

ITEM I3
Refer to question 29.
(Additional visits recommended)

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.

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.

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)?

[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.

36. Has a medical professional told you that because you did not have follow-up care --

[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 ____ ?

b. Did you need the services of ____ in the past 12 months?

38a. During the past 12 months, in how many months did you receive services from ___?

b. What was the total number of times you received services from ____ during [that/those] month(s)?

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.

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.

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.

40. During (month), did you receive services from ____ ?

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.

[p.389-390]
Section I - OTHER SERVICES - Continued

42a. During the past 12 months, did you receive ____?

b. Did you need ___ in the past 12 months?

43a. During the past 12 months in how many months did you receive ____ ?

b. What was the total number of times you received ____ during [that/those] month(s)?

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.

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.

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.

45. During (month), did you receive ____ ?

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.

[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.

b. For which of these services are you on a waiting list?
(Any others?)
Mark (X) all that apply.

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.

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.

49a. During the past 12 months, how many times altogether were you admitted to (place(s) in 48b) for mental health care?

b. During the past 12 months, how many nights altogether did you spend in the (place(s) in 48b)?

ITEM I4
Refer to question 49a.
(Number of admissions)

50a. Was that admission on an emergency basis?

b. How many of the (number in 49a) admissions were on an emergency basis?

c. Were any of the admissions in the past 12 months on an emergency basis?

d. How many of the admissions were on an emergency basis?

[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.

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.

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.

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.

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.

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.

53a. During the past 12 months, in how many months did you receive outpatient mental health services?

b. Altogether, how many outpatient mental health visits did you make during [that/those] (number in 53a) month(s)?

ITEM I5
Refer to question 53b.
(Number of visits)

[p.393]
Section I - OTHER SERVICES - Continued

54a. Was that visit on an emergency basis?

b. How many of the (number in 53b) visits were on an emergency basis?

c. Were any of the visits in the past 12 months on an emergency basis?

d. How many visits were on an emergency basis?

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.

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.

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.

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.

57. During the past 12 months, were you on a waiting list for outpatient mental health services?

ITEM I6
Refer to questions 48a on page 68, 52a on page 69, and question 56 above. (Any mental health services)

[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.

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.

59a. During the past 12 months, have you needed any mental health services or counseling that you have not received?

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.

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?

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?

b. Do your doctors talk to each other about your health and the care you get, including any tests or medications?

62a. Is there anyone who is not a doctor who coordinates your medical care?

b. Who does this for you?
Anyone else?
Mark (X) all that apply.

[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?

b. Is this person or does this person work for a general care physician or a specialist?
Mark (X) only one.

c. Is this person a -- (Read category)
Mark (X) all that apply.

64a. Does anyone NOT in a physician's office help you with arranging non-medical services?

b. Who does this for you?
Anyone else?
Mark (X) all that apply.

ITEM I7
Refer to questions 61a and 62 a on page 71, 63a and 64a above. (Service coordinator)

ITEM I8
Refer to questions 62b on page 71 and 64b above. (Who arranges services)

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.

ITEM I9
Refer to question 64b above.
(Who arranges services)

[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?

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.

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.

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?

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.

69. During the past 12 months, have you felt that you NEEDED someone to arrange or coordinate personal care or social services?

70. Do you NEED help filling out insurance forms or benefit applications?
Mark (X) only one.

b. Who helps you fill out insurance forms or applications for public programs or benefits?
Mark (X) all that apply.

[p.397]

Section I - OTHER SERVICES - Continued

ITEM I10
Refer to question 42a, Service K on page 68.
(Center for independent living)

71. Did you receive any of the following services from the Center for Independent Living --

ITEM I11
Refer to 37a, Service I on page 65.
(Adult Day Care)

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.

[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?

b. Who generally gives medical consent for you?
Mark (X) only one.

ITEM J1
Refer to SP's age.

2. Do you now have Individual Education Plan or IEP?

3. Do you currently have Individual Written Rehabilitation Plan or IWRP?

[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.

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.

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.

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.

e. Have you received any of these special education services during the past month?

f. Why haven't you received any special education services in the past month?
Any other reason?
Mark (X) all that apply.

[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?

6a. DURING THE PAST 12 MONTHS, have you tried to get any (additional) special education services?

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.

c. During the past 12 months were you on a waiting list for any special education services?

