C: REGARDS 6 Month Follow Up
REGARDS
Follow Up Survey
Voxco
Code Book
Updated September 2009
Table of Contents
First Screen
Allows interviewer to choose at the beginning of survey whether Pg 9
to follow the regular study or proxy study path
Introductions for Original and Proxy Follow Up Surveys Pg 9
Intro: Original ppts or proxies may follow this path
IntroP1: Used to reach either the original ppt or proxy after unsuccessful
at reaching ppt. in normal survey
IntroP2: Shows proxy contact information
PrxTN: Identification of incorrect proxy information
Pr#TNa Correction of area code for Proxy #
Pr#TNb Correction of phone number for Proxy #
IntroP3 Reason ppt cannot complete telephone follow up
Requesting permission for proxy survey if respondent deceased or incapacitated Pg 12
Sorry5 Respondent deceased
Sorry5a Proxy refused
Sorry15 Respondent ill or incapacitated
Sorry15a Proxy refused
Respondent or Proxy Refuses Pg 13 Sorry45 Reasons for discontinuing participation
Sor45_sp Text for reasons for discontinuing not covered in Sorry45
Sorry45a Indicates whether refusal is by original ppt or a proxy
Sorry45b Indicates level of concern
Sorry45c Apology and 800 number if interested in re-joining study
Proxy Name and Relationship to Participant Pg 14
ProxyFN First name of person completing proxy interview
ProxyLN Last name of person completing proxy interview
ProxyRel Relationship of proxy to original ppt.
Reintroduction of study to participants and proxies Pg 15
Intro2
Intro3
Intro4
Intro4a
Intro5
Intro5a
Intro5b
Respondent deceased: cause and date of death Pg 17
Qdead: Cause of death
Qdeadsp: Additional list of causes of death
Qdead1: Date of death
Qdead1a: Where did ppt die: home, hospital, etc.
Qdead1b: Name of facility where ppt died
Qdead1c: City where facility is located
Qdead1c1: State where facility located
Qdead1d: Street address of facility
Qdead1d1: ZipCode
Qdead1e: Name of doctor
Qdead2: If ppt died at home, name of city
Qdead2a: If ppt died at home, name of county
Qdead2b: If ppt died at home, name of state
Qdead3: Any hospitalizations or doc visits in month prior to death?
Qdead3_1: Reason for hospitalization or doc visit?
Qdead3_sp: Additional list of reasons for hospitalization or doc visit
Qdead3_2 Inpatient, outpatient or emergency room visit?
Qdead3a Date of last hospital admission or doctor visit
Qdead4 Name of medical office or hospital
Qdead4a Doctor’s office or hospital?
Qdead5 Location of facility: city
Qdead5a Location of facility: state
Qdead6 Location of facility: street address
Qdead6a Location of facility: zip code
Qdead7 Name of doctor seen
Respondent incapacitated or ill: cause and date of diagnosis Pg 21
QIncap Specification of illness or incapacitation
Qincapsp List of additional potential causes of illness or incapacitation
Qincap1 Name of doctor
Qincap2 Date of diagnosis
Qincap3 Name of medical office or hospital
Qincap3a Doctor’s office or hospital?
Qincap4 Location of facility: city
Qincap4a Location of facility: state
Qincap5 Location of facility: street address
Qincap5a Location of facility: zip code
Report of stroke Pg 23
Q1 Experienced a stroke since last contact?
Q1_1 Name of doctor
Q1_2 Date of stroke
Q1_3 Name of facility where treated
Q1_3a Doctor’s office or hospital?
Q1_4 Location of facility: city
Q1_4a Location of facility: state
Q1_5 Location of facility: street address
Q1_5a Location of facility: zip code
Report of TIA Pg 25
Q2 Experienced a TIA since last contact?
Q2_1 Name of doctor
Q2_2 Date of TIA
Q2_3 Name of facility where treated
Q2_3a Doctor’s office or hospital?
Q2_4 Location of facility: city
Q2_4a Location of facility: state
Q2_5 Location of facility: street address
Q2_5a Location of facility: zip code
Stroke Free Phenotype (Stroke Symptom) Questions Pg 28
Q3_1 Sudden painless weakness on one side of body?
Q3_1a Known cause?
Q3_2 Sudden numbness or a dead feeling on one side of body?
Q3_2a Known cause?
Q3_3 Sudden painless loss of vision in one or both eyes?
Q3_3a Known cause?
Q3_4 Sudden loss of half of vision?
Q3_4a Known cause?
Q3_5 Sudden loss of ability to understand what others are saying
Q3_5a Known cause?
Q3_6 Sudden loss of ability to express self verbally or in writing
Q3_6a Known cause?
Doctor visits or hospitalizations for stroke symptoms Pg 32
Q3_7a Doc visit or hospitalization for any reported stroke symptoms?
Q3_7a1 Specifically: seen for painless weakness on one side?
Q3_7b1 Know name of doctor or facility?
Q3_7_1sp Name of doctor
Q3_7a1sp Name of facility
Q3_7c1 Date of visit
Q3_7d1 Address of facility: street address
Q3_7e11 Address of facility: city
Q3_7f1 Address of facility: state
Q3_7g1 Address of facility: zip code
Q3_7a2 Specifically: seen for sudden numbness or a dead feeling on one side?
Q3_7a2a Was this the same doctor and facility as for painless weakness?
Q3_7b2 Know name of doctor or facility?
Q3_7_2sp Name of doctor
Q3_7a2sp Name of facility
Q3_7c2 Date of visit
Q3_7d2 Location of facility: street address
Q3_7e2 Location of facility: city
Q3_7f2 Location of facility: state
Q3_7g2 Location of facility: zip code
Q3_7a3 Specifically: seen for painless loss of vision in one or both eyes?
Q3_7a3a Visit with same doctor or facility as earlier reported symptom(s)?
Q3_7a3b Same as which previous symptom?
Q3_7b3 Know name of doctor or facility?
Q3_7_3sp Name of doctor
Q3_7a3sp Name of facility
Q3_7c3 Date of visit
Q3_7d3 Location of facility: street address
Q3_7e3 Location of facility: city
Q3_7f3 Location of facility: state
Q3_7g3 Location of facility: zip code
Q3_7a4 Specifically: seen for sudden loss of half of vision?
Q3_7a4a Visit with same doctor or facility as earlier reported symptom(s)?
Q3_7a4b Same as which previous symptom?
Q3_7b4 Know name of doctor or facility?
Q3_7_4sp Name of doctor
Q3_7a4sp Name of facility
Q3_7c4 Date of visit
Q3_7d4 Location of facility: street address
Q3_7e4 Location of facility: city
Q3_7f4 Location of facility: state
Q3_7g4 Location of facility: zip code
Q3_7a5 Specifically: seen for sudden loss of verbal comprehension?
Q3_7a5a Visit with same doctor or facility as earlier reported symptom(s)?
Q3_7a5b Same as which previous symptom?
Q3_7b5 Know name of doctor or facility?
Q3_7_5sp Name of doctor
Q3_7a5sp Name of facility
Q3_7c5 Date of visit
Q3_7d5 Location of facility: street address
Q3_7e5 Location of facility: city
Q3_7f5 Location of facility: state
Q3_7g5 Location of facility: zip code
Q3_7a6 Specifically: seen for sudden loss of ability for self expression?
Q3_7a6a Visit with same doctor or facility as earlier reported symptom(s)?
Q3_7a6b Same as which previous symptom?
Q3_7b6 Know name of doctor or facility?
Q3_7_6sp Name of doctor
Q3_7a6sp Name of facility
Q3_7c6 Date of visit
Q3_7d6 Location of facility: street address
Q3_7e6 Location of facility: city
Q3_7f6 Location of facility: state
Q3_7g6 Location of facility: zip code
Cognitive Assessment
Sequence for administering tests Pg 41 Six Item Screener Pg 42
Q11_9 Repeat 3 word list
Q11_10 What year is it?
Q11_11 What month is it?
Q11_12 What is the day of the week
Q11_13 Delayed recall of 3 word list
Word List Learning Pg 44
QInst1 Plays recorded instructions and list for test
QWLL_1 Documents words remembered from recorded list
QInst2 Plays recorded instructions and list for test
QWLL_2 Documents words remembered from recorded list
QInst3 Plays recorded instructions and list for test
QWLL_3 Documents words remembered from recorded list
QInst4 Plays recorded instructions for delayed recall of list Pg 57
QWLL_4 Documents delayed recall of words on list
CESD-4 Depression and Cohen’s Perceived Stress Scale Pg 58
CESD_1 # of days depressed in last week
CESD_2 # of days felt lonely in last week
CESD_3 # of days having crying spells in last week
CESD_4 # of days feeling sad in last week
Word Fluency Cognitive Tests Pg 59
QAllow Permission to record responses
LETTER_F 60 second timed test naming words beginning with “F”
QKIT1 Name things commonly found in a kitchen
QAnim 60 second timed test naming animals
MOCA (Montreal Cognitive Assessment) Pg 61
MOCA_1 Repeat 5 word list
MOCA_2 Repeat of same 5 word list
MOCA_3 What is today’s date? (mm/dd/yyyy)?
MOCA_4 What is the day of the week?
MOCA_5 What is your permanent or primary street address?
MOCA_5a Non-matching address given by participant
MOCA_6 What city is your primary or permanent street address in?
MOCA_6a Non matching city name given by participant
MOCA_7 Delayed recall of 5 word list
Ethnic Differences in Risk of Fracture and Related Vascular Events Pg 47
Q3_98a History of fractures for parents
Q3_98b Personal history of fracture since age 45
Q3_98c Fracture since last contact?
Q3_98d Age of first fracture since age 45
Q3_98e Enumeration of bones fractured, crushed or broken since age 45
Q3_98es Text of name of bone not listed in Q3_98e
Q3_98e# How was/were bone/bones listed in Q3_98e broken
Q3_e#s Text of causes of fracture, crushed, broken bones listed in 3_98es
Q3_98fa First time fracture since last contact
Q3_98f Enumeration of bones fractured, broken or crushed since last contact
Q3_98fs Text of name of bone not listed in Q3_98f
Q3_98f# How was/were bone/bones listed in Q3_98f broken
Q3f#s Text of causes of fracture, crushed, broken bones listed in Q3_98fs
Q3_f#a Name of facility for X-ray or imaging scan
Q3_f#b Location of facility for X-ray or imaging scan
Q3_f#c Date of X-ray or imaging scan
Sleep Apnea Module Pg 51
Sleep Intro to module
Slp1 Diagnosed with sleep apnea?
Slp1_1 Participate in overnight sleep study?
Slp1_1a Treated for sleep apnea?
Slp1_1b Surgery for sleep apnea?
Slp1_1c Use of CPap or BiPap
Slp1_1d Current # of nights using mask per week
Slp1_1e Current # of hours using mask when used
Slp2 Do you snore?
Slp3 How loud is your snoring?
Slp4 How often do you snore?
Slp5 Has your snoring bothered other people?
Slp6 Has anyone noticed that you quit breathing while asleep?
Slp6a How often have you been told that this occurs?
Slp7 Tiredness or fatigue after sleeping
Slp7a How often do you feel tired or fatigued after sleeping
Slp8 During waking hours are you tired or fatigued?
Slp8a Frequency of fatigue during waking hours
Slp9 Ever fallen asleep while driving?
Slp9a How often do you fall asleep while driving?
Slp10 How many hours of sleep do you get per night on work days?
Slp11 How many hours of sleep do you get per night on non work days?
Slp12 Perscription sleep aid use in last month
Slp13 OTC sleep aid use in the last month
Medical Visits and Hospital Stays Not Reported Earlier in Survey Pg 63
Q4 How many visits since last contact?
Q5_#a Reason for visit #
Q5_#spec Other/specify response for reason for visit #
Q5_#a1 Inpatient, outpatient or emergency room?
Q5_#b Name of facility
Q5_#b1 Location of facility
Q5#c Name of doctor
Q5_#d Date of visit/admission
Medical Release Disclaimer
QMEDREL Pg 66
Surrogate contact information for sending medical release forms Pg 67
Surro Should medical release forms be sent to you?
SurroFN First name of surrogate, if not person completing survey
SurroLN Last name of surrogate, if not person completing survey
Surro1a Street address
Surro1b City
Surro1c State
Surro1d Zip code
Surro1e Verification of state
Surro1f Phone number
Verification of Contact Information for Original Respondent Pg 69
QAddver Verification of address on file
Qaddcor Correction of street address
Qaddcor2 Correction of city name
Qaddcor3 Correction of state
Qaddcor4 Correction of zip code
QAddcor5 Verification of corrected state
QStay Best address and phone # for next contact
Q6moadd Correction of street address
Q6moadd1 Correction of city
Q6moadd2 Correction of state
Q6moadd3 Correction of zip code
Q6moadd4 Correction of phone number
QStay2 Who should be contacted at next follow up? Ppt? Proxy?
QStay3a First name of person to contact for next follow up if not person doing survey or person identified to receive medical release forms
QStay3b Last name of person to contact for next follow up
QStay4a Home number for next contact
QStay4b Work number for next contact
QStay4c Cell phone number for next contact
Conclusion and Additional Notes Pg 73
QClose Text for thank you, enter interviewer id
QClose1 Enter interviewing station number
SpAtt Additional comments from the respondent or interviewer.
Physical Activity Module
QPhA_1 Screening for activity level eligible for inclusion in study Pg 27
QPhA_1a Comments from ppt regarding activity level
QPhA_2 Explanation of PA study and invitation to participate Pg 72
QPhA_2a Comments from ppt regarding response to QPhyA_2
QPhyA_3 Thanks and information regarding mailing and use of device
C: BIG PICTURE INFO FOR SEQUENCE OF EVENTS -
C:
C: 1) Ask interviewer if proxy interview or regular follow-Up - Note that answer to this will lead into what
C: is equal to the current proxy interview or the current followup interview. Both of these had a second
C: chance at whether or not they had the participant or the proxy on the phone.
C: 2) Next, the logic falls along the same path as before in regards to if interviewer is talking to participant
C: or proxy. Depending on answers to questions, the Sorry series could be called next and then the interview
C: could exit out.
C: 3) Q1 series - Has participant been told by doctor that they had stroke or cerebrovascular event?
C: 4) Q2 series - Has participant been told by doctor that they had TIA or mini stroke?
C: 5) Q3_1 thru Q3_6 series - Stroke Free Phenotype questions (sudden painless weakness on one side of body,
C: sudden numbness or dead feeling on one side, sudden painless loss of vision in one or both eyes,
C: sudden loss of half vision, loss of the ability to understand what people were saying,
C: loss of the ability to express oneself verbally or in writing)
C: 6) Q3_7 series - Did you go to doctor for any of these? If so, ask doctor & facilty info
C:
C: ********** COGNITIVE AND BONE QUESTIONS NEXT
C: 7) Q11 Series (Q11_9 thru Q11_13) (6 Item Screener)
C: Q11_9 (orange, airplane, tobacco OR apple, table, penny) --> Q11_10 (year) -->
C: Q11_11 (month) --> Q11_12 (week day) --> Q11_13 (name same 3 objects again)
C: 8) QINST1 (listen to recording) --> QWLL_1 (butter, arm, shore, letter, queen, cabin, etc.)
C: 9) QINST2 (listen to recording) --> QWLL_2 (ticket, cabin, butter, shore, engine, arm, etc.)
C: 10) QINST3 (listen to recording) --> QWLL_3 (queen, grass, arm, cabin, pole, shore, etc.)
C: 11) Q3_98 series --> Bone Health/Fracture
C: 12) Sleep Apnea series (one time only per participant)
C: 13) QINST4 (listen to recording) --> QWLL_4 (butter, arm, shore, letter, queen, cabin, etc.)