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.

7. Overall, how satisfied are you with the educational services that you receive? Are you very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?

[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.

2a. How long have you been married to your current spouse?

b. How long have you been [widowed/divorced/separated]?

ITEM K1
Status of SP

3. Including yourself, how many people altogether live in this household?

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.

b. If necessary, ask: What is (name's) sex?

c. If necessary ask: How is (name) related TO YOU? Record relationship to sample person

[p.402]

Section K - FAMILY STRUCTURE, RELATIONSHIPS, AND LIVING ARRANGEMENTS - Continued

5a. Including step and adopted children, how many LIVING SONS do you have?

b. Including step and adopted children, how many LIVING DAUGHTERS do you have?

ITEM K2
Refer to 5a and 5b above.
(Living children)

ITEM K3
Refer to question 4 on page 78.
(Household composition)

6a. How quickly can [any of your children/your son/your daughter] get here?
If asked, "Here" means where the SP resides.

b. How often do you see [any of your children/your son/your daughter]?

c. How often do you talk on the telephone with [any of your children/your son/your daughter]?

d. How often do you get mail from [any of your children/your son/your daughter]?

7. [Do your children/Does your son/Does your daughter] routinely give you money to help with your living expenses or pay your bills?

[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.

8. (Other than your spouse) [is/are any of] the person(s) living with you 18 years of age or older?

9. Do you live with [these people/this person] NOW because YOU need to share living expenses?

10. Do you live with [these people/this person] NOW because of a health or physical problem YOU have?

11. Including step and adopted brothers, how many LIVING brothers do you have?

12. Including step and adopted sisters, how many LIVING sisters do you have?

ASK OR VERIFY:
13a. Is your mother still living?

b. Is your father still living?

[p.404]

Section K - FAMILY STRUCTURE, RELATIONSHIPS, AND LIVING ARRANGEMENTS - Continued

ITEM K5
Refer to Item K4.
(SP's living arrangements)

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.

b. How often do you see any member of your family (other than your spouse or children)?

c. How often do you talk on the telephone with any member of your family (other than your spouse or children?

d. How often do you get mail from any member of your family (other than your spouse or children)?

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?

[p.405]

Section L - CONDITIONS AND IMPAIRMENTS

ITEM L1
Refer to SP's age

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 --

2a. Do you use eyeglasses? Include eyeglasses that just magnify.

b. Were these eyeglasses prescribed for you?

c. Do you use contact lenses?

3. Have you EVER had an operation for cataracts?

ITEM L2
Refer to 1c above.
(Blind in both eyes)

4. Do you have a lens implant?

5. Do you use a magnifying glass to read or to do other close work?

6. Do you NOW have --

[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 --

Ask 7b-d as appropriate for each "Yes" in 7a.
b. In what year [did/was] (condition) first [occur/noticed]?

c. Did a doctor ever tell you that you had (condition)?

d. Do you still have (condition)?

ITEM L3
Refer to 7a (11).
(Cancer of any kind)

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.

[p.407]

Section L - CONDITIONS AND IMPAIRMENTS - Continued

9a. Do you sometimes have trouble with dizziness?

b. Does dizziness prevent you in any way from doing things you otherwise could do?

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.

[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?

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.

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.

4. Do you follow a REGULAR routine of physical exercise?

5. About how tall are you without shoes?

6. About how much do you weight without shoes?

If proxy respondent, skip to 8; otherwise ask.
7. What was your usual weight at the age of 50?

8. Have you ever smoked at least 100 cigarettes in your entire life?
If asked: Approximately 5 packs.

9. Do you NOW smoke cigarettes every day, some days, or not at all?

10. For how many years [have you smoked/did you smoke] cigarettes?

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?

12. During the past year, on the average, on how many days did you drink alcoholic beverages, that is beer, wine, or liquor?

13. On [the/those] day(s) when you drank, about how many drinks would you say you had?

[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 --

2. How often did you use it -- frequently, sometimes, or rarely?

[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.

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?

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

[p.411]

Section P - INTERVIEWER OBSERVATIONS

ITEM P1
Mark (X) the one that best represents this interview.

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.

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.

ASK OR VERIFY:
c. Do(es) [you/(assistant)] live here?