C: 14) CESD series (depression)
C: 15) QAllow (ask if can record responses)
C: 16) Letter_F (letter F words - recorded as wav file)
C: 17) QKIT (name 2 kitchen items - not recorded)
C: 18) ANIM (name animals - recorded as wav file)
C: 19) MOCA series (name 5 objects - face, velvet, church, daisy, red
C: PLUS give current date, weekday, street & city address)
C: *********** END OF COGNITIVE AND BONE QUESTIONS
C: 20) Hospital (Q4, Q5)
C: 21) Verify phone number & address
C: 22) In closing, thanking them for their time, etc.
C: 23) Interviewer comments (SPATT)
C:
Variables imported from Sample File
Ident 7 digit study id number unique to each participant
Seqno Sequence for this follow up call
First Name First Name of respondent
Last Name Last Name of respondent
Address Street address of respondent
City City of residence for respondent
State State of residence for respondent
ZipCode Zip Code of residence for respondent
SlpFlg Indicates whether the Sleep Module has already been asked of a participant
PA_Flg Indicates whether the participant has been asked if interested in Physical
Activity Module
IntDate Date of original baseline survey
Lstctct Date of last contact
Phon1 Phone number for respondent including area code
Phon2 Alternate number for respondent including area code
Age Age of respondent at original baseline interview
Proxy1FN First Name of designated Proxy #1
Proxy1LN Last Name of designated Proxy #1
Proxy1HP Home phone number of designated Proxy #1
Proxy1WP Work phone number of designated Proxy #1
Proxy1CP Cell phone of designated Proxy #2
Proxy2FN First Name of designated Proxy #2
Proxy2LN Last Name of designated Proxy #2
Proxy2HP Home phone number of designated Proxy #2
Proxy2WP Work phone number of designated Proxy #1
Proxy2CP Cell phone of designated Proxy #2
Proxy3FN First Name of designated Proxy #3
Proxy3LN Last Name of designated Proxy #3
Proxy3HP Home phone number of designated Proxy #3
Proxy3WP Work phone number of designated Proxy #3
Proxy3CP Cell phone of designated Proxy #3
Variables created by or changed during survey
MedRel Initialized at 0, increments when a respondent has been to a doctor or hospital
Stroke Initialized at 0, if respondent reports a stroke = 1
PrxCall 0 = Regular Follow-up Interview; 1 = Proxy Follow-up Interview
CallTime Time that the call was made (initialized to the system time)
FUDate Date of followup (initialized to system date)
StartDte Date followup was started (initialized to system date)
Study Study name
Sequence Sequence
Rsncode Reason code
AgeYrsR Age in years (initialized to Imported Age)
SFP
Visit Total visit to the doctor the for symptoms
Visit1 Visit to doctor for painless weakness on one side
Visit2 Visit to doctor for sudden numbness or a dead feeling on one side
Visit3 Visit to doctor for sudden painless loss of vision in one or both eyes
Visit4 Visit to doctor for sudden loss of half vision
Visit5 Visit to doctor for loss of the ability to understand what people were saying
Visit6 Visit to doctor for loss of the ability to express oneself verbally or in writing
Bone1
Bone2
Bone3
Bone4
Bone5
Bone6
Bone7
Bone8
Bone9
Bone10
Bone11
Bone12
Bone13
Bone14
Bone15
Bone16
Bone17
Bones1
Bones2
Bones3
Bones4
Bones5
Bones6
Bones7
Bones8
Bones9
Bones10
Bones11
Bones12
Bones13
Bones14
Bones15
Bones16
Bones17
BrokeOld
BrokeNew
EvtStr
EvtNStr
EvtTot
Attmpt
AttmptID
RespNo
RespLen
Do_Wav
Disposition Codes
Introductions for Original and Proxy Follow Up Surveys
Information inserted from sample file indicated in blue
Skip patterns indicated in green
Interviewer Instructions in Brown
Variable initialization, incrementation or change in Pink
Additional comments for programming in Purple
CallTime = System Time
Q: FIRSTSCR
REGARDS FOLLOW-UP STUDY
PRESS '1' to continue with Regular Follow-Up Interview
PRESS '2' to continue with Proxy Follow-Up Interview
If (FIRSTSCR = 1) THEN PrxCall = 0
If (FIRSTSCR = 2) THEN PrxCall = 1
Study = Current Survey Name
IF (SlpFlag 1) THEN SlpFlag = 0
IF (PA_Flag 1) THEN PA_Flag = 0
FUDate = system date
StartDte = system date
IF (seqno = “F”)
Sequence = “Final”
Rsncode = 1
ENDIF
IF (seqno = “A”) THEN Sequence = “A”
IF (seqno = 1) THEN Sequence = 6
IF (seqno = 2) THEN Sequence = 12
IF (seqno = 3) THEN Sequence = 18
IF (seqno = 4) THEN Sequence = 24
IF (seqno = 5) THEN Sequence = 30
IF (seqno = 6) THEN Sequence = 36
IF (seqno = 7) THEN Sequence = 42
IF (seqno = 8) THEN Sequence = 48
IF (seqno = 9) THEN Sequence = 54
IF (seqno = 10) THEN Sequence = 60
IF (seqno = 11) THEN Sequence = 66
IF (seqno = 12) THEN Sequence = 72
IF (seqno = 13) THEN Sequence = 78
IF (seqno = 14) THEN Sequence = 84
IF (seqno = 15) THEN Sequence = 90
IF (seqno = 16) THEN Sequence = 96
IF (seqno = 17) THEN Sequence = 102
IF (seqno = 18) THEN Sequence = 108
IF (seqno = 19) THEN Sequence = 114
IF (seqno = 20) THEN Sequence = 120
IF (seqno = 21) THEN Sequence = 126
IF (seqno = 22) THEN Sequence = 132
IF (seqno = 23) THEN Sequence = 138
IF (seqno = 24) THEN Sequence = 144
IF (seqno = 25) THEN Sequence = 150
Medrel = 0
Stroke = 0
SFP = 0
Visit = 0
Visit1 = 0
Visit2 = 0
Visit3 = 0
Visit4 = 0
Visit5 = 0
Visit6 = 0
Bone1 = 0
Bone2 = 0
Bone3 = 0
Bone4 = 0
Bone5 = 0
Bone6 = 0
Bone7 = 0
Bone8 = 0
Bone9 = 0
Bone10 = 0
Bone11 = 0
Bone12 = 0
Bone13 = 0
Bone14 = 0
Bone15 = 0
Bone16 = 0
Bone17 = 0
Bones1 = 0
Bones2 = 0
Bones3 = 0
Bones4 = 0
Bones5 = 0
Bones6 = 0
Bones7 = 0
Bones8 = 0
Bones9 = 0
Bones10 = 0
Bones11 = 0
Bones12 = 0
Bones13 = 0
Bones14 = 0
Bones15 = 0
Bones16 = 0
Bones17 = 0
BrokeOld = 0
BrokeNew = 0
EvtStr = 0
EvtNStr = 0
EvtTot = 0
Attmpt = 1
AttmptID = ident
RespNo = Respnum
RespLen = anslen(RespNo)
Do_Wav = 0
Zero1 = 0
AgeYrsR = age
IF (AgeYrsR > 120) THEN AgeYrsR = 0
IF (FIRSTSCR = 1) THEN Skip to Intro
IF (FIRSTSCR = 2) THEN Skip to IntroP1
Q: Intro
(Used for attempts to reach original respondents;
original respondents or proxies may follow this path)
INTERVIEWER: Please dial Insert Number from Sample File
Hello! My name is ___________________ and I'm calling long distance from the University of Alabama at Birmingham for the REGARDS Stroke Project.
May I please speak to Insert name from Sample File
1. Correct respondent on phone Skip to Intro3
2. Correct respondent available Skip to Intro2
3. Correct number for respondent, but not available right now Schedule a call back
4. Wrong number, respondent does not live at this number Skip to IntroP1
5. Respondent chronically ill or unable to complete a survey Skip to Sorry15
6. Respondent in the hospital Skip to Sorry15
7. Respondent in a nursing home Skip to Sorry15
8. Respondent deceased Skip to Sorry5
9. Respondent or proxy refuses to do follow up Skip to Sorry45
INTERVIEWER: If a proxy answers the phone, but declines to complete the survey, at least find out if the original respondent is in the hospital, incapacitated or dead. If respondent is ill and is expected to be better in the near future, set a call back appointment.
IF (Intro = 1) THEN Skip to INTRO3
IF (Intro = 2) THEN Skip to INTRO2
IF (Intro = 3) THEN Skip to XOUT
IF (Intro = 4)
rsncode = 3
ActDes = 4
Skip to SORRY
ENDIF
IF (Intro = 8)
ActDes = 8
rsncode = 3
MedRel = 1
Skip to SORRY5
ENDIF
IF (Intro = 5)
rsncode = 3
ActDes = 5
MedRel = 1
Skip to Sorry15
ENDIF
IF (Intro = 6)
rsncode = 3
ActDes = 6
MedRel = 1
Skip to Sorry15
ENDIF
IF (Intro = 7)
rsncode = 3
ActDes = 7
MedRel = 1
Skip to Sorry15
ENDIF
IF (Intro = 9) THEN Skip to Sorry45
Proxy Survey Introduction
IF FirstScr 2 or Intro 4, Skip to Intro3
Q: IntroP1
INTERVIEWER: Insert name from Sample File is the original respondent
You are calling to try to get additional information from one of the people the respondent said would be able to answer a few questions in case he/she was not able to for some reason.
Proxy 1: Proxy 1 Name Phone: Proxy 1 Phone
Work: Proxy 1 Work
Cell: Proxy 1 Cell
Proxy 2: Proxy 2 Name Phone: Proxy 2 Phone
Work: Proxy 2 Work
Cell: Proxy 2 Cell
Proxy 3: Proxy 3 Name Phone: Proxy 3 Phone
Work: Proxy 3 Work
Cell: Proxy 3 Cell
IF YOU DO GET THE ORIGINAL RESPONDENT, PRESS ANY KEY TO GO
TO NEXT SCREEN AND CHOOSE THE "ORIGINAL RESPONDENT" OPTION (5)
Q: IntroP2
Proxy 1: Proxy 1 Name Phone: Proxy 1 Phone
Work: Proxy 1 Work
Cell: Proxy 1 Cell
Proxy 2: Proxy 2 Name Phone: Proxy 2 Phone
Work: Proxy 2 Work
Cell: Proxy 2 Cell
Proxy 3: Proxy 3 Name Phone: Proxy 3 Phone
Work: Proxy 3 Work
Cell: Proxy 3 Cell
Hello! My name is ___________________ and I'm calling long distance from the University of Alabama at Birmingham for the Stroke Project. May I please speak to name of appropriate proxy
1. Proxy on phone
2. Proxy available
3. Correct number for proxy, but not available right now
4. Incorrect number for one or more of the Proxies
5. Original respondent on the phone able/willing to do follow up
9. Proxy or original respondent refuses to do follow up
INTERVIEWER: If no proxy names appear on the screen, enter "4"
Attmpt = 1
AttmptID = ident
IF (IntroP2 = 1) THEN Skip to IntroP3
IF (IntroP2 = 2) THEN Skip to IntroP3
IF (IntroP2 = 3) THEN Skip to Xout
IF (IntroP2 = 4) THEN Skip to Prx_TN
IF (IntroP2 = 5)
PrxCall = 0
Skip to Intro5
ENDIF
IF (IntroP2 = 9) THEN Skip to Sorry45
Q: Prx_TN
INTERVIEWER – Make a written note as to which telephone number(s) need to be corrected. Be sure to list all necessary information.
Proceed to next question, IntroP3
Q: IntroP3
Can you please tell me why Insert Name of Original Respondent is not able to complete this brief follow up survey?
1. Respondent is able to complete, but not available right now Set a callback
2. Respondent chronically ill or unable to talk on the phone Skip to Sorry15
3. Respondent is in the hospital Skip to Sorry15
4. Respondent is in a nursing home Skip to Sorry15
5. Respondent is deceased Skip to Sorry5
9. Respondent or proxy refuses to do follow up Skip to Sorry45
IF (IntroP3 = 1)
rsncode = 0
Skip to Xout
ENDIF
IF (IntroP3 = 5)
rsncode = 1
Skip to Sorry5
ENDIF
IF (IntroP3 = 2)
rsncode = 2
Skip to Sorry15
ENDIF
IF (IntroP3 = 3)
rsncode = 2
Skip to Sorry15
ENDIF
IF (IntroP3 = 4)
rsncode = 2
Skip to Sorry15
ENDIF
IF (IntroP3 = 9) THEN Skip to Sorry45
Q: Xout
We will call back later. Thank you for your time.
DISPOS = 11
End call
Q: SORRY
I am terribly sorry to have dialed this number in error. Please have a nice day.
DISPOS = 46
Rsncode = 3
End call
Respondent deceased or Incapacitated
Requesting permission for proxy survey
Respondent deceased
Q: Sorry5
Sorry5
I'm sorry to bother you at this difficult time, but as you may know, Insert Name from Sample File, was participating in a project to better understand risk factors for stroke. As part of this study
he/she had agreed to allow us to ask a few questions of a friend or family member if he/she passed away.
May I ask you just a few questions for our records?
1. Yes
2. No
IF (Sorry5 = 1) THEN Skip to ProxyFN
Proceed to next question, Sorry5a
Q: Sorry5a
Thank you very much for your time. I am sorry to have bothered you.
INTERVIEWER: Press any key
DISPOS = 72
End call
Respondent unable to complete survey due to illness or incapacitation
Q: Sorry15
I'm sorry to bother you at this difficult time, but as you may know, Insert Name from Sample File was participating in a project to better understand risk factors for stroke. As part of this study
he/she had agreed to allow us to ask a few questions of a friend or family member if he/she was unable to complete a telephone survey.
May I ask you just a few questions for our records?
1. Yes
2. No `
IF (Sorry15 = 1) THEN Skip to ProxyFN
Proceed to next question, Sorry15a
Q: Sorry15a
Thank you very much for your time. I am sorry to have bothered you.
INTERVIEWER: Press any key
DISPOS = 75
End call
Respondent or Proxy refuses
Q: Sorry45 Can you please tell me why you choose not to continue? If there are problems with the study, we'd like the opportunity to correct them.
01. Check not received
02. Letter with test results not received
03. In home exam not performed
04. Unhappy with in home exam
05. More than one reason Specify: _________________________
06. Other Specify: _______________
09. Refused, just wants out
10. Respondent deceased, proxy refused
11. Respondent hospitalized, proxy refused
12. Respondent in nursing home, proxy refused
13. Respondent ill or incapacitated, proxy refused
INTERVIEWER: If possible, proceed to the next screens. If not, use Ctrl End,but use these codes:
65: Refusal, no explanation 71: Refusal, other specify
66: Refusal, no check 72: Refusal, resp. deceased
67: Refusal, no test results 73: Refusal, resp. hospitalized
68: Refusal, no in home exam 74: Refusal, resp. in nursing home
69: Refusal, bad in home experience 75. Refusal, resp. ill
70: Refusal, multiple reasons 76. Respondent had a stroke, but refuses to complete survey
77. Respondent had a TIA, but refuses to complete survey
IF (Sorry45 = 5) THEN Skip to Sor45_sp
If (Sorry45 = 6) THEN Skip to Sor45_sp
IF (Sorry45 = 1)
Issue = "Check not received"
Origin = "SRU"
FollowUp = "Ceased"
DISPOS = 66
Skip to Sorry45a
ENDIF
IF (Sorry45 = 2)
Issue = "Test results not received"
Origin = "SRU"
FollowUp = "Ceased"
DISPOS = 67
Skip to Sorry45a
ENDIF
IF (Sorry45 = 3)
Issue = "No in home exam"
Origin = "SRU"
FollowUp = "Ceased"
DISPOS = 68
Skip to Sorry45a
ENDIF
IF (Sorry45 = 4)
Issue = "Unhappy with in home exam"
Origin = "SRU"
FollowUp = "Ceased"
DISPOS = 69
Skip to Sorry45a
ENDIF
IF (Sorry45 = 9)
Issue = "Refused, would not specify"
FollowUp = "Ceased"
DISPOS = 65
Skip to Sorry45a
ENDIF
IF (Sorry45 = 10)
DISPOS = 72
Skip to Sorry45b
ENDIF
IF (Sorry45 = 11)
DISPOS = 73
Skip to Sorry45b
ENDIF
IF (Sorry45 = 12)
DISPOS = 74
Skip to Sorry45b
ENDIF
IF (Sorry45 = 13)
DISPOS = 75
Skip to Sorry45b
ENDIF
Q: Sor45_sp
INTERVIEWER: Please enter reason or reasons participant gives for wishing to discontinue participation. Enter UNKNOWN if not available
Ans_Len = 0
Ans_Len = Text Length of Sorry45_sp
IF (Ans_Len = 0)
Re Ask Sorry45_sp
ENDIF
Issue = Sor45_sp
Proceed to next question, Sorry45a
Q: Sorry45a
INTERVIEWER: Indicate whether you are talking with the original respondent or someone else.
1. Original Respondent
2. Other person
IF (Sorry45a = 1) THEN Who = "Respondent"
IF (Sorry45a = 2) THEN Who = "Proxy"
IF (Sorry45a = 2) THEN Skip to ProxyFN
IF (Sorry45a = 1) THEN Skip to SpAtt
Q: Sorry45b
INTERVIEWER: Indicate level of concern
1. Very angry
2. Angry
3. Upset
4. Concerned
IF (Sorry45b = 1) Level = "Very Angry"
IF (Sorry45b = 2) Level = "Angry"
IF (Sorry45b = 3) Level = "Upset"
IF (Sorry45b = 4) Level = "Concerned"
Proceed to next question, Sorry45c
Q: Sorry45c
I am so sorry that you had that experience participating in the REGARDS study. The researchers in charge of the study will be informed of your experience and will take necessary steps to make sure that this problem is remedied. If you change your mind and wish to resume participation in the REGARDS study, please call
1-888-REGARDS (1-888-734-2737)
Thank you very much for your time today.
End Call
Proxy Name and Relationship to Original Respondent
Q: ProxyFN and ProxyLN
Let me first get your name and relationship to Insert Name from Sample File
Let's start with your name:
First Name: ________________________________________
Last Name: ________________________________________
Ans_Len = 0
Ans_Len = Text Length of ProxyFN
IF (Ans_Len = 0)
Re Ask ProxyFN
ENDIF
Ans_Len = 0
Ans_Len = Text Length of ProxyLN
IF (Ans_Len = 0)
Re Ask ProxyLN
ENDIF
Q: ProxyRel
IF (Intro = 8) – participant is deceased
What was your relationship to Insert Name from Sample File? For example, were you his/her spouse, partner or significant other, daughter, son, daughter-in-law, son-in-law, sister, brother, mother, father, grand-daughter, grandson, niece, nephew, other relative, friend or neighbor?
IF (Intro 8) – not deceased
What is your relationship to Insert Name from Sample File? For example, are you his/her spouse, partner or significant other, daughter, son, daughter-in-law, son-in-law, sister, brother, mother, father, grand-daughter, grandson, niece, nephew, other relative, friend or neighbor?
Enter code: _________
11. Spouse 21. Grand-daughter
12. Partner, significant other 22. Grand-son
13. Daughter 23. Niece
14. Son 24. Nephew
15. Daughter in law 25. Other relative
16. Son in law 26. Friend or neighbor
17. Sister 88. Don't Know/Not Sure
18. Brother 99. Refused
19. Mother
20 Father
IF (ProxyRel = 11) THEN Relation = "Spouse"
IF (ProxyRel = 12) THEN Relation = "Partner or significant other"
IF (ProxyRel = 13) THEN Relation = "Daughter"
IF (ProxyRel = 14) THEN Relation = "Son"
IF (ProxyRel = 15) THEN Relation = "Daughter in law"
IF (ProxyRel = 16) THEN Relation = "Son in law"
IF (ProxyRel = 17) THEN Relation = "Sister"
IF (ProxyRel = 18) THEN Relation = "Brother"
IF (ProxyRel = 19) THEN Relation = "Mother"
IF (ProxyRel = 20) THEN Relation = "Father"
IF (ProxyRel = 21) THEN Relation = "Grand-daughter"
IF (ProxyRel = 22) THEN Relation = "Grand-son"
IF (ProxyRel = 23) THEN Relation = "Niece"
IF (ProxyRel = 24) THEN Relation = "Nephew"
IF (ProxyRel = 25) THEN Relation = "Relative, other"
IF (ProxyRel = 26) THEN Relation = "Friend or relative"
IF (ProxyRel > 27) THEN Relation = "Not divulged"
IF (Sorry45 > 0) THEN Skip to Sorry45c
Others, Skip to Intro4a
Reintroducing interviewer to respondent called to the phone
Q: INTRO2
Hello. My name is _____________________ and I'm calling long distance from the University of Alabama at Birmingham for the REGARDS Stroke Project.
INTERVIEWER: Press any key to continue
Proceed to next question, Intro3
Q: INTRO3
First of all I'd like to thank you again for taking the time to be a part of this important study. About a week ago we sent you a letter reminding you that we would be calling to ask you a few questions about
your health since we last talked to you.
Do you remember talking to us
1. Yes, remembers the interview and/or in home exam Skip to Intro5
2. No, does not remember the interview or in home exam
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
IF (seqno = 1) THEN Sequence = 6
IF (seqno = 2) THEN Sequence = 12
IF (seqno = 3) THEN Sequence = 18
IF (seqno = 4) THEN Sequence = 24
IF (seqno = 5) THEN Sequence = 30
IF (seqno = 6) THEN Sequence = 36
IF (seqno = 7) THEN Sequence = 42
IF (seqno = 8) THEN Sequence = 48
IF (seqno = 9) THEN Sequence = 54
IF (seqno = 10) THEN Sequence = 60
IF (seqno = 11) THEN Sequence = 66
IF (seqno = 12) THEN Sequence = 72
IF (seqno = 13) THEN Sequence = 78
IF (seqno = 14) THEN Sequence = 84
IF (seqno = 15) THEN Sequence = 90
IF (seqno = 16) THEN Sequence = 96
IF (seqno = 17) THEN Sequence = 102
IF (seqno = 18) THEN Sequence = 108
IF (seqno = 19) THEN Sequence = 114
IF (seqno = 20) THEN Sequence = 120
IF (seqno = 21) THEN Sequence = 126
IF (seqno = 22) THEN Sequence = 132
IF (seqno = 23) THEN Sequence = 138
IF (seqno = 24) THEN Sequence = 144
IF (seqno = 25) THEN that Sequence = 150
IF (Intro3=2) then proceed to next question, Intro4
Q: Intro4
REGARDS is a nationwide project designed to understand why people in different parts of the country, and people of different ethnic groups, have different rates of stroke and heart disease. Stroke is the 3rd leading cause of death in our country and the number 1 cause of disability. By participating in the REGARDS project, you will help improve our understanding of risk factors for stroke. This is an important first step n discovering ways to prevent stroke.
You are one of about 30,000 people age 45 and older who were selected from around the United States to participate in this first study. For reasons that are not understood, people in some parts of the country develop strokes more often people in other parts of the country. In addition, African Americans develop more strokes than whites. This project will follow 30,000 people for several years to learn why there are these differences in stroke risk.
INTERVIEWER: Press any key to continue
Skip to Intro5
Q: Intro4a
IF (Intro = 8 OR IF IntroP3 = 5) – participant is deceased
REGARDS is a nationwide project designed to understand why people in different parts of the country, and people of different ethnic groups, have different rates of stroke and heart disease. Stroke is the 3rd leading cause of death in our country and the number 1 cause of disability. This study is an important first step in discovering ways to prevent stroke.
Insert Name of Sample File was one of about 30,000 people age 45 and older who were selected from around the United States to participate in this first study. For reasons that are not understood, people in some parts of the country develop strokes more often than people in other parts of the country. In addition, African Americans develop more strokes than whites. This project will follow 30,000 people for several years to learn why there are these differences in stroke risk.
ENDIF
IF Intro8 – participant not desceased
REGARDS is a nationwide project designed to understand why people in different parts of the country, and people of different ethnic groups, have different rates of stroke and heart disease. Stroke is the 3rd leading cause of death in our country and the number 1 cause of disability. This study is an important first step in discovering ways to prevent stroke.
Insert Name of Sample File is one of about 30,000 people age 45 and older who were selected from around the United States to participate in this first study. For reasons that are not understood, people in some parts of the country develop strokes more often than people in other parts of the country. In addition, African Americans develop more strokes than whites. This project will follow 30,000 people for several years to learn why there are these differences in stroke risk.
ENDIF
INTERVIEWER: Press any key to continue
IF (Intro = 8) THEN Skip to Intro5b
IF (IntroP3 = 5) THEN Skip to Intro5b
IF (Intro 8) THEN Skip to Intro5a
Q: INTRO5
We are now calling just to see you how have been doing since the last time we talked to you about six months ago. Let me remind you that all your answers will be kept totally confidential and you don't have to answer any questions you don't want to. If you can't remember some of the information I'll be asking for, just let me know and we'll move on.
If you have been hospitalized or had any possible symptoms of a stroke, we may request and review copies of your medical records.
INTERVIEWER: Press "1" to continue
Skip to Q1
Q: Intro5a
Insert Name from Sample File completed a telephone interview several months ago to answer questions about his/her health. We are calling now to see how he/she has been doing since then.
Let me remind you that all of your answers will be kept totally confidential and you don't have to answer any questions you don't want to.
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
Skip to Qincap
Q: Intro5b
Insert Name from Sample File completed a survey about his/her health several months ago. We are calling now as a follow up. Let me remind you that all your answers will be confidential and you don't have to answer any question you don't want to.
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
Proceed to next question, Qdead
Follow Up Questions Regarding Cause and Date of Death
Q: QDEAD
Can you please tell me the cause and date of death for Insert Name from Sample File?
First, please tell me the cause of death:
1. Stroke/brain aneurysm/mini-stroke
2. Heart related condition
3. Cancer
4. Other
7. Don't Know/Not Sure
9. Refused/Survey terminated at this point
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
IF (QDEAD = 1) THEN Skip to Qdead1
IF (QDEAD = 2) THEN Skip to Qdead1
IF (QDEAD = 3) THEN Skip to Qdead1
IF (QDEAD = 7) THEN Skip to Qdead1
IF (QDEAD = 9) THEN Skip to Qdead1
IF (QDEAD = 4) Proceed to next question, Qdeadsp
Q: Qdeadsp
Did he/she die of any of the following?
11. Alzheimer's or dementia
12. Gastrointestinal or stomach problems
13. Pneumonia
14. Asthma, Emphysema or other respiratory problems
15. Diabetes or renal failure
16. Natural causes or old age
77. Other Please specify __________________________________
88. Don't Know/Not Sure
99. Refused
IF (Qdeadsp = 77)
IF (Text Length of Qdeadsp =2)
Re Ask Qdeadsp
ENDIF
Proceed to next question, Qdead1
Q: Qdead1
When did this happen? (Probe for month and year)
__________ Enter date mm/dd/yyyy
01/01/7777 Don't Know/Not Sure
01/01/9999 Refused
If respondent unable to remember exact day, enter the appropriate month and year and "01" INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
DATES ARE VERY IMPORTANT!!! AT THE VERY LEAST, GET MONTH and YEAR. PROBE USING LAST INTERVIEW DATE
IF (Qdead1 < 01/01/2003)
Re Ask Qdead1
ENDIF
IF (Qdead1 > System Date)
IF (Qdead1 < 01/01/7777)
Re ask Qdead1
ENDIF
IF (Qdead1 = 01/01/9999)
Dispos=72
End Call
ENDIF
Proceed to next question, Qdead1a
Q: Qdead1a
Did he/she die at home, in the hospital or somewhere else?
1. Home
2. Hospital
3. Nursing Home
4. Other Specify: ________________________
5. Hospice
8. Don't Know/Not Sure
9. Refused
IF (Qdead1a = 4)
IF (Text length of Qdead1a = 1)
Re ask Qdead1a
ENDIF
ENDIF
IF (Qdead1a = 1) THEN Skip to Qdead2
IF (Qdead1a < 4) THEN Skip to Qdead1b
IF (Qdead1a > 4) THEN Skip to Qdead1b
Q: Qdead1b
IF (Qdead1a = 3)
What is the name of the nursing home where he/she passed away?
ENDIF
IF (Qdead1a = 2)
What is the name of the hospital where he/she passed away?
ENDIF
IF (Qdead1a = 5)
What is the name of the hospice facility where he/she passed away?
ENDIF
What is the name of the hospital/nursing home/hospice or other place where he/she passed away?
_________________________________________________________________________
INTERVIEWER: IT IS VERY IMPORTANT TO GET THE CORRECT NAME AND
SPELLING OF THE FACILITY. ASK RESPONDENT TO SPELL THE NAME FOR
YOU. ENTER ONLY THE NAME OF THE FACILITY,
NO ADDITIONAL COMMENTS HERE
Ans_len = 0
Ans_len = Text Length of Qdead1b
IF (Ans_len = 0)
Re ask Qdead1b
ENDIF
Proceed to next question, Qdead1c and Qdead1c1
Q: Qdead1c and Qdead1c1
IF (Qdead1a = 2)
In what city and state is this hospital?
End IF
IF (Qdead1a = 3)
In what city and state is this nursing home?
End IF
IF (Qdead1a = 5)
In what city and state is this hospice facility?
End IF
City:______________________________________________
State: _____________________________________________
INTERVIEWER: PLEASE BE SURE TO GET THE CORRECT NAME AND SPELLING OF THE CITY. IF YOU ARE AT ALL UNSURE, ASK THE RESPONDENT TO SPELL IT FOR YOU. ENTER ONLY CITY AND STATE NAMES. NO ADDITIONAL COMMENTS HERE.
Ans_len = 0
Ans_len = Text Length of Qdead1c
IF (Ans_len = 0)
Re ask Qdead1c
ENDIF
Ans_len = 0
Ans_len = Text Length of Qdead1c1
IF (Ans_len = 0)
Re ask Qdead1c1
ENDIF
Proceed to next question, Qdead1d and Qdead1d1
Q: Qdead1d and Qdead1d1
IF (Qdead1a = 3)
Do you know the street address or zip code for this nursing home?
ENDIF
IF (Qdead1a = 2)
Do you know the street address or zip code for this hospital?
ENDIF
IF (Qdead1a = 5)
Do you know the street address or zip code for this hospice facility?
ENDIF
Street Address: _____________________________________________
Zip Code: ________________________________________________
INTERVIEWER: DO NOT LEAVE ANY FIELDS ON THIS SCREEN BLANK. IF RESPONDENT DOES NOT KNOW OR CANNOT REMEMBER, ENTER "UNKNOWN"
Ans_len = 0
Ans_len = Text length of Qdead1d
IF (Ans_len = 0)
Re ask Qdead1d
ENDIF
Ans_len = 0
Ans_len = Text Length of Qdead1d1
IF (Ans_len = 0)
Re ask Qdead1d1
ENDIF
Proceed to next question, Qdead1e
Q: Qdead1e
What is the name of the doctor he/she saw? _________________________________________________
INTERVIEWER: DO NOT LEAVE ANY FIELDS ON THIS SCREEN BLANK. IF RESPONDENT DOES NOT KNOW OR CANNOT REMEMBER, ENTER "UNKNOWN"
Ans_len = 0
Ans_len = Text length of Qdead1e
IF (Ans_len = 0)
Re ask Qdead1e
ENDIF
Skip to Q1
Q: Qdead2 , Qdead2a and Qdead2b
In what city or county and state did he/she die?