Mark each to indicate why a proxy/assistant was needed.
2a. Sample person hospitalized

b. Sample person institutionalized

c. Sample person's hearing problem

d. Sample person's speech problem

e. Sample person's language problem

f. Sample person's poor memory, senility, or confusion

g. Sample person's Alzheimer's disease

h. Sample person's other mental condition

i. Sample person's other physical illness and/or disability

j. Other non-health related reason

ITEM P2
Refer to SP's age.

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 --

[p.412]

Section P - INTERVIEWER OBSERVATIONS - Continued

4a. Was there a section which seemed to be particularly upsetting or problematic to the respondent?

b. Which section(s)?
Mark (X) all that apply.

5. How tiring did the interview seem to be for the respondent?

6. Did the respondent have difficulty hearing you during the interview?

7. Do you feel the respondent's hearing difficulty affected the interview?

[p.413]

Part 1 - CALL RECORD
Date

Beginning time

Results ____

Ending time

Comments ____

Part II - STATUS

A. Final Status
Interview

Non interview

B. Mode

C. Respondent

D. Proxy

E. Field Representative's Name

Part III - NEW ADDRESS

A. Address (Different from label)

B. Telephone (Different from label)

[p.414]

INITIAL SCREENING

1. May I please speak with (sample person)?

2. Why is (sample person) not available to be interviewed?

3. Will (sample person) [return/be available] before (closeout date)?

4a. Has (sample person) moved to a new residence or is [he/she] in a health facility, group home, or some other place?

b. What type of facility or group home is this?
Mark (X) first appropriate box.

c. Refer to age on label.

d. Is it possible to interview (sample person) at the [facility/present location]?

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?

6. On what date did (sample person) die?

7. Did (sample person) die at home, in a hospital, in a nursing or convalescent home, or some other place?

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?

[p.415]

INITIAL SCREENING - Continued

NEW ADDRESS (First or only)

Second (if appropriate)

PROXY RESPONDENT

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).

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

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

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

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

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

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?

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?

[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.

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

ITEM A2
Status of SP.

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?

[p.418]

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

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

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

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?

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

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

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?

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

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?

[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.

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.

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.

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?

[p.420]

Section B - TRANSPORTATION

ITEM B1
Status of SP

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.

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

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.

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

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.

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

[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 --

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

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.

[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?

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

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

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

5a. Have you retired from a job or business?

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

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

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

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

[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?

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

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

[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?

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

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)?

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

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.

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?

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.

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

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

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.

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.

[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 --

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?

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

[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.

ITEM G1
(A) Bathing or showering
Refer to question 4.

(B) Dressing
Refer to question 4.

(C) Eating
Refer to question 4.

(D) Getting in and out of bed or chairs
Refer to question 4.

(E) Walking
Refer to question 4.

(F) Getting outside
Refer to question 4.

(G) Using the toilet, including getting to the toilet
Refer to question 4.

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?

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

ITEM G2
(A) Bathing or showering
Refer to question 4

(B) Dressing
Refer to question 4

(C) Eating
Refer to question 4

(D) Getting in and out of bed or chairs
Refer to question 4

(E) Walking
Refer to question 4

(F) Getting outside
Refer to question 4

(G) Using the toilet, including getting to the toilet
Refer to question 4

7a. Do you use any special equipment or aids in (activity)?

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

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

[p.428-429]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM G3
(A) Bathing or showering
Refer to question 4 on page 14

(B) Dressing
Refer to question 4 on page 14

(C) Eating
Refer to question 4 on page 14

(D)
Getting in and out of bed or chairs
Refer to question 4 on page 14

(E) Walking
Refer to question 4

(F) Getting outside
Refer to question 4

(G) Using the toilet, including getting to the toilet
Refer to question 4 on page 14

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

b. Is this hands-on help?

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

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

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

ITEM G4
(A) Bathing or showering
Refer to G3 and 8b above

(B) Dressing
Refer to G3 and 8b above

(C) Eating
Refer to G3 and 8b above

(D) Getting in and out of bed or chairs
Refer to G3 and 8b above

(E) Walking
Refer to G3 and 8b above

(F) Getting outside
Refer to G3 and 8b above

(G) Using the toilet, including getting to the toilet
Refer to G3 and 8b above

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)?

b. Does this person provide --

10. How often do you have supervision or standby help when you are (activity)? Would you say always, sometimes, or rarely?