City: _________________________________________________
County: ______________________________________________
State: ___________________________________________
INTERVIEWER: BE SURE TO GET CORRECT CITY AND COUNTY NAMES. IF AT ALL UNSURE OF PRONUNCIATION OR SPELLING, ASK RESPONDENT TO SPELL THEM FOR YOU
DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN"
Ans_len = 0
Ans_len = Text length of Qdead2
IF (Ans_len = 0)
Re ask Qdead2
ENDIF
Ans_len = 0
Ans_len = Text length of Qdead2a
IF (Ans_len = 0)
Re ask Qdead2a
ENDIF
Ans_len = 0
Ans_len = Text length of Qdead2b
IF (Ans_len = 0)
Re ask Qdead2b
ENDIF
Proceed to next question, Qdead3
Q: Qdead3
Had he/she gone to any hospital or was he/she under a doctor's care within a month before he/she passed away?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
IF (Qdead3 > 1) THEN Skip to Q3_1
IF (Qdead3 = 1), Proceed to next question, Qdead3_1
Q: Qdead3_1
What was the reason for this visit?
1. Stroke/brain aneurysm/TIA
2. Heart-related condition
3. Cancer
4. Other
5. Broken, fractured or crushed bone
8. Don't Know/Not Sure
9. Refused
IF (Qdead3_1 4) THEN Skip to Qdead3_2
Proceed to next question, Qdead3_1sp
Q: Qdd3_1sp
Was the reason for the visit any of the following?
11. Alzheimer's or dementia
12. Gastrointestinal or stomach problems
13. Pneumonia
14. Asthma, Emphysema or other respiratory problems
15. Diabetes or renal failure
16. Deafness or loss of hearing
17. Blindness or loss of sight
77. Other Please specify ______________________________________
88. Don't Know/Not Sure
99. Refused
INTERVIEWER: Do not leave "other" blank include any comments the respondent offers
IF (Qdd3_1sp = 77)
IF (Text length of Qdd3_1sp =2)
Re ask Qdd3_1sp
ENDIF
ENDIF
Proceed to next question, Qdead3_2
Q: Qdead3_2
Was this an in-patient, out-patient or emergency room visit?
1. In-patient
2. Out-patient
3. Emergency room
8. Don't Know/Not Sure
9. Refused
Proceed to next question, Qdead3a
Q: Qdead3a
What was the date of his/her last hospital admission or medical visit?
Enter date
01/01/7777 Don't Know/Not Sure
01/01/8888 Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
DATES ARE VERY IMPORTANT!!! AT THE VERY LEAST, GET MONTH and YEAR. PROBE USING LAST INTERVIEW DATE
IF (Qdead3a < 01/01/2003)
Re ask Qdead3a
ENDIF
IF (Qdead3a > System Date)
IF (ANS < 01/01/7777)
Re Ask Qdead3a
ENDIF
ENDIF
Proceed to next question, Qdead4
Q: Qdead4
What is the name of the medical office or hospital where he/she was treated for this condition?
_____________________________________________________
INTERVIEWER: PROBE FOR FULL NAME OF DOCTOR'S OFFICE OR MEDICAL CENTER, FOR EXAMPLE "BROOKWOOD MEDICAL GROUP" OR "KIRKLAND CLINIC" OR "DR. ADAMS, PC"
Ans_Len = 0
Ans_Len = Text Length of Qdead4
IF (Ans_Len = 0)
Re Ask Qdead4
ENDIF
Proceed to next question, Qdead4a
Q: Qdead4a
And is this a doctor's office or hospital?
1. Doctor's office
2. Hospital
8. Don't Know/Not Sure
9. Refused
Proceed to next question, Qdead5 and Qdead5a
Q: Qdead5 and Qdead5a
And in what city and state was this medical office or hospital?
City: _________________________________________________
State: _________________________________________________
INTERVIEWER: PLEASE BE SURE TO GET CORRECT SPELLING OF CITY. IF AT ALL UNSURE, ASK RESPONDENT TO SPELL IT FOR YOU
DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Qdead5
IF (Ans_Len = 0)
Re Ask Qdead5
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Qdead5a
IF (Ans_Len = 0)
Re Ask Qdead5a
ENDIF
Proceed to next question, Qdead6 and Qdead6a
Q: Qdead6 and Qdead6a
Do you know the street address and/or zip code of this place?
Street address: __________________________________________
ZipCode: ______________________________________________
DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Qdead6
IF (Ans_Len = 0)
Re Ask Qdead6
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Qdead6a
IF (Ans_Len = 0)
Re Ask Qdead6a
ENDIF
Proceed to next question, Qdead7
Q: Qdead7
What is the name of the doctor he/she saw? _______________________
DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Qdead7
IF (Ans_Len = 0)
Re Ask Qdead7
ENDIF
Skip to Q1
Follow Up Questions Regarding Cause and Date of Illness or Incapacitation
Q: QINCAP
Respondent unable to complete survey due to hospitalization, illness, admission to nursing home or other incapacitation
Can you please tell me the nature of the illness or condition which makes it impossible for
Insert Name from Sample File to complete this brief telephone survey personally?
1. Stroke/brain aneurysm/mini-stroke Skip to Qincap1
2. Heart related condition Skip to Qincap1
3. Cancer Skip to Qincap1
4. Other Skip to Qincapsp
5. Broken, crushed or fractured bone Skip to Qincap1
7. Don't Know/Not Sure Skip to Q1
9. Refused Skip to Q1
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
MedRel = 1
IF (QINCAP = 7) THEN Skip to Q1
IF (QINCAP = 9) THEN Skip to Q1
IF (QINCAP 4) THEN Skip to Qincap1
IF (QINCAP = 4), Proceed to next question, Qincapsp
Q: Qincapsp
Is he/she unable to answer a few questions for any of the following reasons?
11. Alzheimer's or dementia
12. Gastrointestinal or stomach problems
13. Pneumonia
14. Asthma, Emphysema or other respiratory problems
15. Diabetes or renal failure
16. Deafness or loss of hearing
17. Blindness or loss of sight
77. Other Please specify: ____________________________________
88. Don't Know/Not Sure
99. Refused
INTERVIEWER: Do not leave "other" blank include any comments the respondent offers
IF (Qincapsp = 77)
IF (Text Length of Qincapsp = 1)
Re Ask Qincapsp
ENDIF
ENDIF
Proceed to next question, Qincap1
Q: Qincap1
If speaking with original respondent, the question is:
What was the name of the doctor who treated him/her for this condition?
If (Intro > 4), which means proxy call entered thru regular follow-up, the question is
What was the name of the doctor who is treating him/her for this condition?
IF (IntroP3 > 1), which means proxy call entered thru proxy follow-up, the question is
What was the name of the doctor who is treating him/her for this condition?
DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Qincap1
IF (Ans_Len = 0)
Re Ask Qincap1
ENDIF
Proceed to next question, Qincap2
Q: Qincap2
When did this happen? (Probe for month and year)
Enter date mm/dd/yyyy
01/01/7777 Don't Know/Not Sure
01/01/9999 Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
DATES ARE VERY IMPORTANT!!! AT THE VERY LEAST, GET MONTH and YEAR. PROBE USING LAST INTERVIEW DATE
IF (Qincap2 < 01/01/2003)
Re Ask Qincap2
ENDIF
IF (Qincap2 > System Date)
IF (ANS < 01/01/7777)
Re Ask Qincap2
ENDIF
ENDIF
Proceed to next question, Qincap3
Q: Qincap3
If speaking with original respondent, the question is:
What is the name of the medical office or hospital where he/she was/is treated for this condition?
If (Intro > 4), which means proxy call entered thru regular follow-up, the question is
What is the name of the medical office or hospital where he/she is treated for this condition?
______________________________________________________
INTERVIEWER: GET THE COMPLETE NAME OF THE HOSPITAL OR MEDICAL CENTER. IF AT ALL UNSURE, ASK RESPONDENT TO SPELL FOR YOU. NO COMMENTS, JUST THE NAME
DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Qincap3
IF (Ans_Len = 0)
Re Ask Qincap3
ENDIF
Proceed to next question, Qincap3a
Q: Qincap3a And is this a doctor's office or a hospital?
1. Doctor's office
2. Hospital
8. Don't Know/Not Sure
9. Refused
Proceed to next question, Qincap4 and Qincap4a
Q: Qincap4 and Qincap4a
And in what city and state was this medical office or hospital?
City: _______________________________________________
State: _______________________________________________
INTERVIEWER: BE SURE TO GET THE CORRECT NAME AND SPELLING OF THE CITY. IF AT ALL UNSURE, ASK RESPONDENT TO SPELL IT FOR YOU. DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Qincap4
IF (Ans_Len = 0)
Re Ask Qincap4
ENDIF
Ans_Len = 0
Ans_Len = Text Length Qincap4a
IF (Ans_Len = 0)
Re Ask Qincap4a
ENDIF
Proceed to next question, Qincap5 and Qincap5a
Q: Qincap5 and Qincap5a
Do you know the street address or zip code of this place?
Street Address: ___________________________________________
Zip Code: ___________________________________________
DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Qincap5
IF (Ans_Len = 0)
Re Ask Qincap5
ENDIF
Ans_Len = 0
Ans_Len = Text Length Qincap5a
IF (Ans_Len = 0)
Re Ask Qincap5a
ENDIF
Proceed to next question, Q1
REPORT OF STROKE
Q: Q1
IF (PrxCall = 0) or (Intro < 4), which means Regular follow up interview, the question is
The questions I am going to ask you now are about things that might have happened since the last time we talked with you.
Since we last spoke with you, has a doctor told you that you have had a stroke or a cerebrovascular event?
IF (Intro > 4), which is Proxy call entered thru regular follow-up, the question is
The questions I am going to ask you now are about things that might have happened since the last time we talked with
Since we last spoke with him/her, was he/she told by a doctor that he/she had a stroke or a cerebrovascular event?
IF (IntroP3 > 1), which means Proxy call entered thru proxy follow-up, the question is
The questions I am going to ask you now are about things that might have happened since the last time we talked with
Since we last spoke with him/her, was he/she told by a doctor that he/she had a stroke or a cerebrovascular event?
1. Yes
2. No
7. Don't Know/Not Sure
9. Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
IF (PrxCall = 0)
IF (Qincap = 1) THEN Skip to Q3_1
IF (Qdead = 1) THEN Skip to Q3_1
ENDIF
IF (Q1 > 1)
Skip to Q2
ENDIF
IF (Q1 = 1)
Medrel = Medrel + 1
Stroke = Stroke + 1
EvtStr = EvtStr + 1
ENDIF
IF (Q1 = 1), proceed to next question, Q1_1
Q: Q1_1
1.1
If speaking with the Original Respondent, the question is:
What was the name of the doctor who treated you/him/her for this condition?
If Intro > 4, which means this is a proxy call entered thru regular follow up, the question is:
What was the name of the doctor who treated him/her for this condition?
If IntroP3 > 1, which means this is a proxy call entered thru proxy follow up, the question is:
What was the name of the doctor who treated him/her for this condition?
___________________________________________________________
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
Ans_Len = 0
Ans_Len = Text Length of Q1_1
IF (Ans_Len = 0)
Re Ask Q1_1
ENDIF
Proceed to next question, Q1_2
Q: Q1_2
1.2 When did this happen? (Probe for month and year)
Enter date mm-dd-yyyy
01/01/7777 Don't Know/Not Sure
01/01/9999 Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
DATES ARE VERY IMPORTANT!!! AT THE VERY LEAST, GET MONTH and YEAR. PROBE USING LAST INTERVIEW DATE
IF (Q1_2 > System Date)
IF (Q1_2 < 77770101)
Re Ask Q1_2
ENDIF
ENDIF
Proceed to next question, Q1_3
Q: Q1_3
1.3
If speaking with the Original Respondent, the question is:
What is the name of the medical office or hospital where you were/he was/she was treated for this condition?
If Intro > 4, which means this is a proxy call entered thru regular follow up, the question is:
What is the name of the medical office or hospital where he/she was treated for this condition?
If IntroP3 > 1, which means this is a proxy call entered thru proxy follow up, the question is:
What is the name of the medical office or hospital where he/she was treated for this condition?
________________________________________________________
INTERVIEWER PROBE FOR SPECIFICS: GET FULL NAME OF HOSPITAL OR DOCTOR'S OFFICE
DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Q1_3
IF (Ans_Len = 0)
Re Ask Q1_3
ENDIF
Proceed to next question, Q1_3a
Q: Q1_3a
And is this a doctor's office or a hospital?
1. Doctor's office
2. Hospital
8. Don't Know/Not Sure
9. Refused
Proceed to next question, Q1_4 and Q1_4a
Q: Q1_4 and Q1_4a
1.4 And in what city and state was that medical office or hospital?
City: __________________________________________
State: __________________________________________
INTERVIEWER: BE SURE TO GET CORRECT NAME AND SPELLING OF CITY. IF AT ALL UNSURE, ASK RESPONDENT TO SPELL IT FOR YOU. DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length Q1_4
IF (Ans_Len = 0)
Re Ask Q1_4
ENDIF
Ans_Len = 0
Ans_Len = Text Length Q1_4a
IF (Ans_Len = 0)
Re Ask Q1_4a
ENDIF
Proceed to next question, Q1_5 and Q1_5a
Q: Q1_5 and Q1_5a
1.5 Do you know the street address or zip code of this place?
Street address:
Zip Code:
DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Q1_5
IF (Ans_Len = 0)
Re Ask Q1_5
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q1_5a
IF (Ans_Len = 0)
Re Ask Q1_5a
ENDIF
Proceed to next question, Q2
REPORT OF TIA
Q: Q2
2.
If speaking with the Original Respondent, the question is:
Since the last time we spoke with you have you had a TIA or mini-stroke that got better?
If Intro > 4, which means this is a proxy call entered thru regular follow up, the question is:
Since the last time we spoke with was he/she told that he had a TIA or mini-stroke
that got better?
If IntroP3 > 1, which means this is a proxy call entered thru proxy follow up, the question is:
Since the last time we spoke with was he/she told that he had a TIA or mini-stroke
that got better?
1. Yes
2. No Skip to Q3_1
7. Don't Know/Not Sure Skip to Q3_1
9. Refused Skip to Q3_1
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
IF (Q2 = 1)
MedRel = MedRel + 1
Stroke = Stroke + 1
EvtStr = EvtStr + 1
ENDIF
IF (Q2 > 1)
IF (PrxCall 1)
IF (PA_Flag = 0)
IF (AgeYrsR > 55.99)
Skip to QPhyA_1
ENDIF
ENDIF
ENDIF
Skip to Q3_1
ENDIF
IF (Q2 = 1) Proceed to next question, Q2_1
Q: Q2_1
2.1
If speaking with the Original Respondent, the question is:
What was the name of the doctor who treated you for this condition?
If Intro > 4, which means this is a proxy call entered thru regular follow up, the question is:
What was the name of the doctor who treated him/her for this condition?
If IntroP3 > 1, which means this is a proxy call entered thru proxy follow up, the question is:
What was the name of the doctor who treated him/her for this condition?
__________________________________________
DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Q2_1
IF (Ans_Len = 0)
Re Ask Q2_1
ENDIF
Proceed to next question, Q2_2
Q: Q2_2
2.2 When did this happen? (Probe for month and year)
Enter date mm-dd-yyyy
01/01/7777 Don't Know/Not Sure
01/01/9999 Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
DATES ARE VERY IMPORTANT!!! AT THE VERY LEAST, GET MONTH and YEAR. PROBE USING LAST INTERVIEW DATE
IF (Q2_2 > System Date)
IF (Q2_2 < 01/01/7777)
Re Ask Q2_2
ENDIF
ENDIF
Proceed to next question, Q2_2
Q: Q2_3
2.3
If speaking with the Original Respondent, the question is:
What is the name of the medical office or hospital where you were treated for this condition?
If Intro > 4, which means this is a proxy call entered thru regular follow up, the question is:
What is the name of the medical office or hospital where he/she was treated for this condition?
If IntroP3 > 1, which means this is a proxy call entered thru proxy follow up, the question is:
What is the name of the medical office or hospital where he/she was treated for this condition?