11. Do you need (more) supervision or standby help with (activity)?

[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

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)

b. How often do you have a partial bath? Would you say -- (Read categories)

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.

b. During the past month, did you experience a burn or scald caused by bathing with water that was too hot?

(B) Dressing
ITEM G5
Refer to 8a, 8e, 9a and 11 on page 16

12a. Do you get dressed for the day -- (Read categories)

b. How often do you change your night clothes? Would you say -- (Read categories)

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?

(C) Eating
ITEM G5
Refer to 8a, 8e, 9a and 11 on page 16

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?

b. During the past month have you --

[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

12a. Because of a health or physical problem, do you usually stay in bed all or most of the time?

b. Because of a health or physical problem, do you usually stay in a chair all or most of the time?

c. How often do you get out of bed? Would you say -- (Read categories)

(E) Walking
ITEM G5
Refer to 8a, 8e, 9a and 11 on page 17

12a. How often do you move around your [house/apartment/room]? Would you say -- (Read categories)

(G) Using the toilet, including getting to the toilet
ITEM G5
Refer to 8a, 8e, 9a and 11 on page 17

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.

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?

c. During the past month, did you experience skin problems such as a rash or irritation because of this?

d. During the past month, did you use a commode or bed pan because no help was available?

[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.

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.

b. Besides (condition), is there any other condition which causes this trouble in (activities)?

c. Is this trouble in (activities) cause by any specific condition?

15a. Do you have difficulty controlling your bowels?

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.

c. Do you have a colostomy or a device to help control bowel movements?

d. Do you need help from another person in taking care of this device?

[p.433]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

16a. Do you have difficulty controlling urination?

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.

c. Do you have a urinary catheter or a device to help control urination?

d. Do you need help from another person in taking care of this device?

ITEM G7
Status of SP

[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.

ITEM G8
(H) Preparing your own meals
Refer to question 17.

(I) Shopping for groceries and personal items
Refer to question 17.

(J) Managing your money
Refer to question 17.

(K) Using the telephone
Refer to question 17.

(L) Doing heavy housework
Refer to question 17.

(M) Doing light housework
Refer to question 17.

(N) Getting to places outside of walking distance
Refer to question 17.

(O) Managing your medication
Refer to question 17.

18. By yourself, how much difficulty do you have (activity), -- some, a lot, or are you unable to do it?

19. When you DO NOT HAVE HELP, is (activity) by yourself --

[p.436-437]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM G9
(H) Preparing your own meals
Refer to question 17 on page 22.

(I) Shopping for groceries and personal items
Refer to question 17 on page 22.

(J) Managing your money
Refer to question 17 on page 22.

(K) Using the telephone
Refer to question 17 on page 22.

(L) Doing heavy housework
Refer to question 17 on page 22.

(M) Doing light housework
Refer to question 17 on page 22.

(N) Getting to places outside of walking distance
Refer to question 17 on page 22.

(O) Managing your medication
Refer to question 17 on page 22.

20a. Do you receive help from another person in (activity)?

b. Is this hands-on help?

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

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

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

ITEM G10
(H) Preparing your own meals
Refer to G9 and 20b

(I) Shopping for groceries and personal items
Refer to G9 and 20b

(J) Managing your money
Refer to G9 and 20b

(K) Using the telephone
Refer to G9 and 20b

(L) Doing heavy housework
Refer to G9 and 20b

(M) Doing light housework
Refer to G9 and 20b

(N) Getting to places outside of walking distance
Refer to G9 and 20b

(O) Managing your medication
Refer to G9 and 20b

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)?

b. Does this person provide --

22. How often do you have supervision or standby help when you are (activity)? Would you say always, sometimes, or rarely?

23. Do you need (more) supervision or standby help with (activity)?

[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

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?

b. During the past month, were you unable to follow a special diet because you needed help cooking?

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?

(I) Shopping for groceries and personal items
ITEM G11
Refer to 20a, 20e, 21a, and 23 on page 24

24a. During the past month, were you unable to follow a special diet because you needed help shopping?

b. During the past month, did you miss a meal because you were unable to shop?

(L) Doing heavy housework
ITEM G11
Refer to 20a, 20e, 21a, and 23 on page 25

24. During the past month, did you experience distress because you were not able to wash clothes or clean up around the house?