_______________________________________________________________
INTERVIEWER: PROBE FOR FULL NAME OF MEDICAL OFFICE OR HOSPITAL. IF AT ALL UNSURE, ASK RESPONDENT TO SPELL IT FOR YOU. DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Q2_3
IF (Ans_Len = 0)
Re Ask Q2_3
ENDIF
Proceed to next question, Q2_3a
Q: Q2_3a
And is this a doctor's office or a hospital?
1. Doctor's office
2. Hospital
8. Don't Know/NotSure
9. Refused
Proceed to next question, Q2_4
Q: Q2_4 and Q2_4a
2.4 And in what city and state was this medical office or hospital?
City: ____________________________________________________
State: _____________________________________________________
INTERVIEWER: BE SURE TO GET CORRECT NAME AND SPELLING OF CITY. IF AT ALL UNSURE, ASK RESPONDENT TO SPELL IT FOR YOU.
DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Q2_4
IF (Ans_Len = 0)
Re Ask Q2_4
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q2_4a
IF (Ans_Len = 0)
Re Ask Q2_4a
ENDIF
Q: Q2_5 and Q2_5a
2.5 Do you know the street address or zip code of this place?
Street address: ____________________________________________
Zip Code: ____________________________________________
DO NOT LEAVE BLANK. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Q2_5
IF (Ans_Len = 0)
Re Ask Q2_5
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q2_5a
IF (Ans_Len = 0)
Re Ask Q2_5a
ENDIF
IF (PrxCall 1)
IF (PA_Flag = 0)
IF (AgeYrsR > 55.99)
Skip to QPhyA_1
ENDIF
ENDIF
ENDIF
ALL OTHERS GO TO Q3_1 REGARDLESS
Skip to Q3_1
PHYSICAL ACTIVITY MODULE SCREENING QUESTION
Q: QPhyA_1
PhyA.1
We are interested in learning more about how physical activity is related to stroke and risk factors for stroke and heart disease. To do this, we need to know more about your physical activity level. On a typical day, are you physically able to go outside where you live and walk, whether or not you actually do?
1. Yes
2. No
INTERVIEWER - IF THE PARTICPANT SAYS NO, THEN SAY "NO PROBLEM".
Proceed to next question, QPhyA_1a
Q: QPhyA_1a
PhyA.1a
INTERVIEWER: Please enter any additional comments the respondent volunteered regarding this Physical Activity question. Enter NONE if the respondent had no comments at all.
Ans_Len = 0
Ans_Len = Text Length of QPhyA_1a
IF (Ans_Len = 0)
Re Ask QPhyA_1a
ENDIF
Proceed to next question, Q3_1
STROKE FREE PHENOTYPE QUESTIONS
Q: Q3_1
3.1
If speaking with the Original Respondent, the question is:
Since the last time we talked with you/him/her, have you/has he/has she had sudden painless weakness on one side of your body? This would be different than an arm or leg falling asleep, by this we mean something that happens suddenly and to an entire side of the body.
If speaking with a Proxy under the following conditions, the question is as follows:
IF (Intro = 6) RESPONDENT IN HOSPITAL
IF (IntroP3 = 3) C: Proxy call entered thru proxy follow-up
IF (Intro = 8) RESPONDENT DECEASED
IF (IntroP3 = 5) C: Proxy call entered thru proxy follow-up
IF (Intro = 5) RESPONDENT CHRONICALLY ILL
IF (IntroP3 = 2) C: Proxy call entered thru proxy follow-up
IF (Intro = 7) RESPONDENT IN NURSING HOME
IF (IntroP3 = 4) C: Proxy call entered thru proxy follow-up
Since we last spoke with him, has he/she experienced sudden painless weakness on one side of his body?
1. Yes
2. No
7. Don't Know/Not Sure
9. Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
INTERVIEWER: Even though the respondent may have had a stroke or TIA, it is important that we determine if they had stroke-like symptoms as well.
IF (Q3_1 = 1)
MedRel = MedRel + 1
SFP = SFP + 1
EvtNStr = EvtNStr + 1
ENDIF
If (Q3_1 > 1) THEN Skip to Q3_2
If Q3_1 = 1, Proceed to next question, Q3_1a
Q: Q3_1a
3.1a Do you know what caused this? For example, was it chronic back or neck problems, nerve damage or neuropathy, poor blood circulation or circulatory problems, a broken bone or injury from an accident, trauma or fall, medications or side effects of medication or some other cause?
1. Chronic Back/Neck Problems
2. Nerve Damage/Neuropathy
3. Circulatory problems/Poor Circulation or blood flow
4. Broken bone or injury from an accident, trauma or fall
5. Medication or side effects from medication
6 Other Specify: _________________________________________
8. Unknown cause
9. Refused
IF RESPONSE IS 'OTHER' DO NOT LEAVE 'SPECIFY' BLANK ENTER ANY INFORMATION VOLUNTEERED BY RESPONDENT
IF (Q3_1a = 6)
IF (Text Length of Q3_1a = 1)
Re Ask Q3_1a
ENDIF
ENDIF
Proceed to next question, Q3_2
Q: Q3_2
3.2
If speaking with the Original Respondent, the question is:
Since the last time we talked with you, have you had sudden numbness or a dead feeling on one side of your body? This would be different than an arm or leg falling asleep, by this we mean something that happens suddenly and to an entire side of the body.
If speaking with a Proxy under the following conditions, the question is as follows:
IF (Intro = 6) RESPONDENT IN HOSPITAL
IF (IntroP3 = 3) C: Proxy call entered thru proxy follow-up
IF (Intro = 8) RESPONDENT DECEASED
IF (IntroP3 = 5) C: Proxy call entered thru proxy follow-up
IF (Intro = 5) RESPONDENT CHRONICALLY ILL
IF (IntroP3 = 2) C: Proxy call entered thru proxy follow-up
IF (Intro = 7) RESPONDENT IN NURSING HOME
IF (IntroP3 = 4) C: Proxy call entered thru proxy follow-up
Since the last time we spoke with him/her, did he/she have sudden numbness or a dead feeling on one side of his/her body? 1. Yes
2. No
7. Don't Know/Not Sure
9. Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
IF (Q3_2 = 1)
MedRel = MedRel + 1
SFP = SFP + 1
EvtNStr = EvtNStr + 1
ENDIF
If (Q3_2 > 1) THEN Skip to Q3_3
If Q3_2 = 1, Proceed to next question, Q3_2a
Q: Q3_2a
3.2a Do you know what caused this? For example, was it chronic back or neck problems, nerve damage or neuropathy, poor blood circulation or circulatory problems, a broken bone or injury from an accident, trauma or fall, medications or side effects of medication or some other cause?
1. Chronic Back/Neck Problems
2. Nerve Damage/Neuropathy
3. Circulatory problems/Poor Circulation or blood flow
4. Broken bone or injury from an accident, trauma or fall
5. Medication or side effects from medication
6 Other Specify: ______________________________________
8. Unknown cause
9. Refused
IF RESPONSE IS 'OTHER' DO NOT LEAVE 'SPECIFY' BLANK ENTER ANY INFORMATION VOLUNTEERED BY RESPONDENT
IF (Q3_2a = 6)
IF (Text Length of Q3_2a = 1)
Re Ask Q3_2a
ENDIF
ENDIF
Proceed to next question, Q3_3
Q: Q3_3
3.3
If speaking with the Original Respondent, the question is:
Since the last time we talked with you, have you had sudden painless loss of vision in one or both eyes?
If speaking with a Proxy under the following conditions, the question is as follows:
IF (Intro = 6) RESPONDENT IN HOSPITAL
IF (IntroP3 = 3) C: Proxy call entered thru proxy follow-up
IF (Intro = 8) RESPONDENT DECEASED
IF (IntroP3 = 5) C: Proxy call entered thru proxy follow-up
IF (Intro = 5) RESPONDENT CHRONICALLY ILL
IF (IntroP3 = 2) C: Proxy call entered thru proxy follow-up
IF (Intro = 7) RESPONDENT IN NURSING HOME
IF (IntroP3 = 4) C: Proxy call entered thru proxy follow-up
Since we last spoke to him/her, has he/she had sudden painless loss of vision in one or both eyes? 1. Yes
2. No
7. Don't Know/Not Sure
9. Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
IF (Q3_3 = 1)
MedRel = MedRel + 1
SFP = SFP + 1
EvtNStr = EvtNStr + 1
ENDIF
If (Q3_3 > 1) THEN Skip to Q3_4
If Q3_3 = 1, Proceed to next question, Q3_3a
Q: Q3_3a
3.3a Do you know what caused this? For example, was it cataracts, glaucoma, eye
surgery, macular degeneration, a detached retina or retinopaty, bleeding or hemorrhage
in the eye, a change in glasses or contact prescription, an eye exam, migraine headaches
or some other cause?
1. Cataracts, glaucoma, eye surgery or macular degeneration
2. Detached retina or retinopathy
3. Bleeding in eye or eye hemorrage
4. Change in glasses or contact prescription/eye exam
5. Migraine headache
6. Other Specify: ______________________________________
8. Unknown Cause
9. Refused
IF RESPONSE IS 'OTHER' DO NOT LEAVE 'SPECIFY' BLANK ENTER ANY INFORMATION VOLUNTEERED BY RESPONDENT
IF (Q3_3a = 6)
IF (Text Length of Q3_3a = 1)
Re Ask Q3_3a
ENDIF
ENDIF
Proceed to next question, Q3_4
Q: Q3_4
3.4
If speaking with the Original Respondent, the question is:
Since the last time we talked with you, have you suddenly lost one half of your vision?
If speaking with a Proxy under the following conditions, the question is as follows:
IF (Intro = 6) RESPONDENT IN HOSPITAL
IF (IntroP3 = 3) C: Proxy call entered thru proxy follow-up
IF (Intro = 8) RESPONDENT DECEASED
IF (IntroP3 = 5) C: Proxy call entered thru proxy follow-up
IF (Intro = 5) RESPONDENT CHRONICALLY ILL
IF (IntroP3 = 2) C: Proxy call entered thru proxy follow-up
IF (Intro = 7) RESPONDENT IN NURSING HOME
IF (IntroP3 = 4) C: Proxy call entered thru proxy follow-up
Since the last time we talked with him/her, has he/has she suddenly lost one half of his/her vision?
1. Yes
2. No
7. Don't Know/Not Sure
9. Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
IF(Q3_4 = 1)
MedRel = MedRel + 1
SFP = SFP + 1
EvtNStr = EvtNStr + 1
ENDIF
If (Q3_4 > 1) THEN Skip to Q3_5
If Q3_4 = 1, Proceed to next question, Q3_4a
Q: Q3_4a
3.4a Do you know what caused this? For example, was it cataracts, glaucoma, eye
surgery, macular degeneration, a detached retina or retinopaty, bleeding or hemorraging
in the eye, a change in glasses or contact prescription, an eye exam, migraine headaches
or some other cause?
1. Cataracts, glaucoma, eye surgery or macular degeneration
2. Detached retina or retinopathy
3. Bleeding in eye or eye hemorrage
4. Change in glasses or contact prescription/eye exam
5. Migraine headache
6. Other Specify: ____________________________
8. Unknown Cause
9. Refused
IF RESPONSE IS 'OTHER' DO NOT LEAVE 'SPECIFY' BLANK ENTER ANY INFORMATION VOLUNTEERED BY RESPONDENT
IF (Q3_4a = 6)
IF (Text Length of Q3_4a = 1)
Re Ask Q3_4a
ENDIF
ENDIF
Proceed to next question, Q3_5
Q: Q3_5
3.5
If speaking with the Original Respondent, the question is:
Since the last time we talked with you, have you suddenly lost the ability to understand what people were saying?
If speaking with a Proxy under the following conditions, the question is as follows:
IF (Intro = 6) RESPONDENT IN HOSPITAL
IF (IntroP3 = 3) C: Proxy call entered thru proxy follow-up
IF (Intro = 8) RESPONDENT DECEASED
IF (IntroP3 = 5) C: Proxy call entered thru proxy follow-up
IF (Intro = 5) RESPONDENT CHRONICALLY ILL
IF (IntroP3 = 2) C: Proxy call entered thru proxy follow-up
IF (Intro = 7) RESPONDENT IN NURSING HOME
IF (IntroP3 = 4) C: Proxy call entered thru proxy follow-up
Since we last spoke with him/her, has he/she suddenly lost the ability to understand what people were saying?
1. Yes
2. No
7. Don't Know/Not Sure
9. Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
IF(Q3_5 = 1)
MedRel = MedRel + 1
SFP = SFP + 1
EvtNStr = EvtNStr + 1
ENDIF
If (Q3_5 > 1) THEN Skip to Q3_6
If Q3_5 = 1, Proceed to next question, Q3_5a
Q: Q3_5a
3.5a Do you know what caused this? For example, was it caused by a hearing problem or hearing loss, a brain injury such as from a fall, accident or tumor, medication or the side effect of medication, migraine headaches, dementia, Alzheimer’s, senility or some other cause?
1. Hearing problem or hearing loss
2. Brain injury from a fall, accident or tumor
3. Medication or side effect of medication
4. Migraine headache
5. Dementia, Alzheimer’s Syndrome or senility
6. Other Specify: __________________________________
8. Unknown Cause
9. Refused
IF RESPONSE IS 'OTHER' DO NOT LEAVE 'SPECIFY' BLANK ENTER ANY INFORMATION VOLUNTEERED BY RESPONDENT
IF (Q3_5a = 6)
IF (Text Length of Q3_5a = 1)
Re Ask Q3_5a
ENDIF
ENDIF
Proceed to next question, Q3_6
Q: Q3_6
3.6
If speaking with the Original Respondent, the question is:
Since the last time we talked with you, have you suddenly lost the ability to express yourself verbally or in writing?
This would be different from what is commonly called a "senior moment" where you find yourself at a loss for words or cannot remember a specific word temporarily.
If speaking with a Proxy under the following conditions, the question is as follows:
IF (Intro = 6) RESPONDENT IN HOSPITAL
IF (IntroP3 = 3) C: Proxy call entered thru proxy follow-up
IF (Intro = 8) RESPONDENT DECEASED
IF (IntroP3 = 5) C: Proxy call entered thru proxy follow-up
IF (Intro = 5) RESPONDENT CHRONICALLY ILL
IF (IntroP3 = 2) C: Proxy call entered thru proxy follow-up
IF (Intro = 7) RESPONDENT IN NURSING HOME
IF (IntroP3 = 4) C: Proxy call entered thru proxy follow-up
Since the last time we talked with him/her, has he/has she suddenly lost the ability to express himself/herself verbally or in writing?
1. Yes
2. No
7. Don't Know/Not Sure
9. Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
IF(Q3_6 = 1)
MedRel = MedRel + 1
SFP = SFP + 1
EvtNStr = EvtNStr + 1
ENDIF
EvtTot = EvtStr + EvtNStr
IF (EvtTot = 0) THEN Skip to Q11_9
IF (Q3_6 > 1) Then Skip to Q3_7a
IF Q3_6 = 1, Proceed to next question, Q3_6a
Q: Q3_6a
3.5a Do you know what caused this? For example, was it caused by a hearing problem or hearing loss, a brain injury such as from a fall, accident or tumor, medication or the side effect of medication, migraine headaches, dementia, Alzheimer’s, senility or some other cause?
1. Hearing problem or hearing loss
2. Brain injury from a fall, accident or tumor
3. Medication or side effect of medication
4. Migraine headache
5. Dementia, Alzheimer’s Syndrome or senility
6. Other Specify: _____________________________________
8. Unknown Cause
9. Refused
IF RESPONSE IS 'OTHER' DO NOT LEAVE 'SPECIFY' BLANK ENTER ANY INFORMATION VOLUNTEERED BY RESPONDENT
IF (Q3_6a = 6)
IF (Text Length of Q3_6a = 1)
Re Ask Q3_6a
ENDIF
ENDIF
Proceed to next question, Q3_7a
DOCTOR VISITS OR HOSPITALIZATIONS FOR STROKE SYMPTOMS
If SFP = 0 THEN Skip to Q11_9
Q: Q3_7a
You mentioned that since we last talked you/he/she had experienced:
IF (Q3_1 = 1)
"painless weakness on one side"
ENDIF
IF (Q3_2 = 1)
"sudden numbness or a dead feeling on one side"
ENDIF
IF (Q3_3 = 1)
"sudden painless loss of vision in one or both eyes"
ENDIF
IF (Q3_4 = 1)
"sudden loss of half vision"
ENDIF
IF (Q3_5 = 1)
"loss of the ability to understand what people were saying"
ENDIF
IF (Q3_6 = 1)
"loss of the ability to express oneself verbally or in writing"
ENDIF
Did you see a doctor or visit an emergency room because of any of these symptoms?
1. Yes
2. No
7. Don't Know/Not Sure
9. Refused
Visit = 0
IF (Q3_7a > 1)
Medrel = Medrel + 0
Skip to Q11_9
ENDIF
IF (Q3_7a = 1)
Medrel = Medrel + 1
IF (Q3_1 = 1) THEN Skip to Q3_7a1
IF (Q3_2 = 1) THEN Skip to Q3_7a2
IF (Q3_3 = 1) THEN Skip to Q3_7a3
IF (Q3_4 = 1) THEN Skip to Q3_7a4
IF (Q3_5 = 1) THEN Skip to Q3_7a5
IF (Q3_6 = 1) THEN Skip to Q3_7a6
ENDIF
Q: Q3_7a1
3.7a1
IF (Intro > 4 OR IntroP3 > 1)
Did he/she see a doctor or visit an emergency room for painless weakness on one side?
ENDIF
IF (Intro < 5 OR IntroP3 = 1)
Did you see a doctor or visit an emergency room for painless weakness on one side?
ENDIF
1. Yes, I saw a doctor or visited a clinic
2. Yes, I went to a hospital or emergency room
3. No
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a1 < 3)
Visit1 = 1
Visit = Visit + 1
Skip to Q3_7b1
ENDIF
IF (Q3_2=1) THEN Skip to Q3_7a2
IF (Q3_3=1) THEN Skip to Q3_7a3
IF (Q3_4=1) THEN Skip to Q3_7a4
IF (Q3_5=1) THEN Skip to Q3_7a5
IF (Q3_6=1) THEN Skip to Q3_7a6
Skip to Q11_9
Q: Q3_7b1
3.7b1
Do you know the name of the doctor or facility?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
IF RESPONDENT INITIALLY SAYS 'YES' BUT THEN CANNOT REMEMBER
THE DOCTOR'S NAME, DO NOT ENTER 'DON'T KNOW' OR 'UNKNOWN'
INSTEAD SELECT RESPONSE 2 OR 8
IF (SFP = 1)
Visit1 = 1
Visit = Visit + 1
ENDIF
IF (Q3_7b1 > 1) THEN Skip to Q3_7c1
Proceed to next question, Q3_7_1sp
Q: Q3_7_1sp
Can you please tell me the name of the doctor _________________________________
INTERVIEWER: PLEASE ASK FOR CORRECT SPELLING!
Enter UNKNOWN if not available.
Ans_Len = 0
Ans_Len = Text Length of Q3_7_1sp
IF (Ans_Len = 0)
Re Ask Q3_7_1sp
ENDIF
Proceed to next question, Q3_7a1sp
Q: Q3_7a1sp
Can you please tell me the name of the facility? ___________________________________
INTERVIEWER: PLEASE ASK FOR CORRECT SPELLING!
Enter UNKNOWN if not available.
Ans_Len = 0
Ans_Len = Text Length of Q3_7a1sp
IF (Ans_Len = 0)
Re Ask Q3_7a1sp
ENDIF
Proceed to next question, Q3_7c1
Q: Q3_7c1
3.7c1 When was this visit ? (Probe for month and year)
Enter date mm-dd-yyyy
01/01/7777 Don't Know/Not Sure
01/01/9999 Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
DATES ARE VERY IMPORTANT!!! AT THE VERY LEAST, GET MONTH and YEAR. PROBE USING LAST INTERVIEW DATE
IF (Q3_7c1 > System Date)
IF (Q3_7c1 < 01/01/7777)
Re Ask Q3_7c1
ENDIF
ENDIF
Proceed to next question, Q3_7d1
Q: Q3_7d1, Q3_e11,Q3_7f1, Q3_7g1
Do you know the address, city or state where this doctor's office or facility is located? Let's start with the street.
Q3_7d1 Street ___________________________________________
Q3_7e11 City: ___________________________________________
Q3_7f1 State: ___________________________________________
Q3_7g1 ZipCode: ___________________
INTERVIEWER: Do not leave any fields blank. If respondent does not know one of the answers enter "unknown"
Ans_Len = 0
Ans_Len = Text Length of Q3_7d1
IF (Ans_Len = 0)
Re Ask Q3_7d1
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_7e11
IF (Ans_Len = 0)
Re Ask Q3_7e11
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_7f1
IF (Ans_Len = 0)
Re Ask Q3_7f1
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_7g1
IF (Ans_Len = 0)
Re Ask Q3_7g1
ENDIF
Proceed to next question, Q3_7a2
Q: Q3_7a2 Asked only if Q3_2 = 1, else Skip to Q3_7a3
3.7a2
IF (Intro > 4 OR IntroP3 > 1)
Did he/she see a doctor or visit an emergency room for sudden numbness or a dead feeling on one side?
ENDIF
IF (Intro < 5 OR IntroP3 = 1)
Did you see a doctor or visit an emergency room for sudden numbness or a dead feeling on one side?
ENDIF
1. Yes, saw a doctor or visited a clinic
2. Yes, went to a hospital or emergency room
3. No
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a2 < 3)
Visit2 = 1
Visit = Visit + 1
IF (Visit = 1) THEN Skip to Q3_7b2
IF (Q3_1 = 1) THEN Skip to Q3_7a2a
IF (Q3_1 1) THEN Skip to Q3_7b2
ENDIF
IF (Q3_3 = 1) THEN Skip to Q3_7a3
IF (Q3_4 = 1) THEN Skip to Q3_7a4
IF (Q3_5 = 1) THEN Skip to Q3_7a5
IF (Q3_6 = 1) THEN Skip to Q3_7a6
Skip to Q11_9
Q: Q3_7a2a
3.7a2a Was this with the same doctor/facility as the visit for sudden painless weakness on one side?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a2a = 1) THEN Skip to Q3_7c3
Proceed to next question, Q3_7b2
Q: Q3_7b2
3.7b2 Do you know the name of the doctor or facility?
1. Yes Specify name of doctor or facility:
2. No
8. Don't Know/Not Sure
9. Refused
IF RESPONDENT INITIALLY SAYS 'YES' BUT THEN CANNOT REMEMBER
THE DOCTOR'S NAME, DO NOT ENTER 'DON'T KNOW' OR 'UNKNOWN'
INSTEAD SELECT RESPONSE 2 OR 8
IF (SFP = 1)
Visit2 = 1
Visit = Visit + 1
ENDIF
IF (Q3_7b2 > 1) THEN Skip to Q3_7c2
Proceed to next question, Q3_7_2sp
Q: Q3_7_2sp
Can you please tell me the name of the doctor ? _______________________________
Ans_Len = 0
Ans_Len = Text Length of Q3_7_2sp
IF (Ans_Len = 0)
Re Ask Q3_7_2sp
ENDIF
Proceed to next question, Q3_7a2sp
Q: Q3_7a2sp
Can you please tell me the name of the facility? _______________________________
Ans_Len = 0
Ans_Len = Text Length of Q3_7a2sp
IF (Ans_Len = 0)
Re Ask Q3_7a2sp
ENDIF
Proceed to next question, Q3_7c2
Q: Q3_7c2
3.7c2 When was this visit ? (Probe for month and year)
Enter date mm-dd-yyyy
01/01/7777 Don't Know/Not Sure
01/01/9999 Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
DATES ARE VERY IMPORTANT!!! AT THE VERY LEAST, GET MONTH and YEAR. PROBE USING LAST INTERVIEW DATE
IF (Q3_7c2 > System Date)
IF (Q3_7c2 < 01/01/7777)
Re Ask Q3_7c2
ENDIF
ENDIF
IF (Q3_7a2a = 1) THEN Skip to Q3_7a3
Proceed to next question, Q3_7d2
Q: Q3_7d2, Q3_e2,Q3_7f2, Q3_7g2
Do you know the address, city or state where this doctor's office or facility is located?
Q3_7d2 Street ___________________________________________
Q3_7e2 City: ___________________________________________
Q3_7f2 State: ___________________________________________
Q3_7g2 ZipCode: ___________________
INTERVIEWER: Do not leave any fields blank. If respondent does not know one of the answers enter "unknown"
Ans_Len = 0
Ans_Len = Text Length of Q3_7d2
IF (Ans_Len = 0)
Re Ask Q3_7d2
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_7e2
IF (Ans_Len = 0)
Re Ask Q3_7e2
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_7f2
IF (Ans_Len = 0)
Re Ask Q3_7f2
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_7g2
IF (Ans_Len = 0)
Re Ask Q3_7g2
ENDIF
Proceed to next question, Q3_7a3
Q: Q3_7a3 Asked only if Q3_3 = 1, Else Skip to Q3_7a4
3.7a3
IF (Intro > 4 OR IntroP3 > 1)
Did he/she see a doctor or visit an emergency room for sudden painless loss of vision in one or both eyes?
ENDIF
IF (Intro < 5 OR IntroP3 = 1)
Did you see a doctor or visit an emergency room for sudden painless loss of vision in one or both eyes?
ENDIF
1. Yes, saw a doctor or visited a clinic
2. Yes, went to a hospital or emergency room
3. No
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a2 < 3)
Visit3 = 1
Visit = Visit + 1
IF (Visit = 1) THEN Skip to Q3_7b3
Skip to Q3_7a2a
ENDIF
IF (Q3_4 = 1) THEN Skip to Q3_7a4
IF (Q3_5 = 1) THEN Skip to Q3_7a5
IF (Q3_6 = 1) THEN Skip to Q3_7a6
Skip to Q11_9
Q: Q3_7a3a Asked only if a doctor was seen for previous symptoms
3.7a3a Was this visit with the same doctor or facility as the visit for
IF (Visit1 = 1) "sudden painless weakness on one side"
IF (Visit2 = 1) "sudden numbness or a dead feeling on one side"
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a3a = 1)
IF (Visit > 2) THEN Skip to Q3_7a3b
IF (Visit < 3) THEN Skip to Q3_7c3
ENDIF
IF (Q3_7a3a > 1) THEN Skip to Q3_7b3
Q: Q3_7a3b Asked only if more than one symptom was reported
3.7a3b Which doctor/facility is it the same as?
1. Same as seen for sudden painless weakness on one side
2. Same as seen for sudden numbness or dead feeling on one side
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a3b < 3) THEN Skip to Q3_7c3
Proceed to next question, Q3_7b3
Q: Q3_7b3
3.7b3 Do you know the name of the doctor or facility?
1. Yes Record response in Q3_7_3sp
2. No
8. Don't Know/Not Sure
9. Refused
IF RESPONDENT INITIALLY SAYS 'YES' BUT THEN CANNOT REMEMBER
THE DOCTOR'S NAME, DO NOT ENTER 'DON'T KNOW' OR 'UNKNOWN'
INSTEAD SELECT RESPONSE 2 OR 8
IF (SFP = 1)
Visit3 = 1
Visit = Visit + 1
ENDIF
IF (ANS > 1) THEN Skip to Q3_7c3
Proceed to next question, Q3_7_3sp
Q: Q3_7_3sp
Can you please tell me the name of the doctor? ______________________________________
INTERVIEWER: ASK FOR CORRECT SPELLING!
Enter UNKNOWN if not available.
Ans_Len = 0
Ans_Len = Text Length of Q3_7_3sp
IF (Ans_Len = 0)
Re Ask Q3_7_3sp
ENDIF
Proceed to next question, Q3_7a3sp
Q: Q3_7a3sp
Can you please tell me the name of the facility? _______________________________________
INTERVIEWER: ASK FOR CORRECT SPELLING!
Enter UNKNOWN if not available.
Ans_len = 0
Ans_Len = Text length of Q3_7a3sp
IF(Ans_Len = 0)
Re ask Q3_7a3sp
ENDIF
Proceed to next question, Q3_7c3
Q: Q3_7c3
3.7c3 When was this visit ? (Probe for month and year)
Enter date mm-dd-yyyy
01/01/7777 Don't Know/Not Sure
01/01/9999 Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
DATES ARE VERY IMPORTANT!!! AT THE VERY LEAST, GET MONTH and YEAR. PROBE USING LAST INTERVIEW DATE
IF (Q3_7c3 >System date)
IF (Q3_7c3 4 OR IntroP3 >1)
Did he/she see a doctor or visit an emergency room for sudden loss of one half of his/her vision?
ENDIF
IF (Intro < 5 OR IntroP3 = 1)
Did you see a doctor or visit an emergency room for sudden loss of one half of your vision?
ENDIF
1. Yes, I saw a doctor or visited a clinic
2. Yes, I went to a hospital or emergency room
3. No
8. Don't Know/Not Sure
. 9. Refused
IF (Q3_7a4 < 3) THEN Visit4 = 1
IF (Q3_7a4 < 3) THEN Visit = Visit + 1
IF (Q3_7a4 < 3)
IF (Visit = 1) THEN Skip to Q3_7b4
ENDIF
IF (Q3_7a4 < 3) THEN Skip to Q3_7a4
IF (Q3_5 = 1) THEN Skip to Q3_7a5
IF (Q3_6 = 1) THEN Skip to Q3_7a6
IF (Q3_5 1) THEN Skip to Q11_9
IF (Q3_6 1) THEN Skip to Q11_9
Q: Q3_7a4a
3.7a4a Was this visit with the same doctor or facility as the visit for
IF (Visit1 = 1)
‘Sudden painless weakness on one side.’
ENDIF
IF (Visit2 = 1)
‘sudden numbness or a dead feeling on one side.’
ENDIF
IF (Visit3 = 1)
‘sudden painless loss of vision.’
ENDIF
1. Yes Skip to Q3_7a5
2. No
8. Don't Know/Not Sure
9. Refused
IF (Q3_7q4a = 1)
IF (Visit > 2) THEN Skip to Q3_7a4b
IF (Visit < 3) THEN Skip to Q3_7c4
End IF
IF (Q3_7q4a > 1) THEN Skip to Q3_7b4
Q: Q3_7a4b
3.7a4b
Which doctor/facility is it the same as?
1. Same as seen for sudden painless weakness on one side
2. Same as seen for sudden numbness or dead feeling on one side
3. Same as seen for sudden painless loss of vision
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a4b = 1)
IF (Visit1 1)
Re ask Q3_7a4b
ENDIF
ENDIF
IF (Q3_7a4b = 2)
IF (Visit2 1)
Re ask Q3_7a4b
ENDIF
ENDIF
IF (Q3_7a4b = 3)
IF (Visit3 1)
Re ask Q3_7a4b
ENDIF
ENDIF
IF (Q3_7a4b System Date)
IF (Q3_7c4 < 01/01/7777)
Re Ask Q3_7c4
ENDIF
ENDIF
IF (Q3_7a4a = 1) THEN Skip to Q3_7a5
Proceed to next question, Q3_7d4
Q: Q3_7d4 Q3_7e4,Q3_7f4, Q3_7g4
Do you know the address, city or state where this doctor's office or facility is located? Let's start with the street.