(M) Doing light housework
ITEM G11
Refer to 20a, 20e, 21a, and 23 on page 25

24. During the past month, did you experience distress because you were not able to do dishes or straighten up around the house?

(N) Getting to places outside of walking distance
ITEM G11
Refer to 20a, 20e, 21a, and 23 on page 25

24a. During the past month, did you miss a doctor's or other medical appointment because you were unable to get there?

b. During the past month, were you unable to go places you wanted to for fun or recreation because you did not have transportation?

c. During the past month, did you run out of food because you were unable to get to the store?

ITEM G12
(H) Prepare your own meals
Refer to 17 on page 22.

(I) Shop for groceries and personal items
Refer to 17 on page 22.

(J) Manage your money
Refer to 17 on page 22.

(L) Do heavy housework
Refer to 17 on page 23.

(M) Do light housework
Refer to 17 on page 23.

25. In your household, how often do YOU (activity)? Would you say always, sometimes, rarely, or never?

[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.

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

b. Besides (condition), is there any other condition which causes this trouble in (activities)?

c. Is this trouble in (activities) caused by any specific condition?

27a. During the past 12 months, that is since (today's date) a year ago, have you fallen?

b. Have you fallen more than once during the past 12 months?

c. Were you injured as a result of the fall(s)?

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.

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?

f. [Did you fall/Were any of these falls] because you felt dizzy?

[p.441]

Section G - ASSISTANCE WITH KEY ACTIVITIES - Continued

ITEM G14
Status of SP

ITEM G15
Refer to questions 8a, columns A, D, and G on pages 16-17. [Receives help]
Mark (X) all that apply.

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?

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?

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.

[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.

Ask 31-35 for each helper in 30.
ASK OR VERIFY:
31. Which activities does (Helper) help you with?
Mark (X) all that apply.

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.

ASK OR VERIFY:
b. Is (Helper) male or female?

If parent, child, spouse, or unpaid volunteer in 32a, skip to 34; otherwise ask:
33a. Is (Helper) paid?

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.

34. DURING THE PAST 2 WEEKS, how many days did (Helper) help you?

35. On the days you receive help from (Helper), about how many hours per day does [he/she] usually help you?

ITEM G17
Refer to 30 above.
(Number of helpers)

[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.

Ask 37 about only helper listed in 30 or main helper in 36.
37. How satisfied are you with --

If helper is present or related to SP, skip to 38; otherwise, ask:
How satisfied are you with --

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?

b. Who is this person?
Probe for description if necessary
Mark (X) only one.

[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?

b. Who is this person?
Probe for description if necessary
Mark (X) only one.

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?

b. What kind of problems did you have?
Anything else?
Read categories if necessary
Mark (X) all that apply.

[p.445]

Section H - OTHER SERVICES

ITEM H1
Status of SP.

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.

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.

3. Are there any prescription medicines that you are supposed to use, but --

4. Have you experienced any problems because you forgot to use your medicine or didn't use your medicine as prescribed?

5. What problems did you experience?
Anything else?
Mark (X) all that apply.

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.

7. Not counting financial help, do you NEED (more) help with your medicine?

8. What do you NEED (more) help with?
Anything else?
Mark (X) all that apply.

[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?

10. Which do you see most often -- a general practitioner, an internist, or family doctor?
Mark (X) only one.

11. Have you seen this [(provider in 10)/doctor] in the past 12 months?

12. In the past 3 months, how many times have you seen this [(provider in 10)/doctor]?

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.

[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 ___ ?

b. Did you need the services of ___ in the past 12 months?

15a. During the past 12 months, in how many months did you receive services from?

b. What was the total number of times you received services from ___ during [that/those] month(s)?

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.

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.

17. During (month) did you receive services from ___ ?

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.

[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?

b. For which of these services are you on a waiting list?
Read list if necessary.
Mark (X) all that apply.

20a. Do you NEED help filling out insurance forms or benefit applications?
Mark (X) only one.

b. Who helps you fill out insurance forms or applications for public programs or benefits?
Mark (X) all that apply.

[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.

2a. How long have you been married to your current spouse?

b. How long have you been [widowed/divorced/separated]?

ITEM I1
Status of SP

3. Including yourself, how many people altogether live in this household?

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.

b. If necessary, ask: What is (name's) sex?

c. If necessary ask: How is (name) related TO YOU? Record relationship to sample person

[p.451]

Section I - FAMILY STRUCTURE, RELATIONSHIPS, AND LIVING ARRANGEMENTS - Continued

5a. Including step and adopted children, how many LIVING SONS do you have?

b. Including step and adopted children, how many LIVING DAUGHTERS do you have?