Q3_7d4 Street ___________________________________________
Q3_7e4 City: ___________________________________________
Q3_7f4 State: ___________________________________________
Q3_7g4 ZipCode: ___________________
INTERVIEWER: Do not leave any fields blank. If respondent does not know one of the answers enter "unknown"
Ans_len = 0
Ans_Len = Text length of Q3_7d4
IF (Ans_Len = 0)
Re Ask Q3_7d4
ENDIF
Ans_len = 0
Ans_Len = Text length of Q3_7e4
IF (Ans_Len = 0)
Re Ask Q3_7e4
ENDIF
Ans_len = 0
Ans_Len = Text length of Q3_7f4
IF (Ans_Len = 0)
Re Ask Q3_7f4
ENDIF
Ans_len = 0
Ans_Len = Text length of Q3_7g4
IF (Ans_Len = 0)
Re Ask Q3_7g4
ENDIF
Proceed to next question, Q3_7a5
Q: Q3_7a5 Asked only if Q3_5 = 1, Else Skip to Q3_7a6
3.7a5
IF (Intro > 4 OR IntroP3 > 1)
Did he/she see a doctor or visit an emergency room for a sudden loss of the ability to understand what people were saying?
ENDIF
IF (Intro < 5 OR IntroP3 = 1)
Did you/he/she see a doctor or visit an emergency room for a sudden loss of the ability to understand what people were saying?
ENDIF
1. Yes, saw a doctor or visited a clinic
2. Yes, went to a hospital or emergency room
3. No
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a5 < 3) THEN Visit5 = 1
IF (Q3_7a5 < 3) THEN Visit = Visit + 1
IF (Q3_7a5 > 2) THEN Skip to Q3_7a6
IF (Q3_7a5 < 3)
IF (Visit = 1) THEN Skip to Q3_7b5
ENDIF
IF (Q3_7a5 < 3) THEN Skip to Q3_7a5a
IF (Q3_6 = 1) THEN Skip to Q3_7a6
IF (Q3_6 1) THEN Skip to Q11_9
Q: Q3_7a5a
3.7a5a Was this visit with the same doctor or facility as the visit for
IF (Visit1 = 1)
"sudden painless weakness on one side"
ENDIF
IF (Visit2 = 1)
"sudden numbness or a dead feeling on one side"
ENDIF
IF (Visit3 = 1)
"sudden painless loss of vision"
ENDIF
IF (Visit4 = 1)
"sudden loss of one half of vision"
ENDIF
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a5a= 1)
IF (Visit > 2) THEN Skip Q3_7a5b
IF (Visit < 3) THEN Skip Q3_7c5
ENDIF
IF (Q3_7a5a > 1) THEN Skip to Q3_7b5
Q: Q3_7a5b
3.7a5b Which doctor/facility is it the same as?
1. Same as seen for sudden painless weakness on one side
2. Same as seen for sudden numbness or dead feeling on one side
3. Same as seen for sudden painless loss of vision
4. Same as seen for sudden loss of one half of vision
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a5b = 1)
IF (Visit1 1)
Re Ask Q3_7a5b
ENDIF
ENDIF
IF (Q3_7a5b = 2)
IF (Visit2 1)
Re Ask Q3_7a5b
ENDIF
ENDIF
IF (Q3_7a5b = 3)
IF (Visit3 1)
Re Ask Q3_7a5b
ENDIF
ENDIF
IF (Q3_7a5b = 4)
IF (Visit4 1)
Re Ask Q3_7a5b
ENDIF
ENDIF
IF (Q3_7a5b < 5) THEN Skip to Q3_7c5
Proceed to next question, Q3_7b5
Q: Q3_7b5
3.7b5 Do you know the name of the doctor or facility?
1. Yes Record response in Q3_7_5sp
2. No
8. Don't Know/Not Sure
9. Refused
IF RESPONDENT INITIALLY SAYS 'YES' BUT THEN CANNOT REMEMBER
THE DOCTOR'S NAME, DO NOT ENTER 'DON'T KNOW' OR 'UNKNOWN'
INSTEAD SELECT RESPONSE 2 OR 8
IF (Q3_7b5 > 1) THEN Skip to Q3_7c5
Proceed to next question, Q3_7_5sp
Q: Q3_7_5sp
3.7.5sp Can you please tell me the name of the doctor? ____________________________
INTERVIEWER: ASK FOR CORRECT SPELLING!
Enter UNKNOWN if not available.
Ans_Len = 0
Ans_Len = Text Length of Q3_7_5sp
IF (Ans_Len = 0)
Re Ask Q3_7_5sp
ENDIF
Proceed to next question, Q3_7a5sp
Q: Q3_7a5sp
3.7a.5sp Can you please tell me the name of the facility? _______________________________
INTERVIEWER: ASK FOR CORRECT SPELLING!
Enter UNKNOWN if not available.
Ans_Len = 0
Ans_Len = Text Length of Q3_7a5sp
IF (Ans_Len = 0)
Re Ask Q3_7a5sp
ENDIF
Proceed to next question, Q3_7c5
Q: Q3_7c5
3.7c5 When was this visit ? (Probe for month and year)
Enter date mm-dd-yyyy
01/01/7777 Don't Know/Not Sure
01/01/9999 Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
DATES ARE VERY IMPORTANT!!! AT THE VERY LEAST, GET MONTH and YEAR. PROBE USING LAST INTERVIEW DATE
IF (Q3_7c5 > System Date)
IF (Q3_7c5 < 01/01/7777)
Re Ask Q3_7c5
ENDIF
ENDIF
IF (Q3_7a5a = 1) THEN Skip to Q3_7a6
Proceed to next question, Q3_7d5
Q: Q3_7d5, Q3_e5,Q3_7f5, Q3_7g5
Do you know the address, city or state where this doctor's office or facility is located? Let's start with the street.
Q3_7d5 Street ___________________________________________
Q3_7e5 City: ___________________________________________
Q3_7f5 State: ___________________________________________
Q3_7g5 ZipCode: ___________________
INTERVIEWER: Do not leave any fields blank. If respondent does not know one of the answers enter "unknown"
Ans_Len = 0
Ans_Len = Text Length of Q3_7d5
IF (Ans_Len = 0)
Re Ask Q3_7d5
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_7e5
IF (Ans_Len = 0)
Re Ask Q3_7e5
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_7f5
IF (Ans_Len = 0)
Re Ask Q3_7f5
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_7g5
IF (Ans_Len = 0)
Re Ask Q3_7g5
ENDIF
Proceed to next question, Q3_7a6
Q: Q3_7a6
3.7a6
IF (Intro > 4 OR IntroP3 > 1)
Did he/she see a doctor or visit an emergency room for a sudden loss of the ability to express himself/herself either verbally or in writing?
ENDIF
IF (IntroP3 = 1 OR Intro < 5)
Did you/he/she see a doctor or visit an emergency room for a sudden loss of the ability to express yourself/himself/herself either verbally or in writing?
ENDIF
1. Yes, saw a doctor or visited a clinic
2. Yes, went to a hospital or emergency room
3. No
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a6 < 3) THEN Visit = Visit + 1
IF (Q3_7a6 < 3)
IF (Q3_7a6 < 3) THEN Visit6 = 1
IF (Visit = 1) THEN Skip to Q3_7b6
ENDIF
IF (Q3_7a6 < 3) THEN Skip to Q3_7a6a
IF (Q3_7a6 > 2) THEN Skip to Q11_9
Q: Q3_7a6a
3.7a6a Was this visit with the same doctor or facility as the visit for
IF (Visit1 = 1)
"sudden painless weakness on one side"
End IF
IF (Visit2 = 1)
"sudden numbness or a dead feeling on one side"
End IF
IF (Visit3 = 1)
"sudden painless loss of vision"
End IF
IF (Visit4 = 1)
"sudden loss of one half of vision"
End IF
IF (Visit5 = 1)
"sudden loss of the ability to understand people"
End IF
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a6a = 1)
IF (Visit > 2) THEN Skip to Q3_7a6b
IF (Visit < 3) THEN Skip to Q3_7c6
ENDIF
IF (Q3_7a6a > 1) THEN Skip to Q3_7b6
Q: Q3_7a6b
3.7a6b Which doctor/facility is it the same as?
1. Same as seen for sudden painless weakness on one side
2. Same as seen for sudden numbness or dead feeling on one side
3. Same as seen for sudden painless loss of vision
4. Same as seen for sudden loss of one half of vision
5. Same as seen for sudden loss of ability to understand people
8. Don't Know/Not Sure
9. Refused
IF (Q3_7a6b = 1)
IF (Visit1 1)
Re Ask Q3_7a6b
ENDIF
ENDIF
IF (Q3_7a6b = 2)
IF (Visit2 1)
Re Ask Q3_7a6b
ENDIF
ENDIF
IF (Q3_7a6b = 3)
IF (Visit3 1)
Re Ask Q3_7a6b
ENDIF
ENDIF
IF (Q3_7a6b = 4)
IF (Visit4 1)
Re Ask Q3_7a6b
ENDIF
ENDIF
IF (Q3_7a6b = 5)
IF (Visit5 1)
Re Ask Q3_7a6b
ENDIF
ENDIF
IF (Q3_7a6b < 6) THEN Skip to Q3_7c6
Q: Q3_7b6
3.7b6 Do you know the name of the doctor or facility?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
IF RESPONDENT INITIALLY SAYS 'YES' BUT THEN CANNOT REMEMBER
THE DOCTOR'S NAME, DO NOT ENTER 'DON'T KNOW' OR 'UNKNOWN'
INSTEAD SELECT RESPONSE 2 OR 8
IF (SFP = 1)
Visit6 = 1
Visit = Visit + 1
ENDIF
IF (Q3_7b6 > 1) THEN Skip to Q3_7c6
Q: Q3_7_6sp
3.7.6sp Can you please tell me the name of the doctor? __________________________________
INTERVIEWER: ASK FOR CORRECT SPELLING!
Ans_Len = 0
Ans_Len = Text Length of Q3_7_6sp
IF (Ans_Len = 0)
Re Ask Q3_7_6sp
ENDIF
Proceed to next question, Q3_7a6sp
Q: Q3_7a6sp
3.7a.6sp Can you please tell me the name of the facility? ___________________________________
INTERVIEWER: ASK FOR CORRECT SPELLING!
Enter UNKNOWN if not available.
Ans_Len = 0
Ans_Len = Text Length of Q3_7a6sp
IF (Ans_Len = 0)
Re Ask Q3_7a6sp
ENDIF
Proceed to next question, Q3_7c6
Q: Q3_7c6
3.7c6 When was this visit ? (Probe for month and year)
Enter date mm-dd-yyyy
01/01/7777 Don't Know/Not Sure
01/01/9999 Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
DATES ARE VERY IMPORTANT!!! AT THE VERY LEAST, GET MONTH and YEAR. PROBE USING LAST INTERVIEW DATE
IF (Q3_7c6 > System Date)
IF (Q3_7c6 < 01/01/7777)
Re Ask Q3_7c6
ENDIF
ENDIF
IF (Q3_7a6a = 1) THEN Skip to Q11_9
Proceed to next question, Q3_7d6
Q: Q3_7d6, Q3_e6,Q3_7f6, Q3_7g6
Do you know the address, city or state where this doctor's office or facility is located? Let's start with the street.
Q3_7d6 Street ___________________________________________
Q3_7e6 City: ___________________________________________
Q3_7f6 State: ___________________________________________
Q3_7g6 ZipCode: ___________________
INTERVIEWER: Do not leave any fields blank. If respondent does not know one of the answers enter "unknown"
Ans_Len = 0
Ans_Len = Text Length of Q3_7d6
IF (Ans_Len = 0)
Re Ask Q3_7d6
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_7e6
IF (Ans_Len = 0)
Re Ask Q3_7e6
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_7f6
IF (Ans_Len = 0)
Re Ask Q3_7f6
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_7g6
IF (Ans_Len = 0)
Re Ask Q3_7g6
ENDIF
Proceed to next question, Q11_9
Cognitive Assessment Section
New schedule is as follows:
6 month follow up No cognitive tests
12 month follow up 6 item cognitive screener
18 month follow up Word List Learning and Animal Naming and MOCA
24 month follow up 6 item screener
30 month follow up No cognitive tests
36 month follow up 6 item screener
42 month follow up Word List Learning and Animal Naming and MOCA
48 month follow up 6 item screener
54 month follow up No cognitive tests
60 month follow up 6 item screener
66 month follow up Word List Learning and Animal Naming and MOCA
72 month follow up 6 item screener
78 month follow up No cognitive tests
84 month follow up 6 item screener
90 month follow up Word List Learning and Animal Naming and MOCA
96 month follow up 6 item screener
102 month follow up No cognitive tests
108 month follow up 6 item screener
114 month follow up Word List Learning and Animal Naming and MOCA
120 month follow up 6 item screener
126 month follow up No cognitive tests
132 month follow up 6 item screener
138 month follow up Word List Learning and Animal Naming and MOCA
144 month follow up 6 item screener
Six Item Cognitive Screener
These questions are not appropriate to ask a proxy; therefore
IF Intro > 4, Skip to Q4
IF IntroP3 > 1, Skip to Q4
The six item screener is asked only on even numbered sequences, i.e., seqno = 2, 4, 6, 8 etc.
IF (seqno = 5) THEN Skip to Q3_98c
IF (seqno = 9) THEN Skip to Q3_98c
IF (seqno = 13) THEN Skip to Q3_98c
IF (seqno = 17) THEN Skip to Q3_98c
IF (seqno = 21) THEN Skip to Q3_98c
IF (seqno = 3) THEN Skip to QINST1
IF (seqno = 7) THEN Skip to QINST1
IF (seqno = 11) THEN Skip to QINST1
IF (seqno = 15) THEN Skip to QINST1
IF (seqno = 19) THEN Skip to QINST1
IF (seqno = 23) THEN Skip to QINST1
Q: Q11_9
These next questions are a little different and ask that you use your memory
11.9 I am going to name three objects. Please wait until I say all three words, then repeat them. Remember what they are because I am going to ask you to name them again in a few minutes, but please do not write anything down. Please repeat these words for me:
12 month follow up = orange, airplane, tobacco (seqno = 2)
24 month follow up = apple, table, penny (seqno = 4)
36 month follow up = orange, airplane, tobacco (seqno = 6)
48 month follow up = apple, table, penny (seqno = 8)
60 month follow up = orange, airplane, tobacco (seqno = 10)
72 month follow up = apple, table, penny (seqno = 12)
84 month follow up = orange, airplane, tobacco (seqno = 14)
96 month follow up = apple, table, penny (seqno = 16)
108 month follow up = orange, airplane, tobacco (seqno = 18)
INTERVIEWER: Did respondent correctly repeat all three words?
1. Yes
2. No
INTERVIEWER: You may repeat the three words up to three times if necessary.