ITEM I2
Refer to 5a and 5b above.
(Living children)

ITEM I3
Refer to question 4 on page 39.
(Household composition)

6a. How quickly can [any of your children/your son/your daughter] get here?
If asked, "Here" means where the SP resides.

b. How often do you see [any of your children/your son/your daughter]?

c. How often do you talk on the telephone with [any of your children/your son/your daughter]?

d. How often do you get mail from [any of your children/your son/your daughter]?

7. [Do your children/Does your son/Does your daughter] routinely give you money to help with your living expenses or pay your bills?

[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.

8. (Other than your spouse) [is/are any of] the person(s) living with you 18 years of age or older?

9. Do you live with [these people/this person] NOW because YOU need to share living expenses?

10. Do you live with [these people/this person] NOW because of a health or physical problem YOU have?

11. Including step and adopted brothers, how many LIVING brothers do you have?

12. Including step and adopted sisters, how many LIVING sisters do you have?

ASK OR VERIFY:
13a. Is your mother still living?

b. Is your father still living?

ITEM I5
Refer to Item I4.
(SP's living arrangements)

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.

b. How often do you see any member of your family (other than your spouse or children)?

c. How often do you talk on the telephone with any member of your family (other than your spouse or children?

d. How often do you get mail from any member of your family (other than your spouse or children)?

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?

[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 --

2a. Do you use eyeglasses? Include eyeglasses that just magnify.

b. Were these eyeglasses prescribed for you?

c. Do you use contact lenses?

3. Have you EVER had an operation for cataracts?

ITEM J1
Refer to 1c above.
(Blind in both eyes)

4. Do you have a lens implant?

5. Do you use a magnifying glass to read or to do other close work?

6. Do you NOW have --

[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 --

Ask 7b-d as appropriate for each "Yes" in 7a.
b. In what year [did/was] (condition) first [occur/noticed]?

c. Did a doctor ever tell you that you had (condition)?

d. Do you still have (condition)?

ITEM J2
Refer to 7a (11).
(Cancer of any kind)

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.

[p.455]

Section J - CONDITIONS AND IMPAIRMENTS - Continued

9a. Do you sometimes have trouble with dizziness?

b. Does dizziness prevent you in any way from doing things you otherwise could do?

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.

[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?

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.

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.

4. Do you follow a REGULAR routine of physical exercise?

5. About how tall are you without shoes?

6. About how much do you weight without shoes?

If proxy respondent, skip to 8; otherwise ask.
7. What was your usual weight at the age of 50?

8. Have you ever smoked at least 100 cigarettes in your entire life?
If asked: Approximately 5 packs.

9. Do you NOW smoke cigarettes every day, some days, or not at all?

10. For how many years [have you smoked/did you smoke] cigarettes?

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?

12. During the past year, on the average, on how many days did you drink alcoholic beverages, that is beer, wine, or liquor?

13. On [the/those] day(s) when you drank, about how many drinks would you say you had?

[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 --

2. How often did you use it -- frequently, sometimes, or rarely?

[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.

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?

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

[p.459]

Section N - INTERVIEWER OBSERVATIONS

ITEM N1
Mark (X) the one that best represents this interview.

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.

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.

ASK OR VERIFY:
c. Do(es) [you/(assistant)] live here?

Mark each to indicate why a proxy/assistant was needed.
2a. Sample person hospitalized

b. Sample person institutionalized

c. Sample person's hearing problem

d. Sample person's speech problem

e. Sample person's language problem

f. Sample person's poor memory, senility, or confusion

g. Sample person's Alzheimer's disease

h. Sample person's other mental condition

i. Sample person's other physical illness and/or disability

j. Other non-health related reason

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 --

[p.460]

Section N - INTERVIEWER OBSERVATIONS - Continued

4a. Was there a section which seemed to be particularly upsetting or problematic to the respondent?

b. Which section(s)?
Mark (X) all that apply.

5. How tiring did the interview seem to be for the respondent?

6. Did the respondent have difficulty hearing you during the interview?

7. Do you feel the respondent's hearing difficulty affected the interview?