IF (Intro > 4) THEN Skip to Q4
IF (IntroP3 > 1) THEN Skip to Q4
IF (seqno = 0) THEN Skip to Q4
IF (seqno = " ") THEN Skip to Q4
IF (seqno = "A") THEN Skip to Q4
IF (seqno = 1) THEN Skip to Q3_98a
IF (seqno = 5) THEN Skip to Q3_98c
IF (seqno = 9) THEN Skip to Q3_98c
IF (seqno = 13) THEN Skip to Q3_98c
IF (seqno = 17) THEN Skip to Q3_98c
IF (seqno = 21) THEN Skip to Q3_98c
IF (seqno = 3) THEN Skip to QINST1
IF (seqno = 7) THEN Skip to QINST1
IF (seqno = 11) THEN Skip to QINST1
IF (seqno = 15) THEN Skip to QINST1
IF (seqno = 19) THEN Skip to QINST1
IF (seqno = 23) THEN Skip to QINST1
Proceed to next question, Q11_10
Q: Q11_10
11.10 Now, without looking at a calendar or watch, what year is this?
Current year = CATI SHOWS CURRENT DAY
1. Respondent answered correctly
2. Respondent answered incorrectly
IF (Q11_10 = 1) THEN CogScore = CogScore + 1
IF (Q11_10 = 2) THEN CogScore = CogScore + 0
Proceed to next question, Q11_11
Q: Q11_11
11.11 Without looking at a calendar or watch, what month is this?
Current month =
1. Respondent answered correctly
2. Respondent answered incorrectly
IF (Q11_11 = 1) THEN CogScore = CogScore + 1
IF (Q11_11 = 2) THEN CogScore = CogScore + 0
Proceed to next question, Q11_12
Q: Q11_12
11.12 Without looking at a calendar or watch, what is the day of the week?
Today is
1. Respondent answered correctly
2. Respondent answered incorrectly
IF (Q11_12 = 1) THEN CogScore = CogScore + 1
IF (Q11_12 = 2) THEN CogScore = CogScore + 0
Q: Q11_13
11.13 What were the three objects I asked you to remember?
Any order is acceptable
12 month follow up = orange, airplane, tobacco (seqno = 2)
24 month follow up = apple, table, penny (seqno = 4)
36 month follow up = orange, airplane, tobacco (seqno = 6)
48 month follow up = apple, table, penny (seqno = 8)
60 month follow up = orange, airplane, tobacco (seqno = 10)
72 month follow up = apple, table, penny (seqno = 12)
84 month follow up = orange, airplane, tobacco (seqno = 14)
96 month follow up = apple, table, penny (seqno = 16)
108 month follow up = orange, airplane, tobacco (seqno = 18)
1. Respondent able to remember 1 item
2. Respondent able to remember 2 items
3. Respondent able to remember all 3 items
4. Respondent unable to remember any of the items
INTERVIEWER: Any order is acceptable. Do not prompt
If (Q11_13 = 1) Cog11_13 = 1
If (Q11_13 = 2) Cog11_13 = 2
If (Q11_13 = 3) Cog11_13 = 3
If (Q11_13 = 4) Cog11_13 = 0
CogScore = (Cog11_10 + Cog11_11 + Cog11_12 + Cog11_13)
IF (PrxCall = 1)
IF (seqno = 2) THEN Skip to Q4
IF (seqno = 4) THEN Skip to Q4
IF (seqno = 6) THEN Skip to Q4
IF (seqno = 8) THEN Skip to Q4
IF (seqno = 10) THEN Skip to Q4
IF (seqno = 12) THEN Skip to Q4
IF (seqno = 14) THEN Skip to Q4
IF (seqno = 16) THEN Skip to Q4
IF (seqno = 18) THEN Skip to Q4
IF (seqno = 20) THEN Skip to Q4
IF (seqno = 22) THEN Skip to Q4
IF (seqno = 24) THEN Skip to Q4
ENDIF
IF (PrxCall = 0)
IF (SlpFlag = 0)
IF (seqno = 2) THEN Skip to Sleep
IF (seqno = 4) THEN Skip to Sleep
IF (seqno = 6) THEN Skip to Sleep
IF (seqno = 8) THEN Skip to Sleep
IF (seqno = 10) THEN Skip to Sleep
IF (seqno = 12) THEN Skip to Sleep
IF (seqno = 14) THEN Skip to Sleep
IF (seqno = 16) THEN Skip to Sleep
IF (seqno = 18) THEN Skip to Sleep
IF (seqno = 20) THEN Skip to Sleep
IF (seqno = 22) THEN Skip to Sleep
IF (seqno = 24) THEN Skip to Sleep
ENDIF
IF (SlpFlag = 1)
IF (seqno = 2) THEN Skip to Q4
IF (seqno = 4) THEN Skip to Q4
IF (seqno = 6) THEN Skip to Q4
IF (seqno = 8) THEN Skip to Q4
IF (seqno = 10) THEN Skip to Q4
IF (seqno = 12) THEN Skip to Q4
IF (seqno = 14) THEN Skip to Q4
IF (seqno = 16) THEN Skip to Q4
IF (seqno = 18 THEN Skip to Q4
IF (seqno = 20) THEN Skip to Q4
IF (seqno = 22) THEN Skip to Q4
IF (seqno = 24) THEN Skip to Q4
ENDIF
ENDIF
Word List Learning
Q: QINST1
Now I am going to play some recorded instructions for an activity that will use your memory. Please listen carefully, but do not write anything down. There will be a slight pause before the recording begins. Just relax and do the best you can.
INTERVIEWER: The Screen will go blank for a few seconds and then the recorded instructions will begin.
INTERVIEWER: On the next screen as respondent lists remembered words, if they pause for more than 15 seconds prompt with: "Do you remember any other words?"
INTERVIEWER: HIT "NEXT" TO CONTINUE
Proceed to next question, QWLL_1
Q: QWLL_1
INTERVIEWER: Press F6 to begin playing recorded instructions Play segment1
Press F7 to end playing recorded instructions
MARK THE WORDS AS THE RESPONDENT NAMES THEM IF THE RESPONDENT
REPEATS A WORD, USE THE SECOND AND THIRD COLUMNS. IF THE
RESPONDENT NAMES A WORD NOT ON THE LIST, MARK IT AS "UNLISTED"
INTERVIEWER: WHEN RECORDED INSTRUCTIONS ARE FINISHED SAY THIS:
Please repeat as many of the words as you can remember
Butter
Arm
Shore
Letter
Queen
Cabin
Pole
Ticket
Grass
Engine
Unlisted
Could not hear
Refused
NOTE TO PROGRAMMERS: We need to be able to capture the order in which the words were repeated and if the respondent repeated a word more than once, up to 3 times
IF (QWLL_1= 1) THEN WLL_1a = 1
IF (QWLL_1= 2) THEN WLL_1b = 2
IF (QWLL_1= 3) THEN WLL_1c = 3
IF (QWLL_1 = 4) THEN WLL_1d = 4
IF (QWLL_1= 5) THEN WLL_1e = 5
IF (QWLL_1= 6) THEN WLL_1f = 6
IF (QWLL_1= 7) THEN WLL_1g = 7
IF (QWLL_1= 8) THEN WLL_1h = 8
IF (QWLL_1= 9) THEN WLL_1i = 9
IF (QWLL_1= 10) THEN WLL_1j = 10
IF (QWLL_1= 11) THEN WLL_1k = 11
IF (QWLL_1= 12) THEN WLL_1l = 12
IF (QWLL_1= 13) THEN WLL_1m = 13
IF (QWLL_1= 14) THEN WLL_1n = 14
IF (QWLL_1= 15) THEN WLL_1o = 15
IF (QWLL_1= 16) THEN WLL_1p = 16
IF (QWLL_1= 17) THEN WLL_1q = 17
IF (QWLL_1= 18) THEN WLL_1r = 18
IF (QWLL_1= 19) THEN WLL_1s = 19
IF (QWLL_1= 20) THEN WLL_1t = 20
IF (QWLL_1= 21) THEN WLL_1u = 21
IF (QWLL_1= 22) THEN WLL_1v = 22
IF (QWLL_1= 23) THEN WLL_1w = 23
IF (QWLL_1= 24) THEN WLL_1x = 24
IF (QWLL_1 = 25) THEN WLL_1y = 25
IF (QWLL_1 = 26) THEN WLL_1z = 26
IF (QWLL_1 = 27) THEN WLL_1aa = 27
IF (QWLL_1 = 28) THEN WLL_1ab = 28
IF (QWLL_1 = 29) THEN WLL_1ac = 29
IF (QWLL_1 = 30) THEN WLL_1ad = 30
IF (QWLL_1 = 31) THEN WLL_1ae = 31
IF (QWLL_1 = 32) THEN WLL_1af = 32
IF (QWLL_1 = 33) THEN WLL_1ag = 33
IF (QWLL_1 = 34) THEN WLL_1ah = 34
IF (QWLL_1 = 35) THEN WLL_1ai = 35
IF (QWLL_1 = 36) THEN WLL_1aj = 36
IF (QWLL_1 = 1) THEN SWLL1_a = 1
IF (QWLL_1 = 2) THEN SWLL1_b = 2
IF (QWLL_1 = 3) THEN SWLL1_c = 3
IF (QWLL_1 = 4) THEN SWLL1_d = 4
IF (QWLL_1 = 5) THEN SWLL1_e = 5
IF (QWLL_1 = 6) THEN SWLL1_f = 6
IF (QWLL_1 = 7) THEN SWLL1_g = 7
IF (QWLL_1 = 8) THEN SWLL1_h = 8
IF (QWLL_1 = 9) THEN SWLL1_i = 9
IF (QWLL_1 = 10) THEN SWLL1_j = 10
IF (QWLL_1 = 11) THEN SWLL1_k = 11
IF (QWLL_1 = 12) THEN SWLL1_l = 12
IF (QWLL_1 = 13) THEN SWLL1_m = 13
IF (QWLL_1 = 14) THEN SWLL1_n = 14
IF (QWLL_1 = 15) THEN SWLL1_o = 15
IF (QWLL_1 = 16) THEN SWLL1_p = 16
IF (QWLL_1 = 17) THEN SWLL1_q = 17
IF (QWLL_1 = 18) THEN SWLL1_r = 18
IF (QWLL_1 = 19) THEN SWLL1_s = 19
IF (QWLL_1 = 20) THEN SWLL1_t = 20
Proceed to next question, QINST2
Q: QINST2
I am now going to play another set of recorded instructions. Please listen carefully. There will be a slight pause before the recording begins.
INTERVIEWER: The Screen will go blank for a few seconds and then the recorded instructions will begin.
INTERVIEWER: On the next screen as respondent lists remembered words, if they pause for more than 15 seconds prompt with: "Do you remember any other words?"
INTERVIEWER: HIT "NEXT" TO CONTINUE
Proceed to next question, QWLL_2
Q: QWLL_2
INTERVIEWER: Press F6 to begin playing recorded instructions Play segment 2
Press F7 to end playing recorded instructions
MARK THE WORDS AS THE RESPONDENT NAMES THEM IF THE RESPONDENT
REPEATS A WORD, USE THE SECOND AND THIRD COLUMNS. IF THE
RESPONDENT NAMES A WORD NOT ON THE LIST, MARK IT AS "UNLISTED"
INTERVIEWER: WHEN RECORDED INSTRUCTIONS ARE FINISHED SAY THIS:
Please repeat as many of the words as you can remember
Ticket
Cabin
Butter
Shore
Engine
Arm
Queen
Letter
Pole
Grass
Unlisted
Could not hear
Refused
NOTE TO PROGRAMMERS: We need to be able to capture the order in which the words were repeated and if the respondent repeated a word more than once, up to 3 times
IF (QWLL_2 = 1) WLL_2a = 1
IF (QWLL_2 = 2) WLL_2b = 2
IF (QWLL_2 = 3) WLL_2c = 3
IF (QWLL_2 = 4) WLL_2d = 4
IF (QWLL_2 = 5) WLL_2e = 5
IF (QWLL_2 = 6) WLL_2f = 6
IF (QWLL_2 = 7) WLL_2g = 7
IF (QWLL_2 = 8) WLL_2h = 8
IF (QWLL_2 = 9) WLL_2i = 9
IF (QWLL_2 = 10) WLL_2j = 10
IF (QWLL_2 = 11) WLL_2k = 11
IF (QWLL_2 = 12) WLL_2l = 12
IF (QWLL_2 = 13) WLL_2m = 13
IF (QWLL_2 = 14) THEN WLL_2n = 14
IF (QWLL_2 = 15) THEN WLL_2o = 15
IF (QWLL_2 = 16) THEN WLL_2p = 16
IF (QWLL_2 = 17) THEN WLL_2q = 17
IF (QWLL_2 = 18) THEN WLL_2r = 18
IF (QWLL_2 = 19) THEN WLL_2s = 19
IF (QWLL_2 = 20) THEN WLL_2t = 20
IF (QWLL_2 = 21) THEN WLL_2u = 21
IF (QWLL_2 = 22) THEN WLL_2v = 22
IF (QWLL_2 = 23) THEN WLL_2w = 23
IF (QWLL_2 = 24) THEN WLL_2x = 24
IF (QWLL_2 = 25) THEN WLL_2y = 25
IF (QWLL_2 = 26) THEN WLL_2z = 26
IF (QWLL_2 = 27) THEN WLL_2aa = 27
IF (QWLL_2 = 28) THEN WLL_2ab = 28
IF (QWLL_2 = 29) THEN WLL_2ac = 29
IF (QWLL_2 = 30) THEN WLL_2ad = 30
IF (QWLL_2 = 31) THEN WLL_2ae = 31
IF (QWLL_2 = 32) THEN WLL_2af = 32
IF (QWLL_2 = 33) THEN WLL_2ag = 33
IF (QWLL_2 = 34) THEN WLL_2ah = 34
IF (QWLL_2 = 35) THEN WLL_2ai = 35
IF (QWLL_2 = 36) THEN WLL_2aj = 36
IF (QWLL_2 = 1) THEN SWLL2_a = 1
IF (QWLL_2 = 2) THEN SWLL2_b = 2
IF (QWLL_2 = 3) THEN SWLL2_c = 3
IF (QWLL_2 = 4) THEN SWLL2_d = 4
IF (QWLL_2 = 5) THEN SWLL2_e = 5
IF (QWLL_2 = 6) THEN SWLL2_f = 6
IF (QWLL_2 = 7) THEN SWLL2_g = 7
IF (QWLL_2 = 8) THEN SWLL2_h = 8
IF (QWLL_2 = 9) THEN SWLL2_i = 9
IF (QWLL_2 = 10) THEN SWLL2_j = 10
IF (QWLL_2 = 11) THEN SWLL2_k = 11
IF (QWLL_2 = 12) THEN SWLL2_l = 12
IF (QWLL_2 = 13) THEN SWLL2_m = 13
IF (QWLL_2 = 14) THEN SWLL2_n = 14
IF (QWLL_2 = 15) THEN SWLL2_o = 15
IF (QWLL_2 = 16) THEN SWLL2_p = 16
IF (QWLL_2 = 17) THEN SWLL2_q = 17
IF (QWLL_2 = 18) THEN SWLL2_r = 18
IF (QWLL_2 = 19) THEN SWLL2_s = 19
IF (QWLL_2 = 20) THEN SWLL2_t = 20
Proceed to next question, QINST3
QINST3
I am now going to play a third set of recorded instructions. Please listen carefully. There will be a slight pause before the recording begins.
INTERVIEWER: The Screen will go blank for a few seconds and then the recorded instructions will begin.
INTERVIEWER: On the next screen as respondent lists remembered words, if they pause for more than 15 seconds prompt with: "Do you remember any other words?"
INTERVIEWER: HIT "NEXT" KEY TO CONTINUE
Proceed to next question, QWLL_3
Q: QWLL_3
INTERVIEWER: Press F6 to begin playing recorded instructions Play segment 3
Press F7 to end playing recorded instructions
MARK THE WORDS AS THE RESPONDENT NAMES THEM IF THE RESPONDENT
REPEATS A WORD, USE THE SECOND AND THIRD COLUMNS. IF THE
RESPONDENT NAMES A WORD NOT ON THE LIST, MARK IT AS "UNLISTED"
INTERVIEWER: WHEN RECORDED INSTRUCTIONS ARE FINISHED SAY THIS:
Please repeat as many of the words as you can remember
Queen
Grass
Arm
Cabin
Pole
Shore
Butter
Engine
Ticket
Letter
Unlisted
Could not hear recording
Refused
NOTE TO PROGRAMMERS: We need to be able to capture the order in which the words were repeated and if the respondent repeated a word more than once, up to 3 times
IF (QWLL_3 = 1) THEN WLL_3a = 1
IF (QWLL_3 = 2) THEN WLL_3b = 2
IF (QWLL_3 = 3) THEN WLL_3c = 3
IF (QWLL_3 = 4) THEN WLL_3d = 4
IF (QWLL_3 = 5) THEN WLL_3e = 5
IF (QWLL_3 = 6) THEN WLL_3f = 6
IF (QWLL_3 = 7) THEN WLL_3g = 7
IF (QWLL_3 = 8) THEN WLL_3h = 8
IF (QWLL_3 = 9) THEN WLL_3i = 9
IF (QWLL_3 = 10) THEN WLL_3j = 10
IF (QWLL_3 = 11) THEN WLL_3k = 11
IF (QWLL_3 = 12) THEN WLL_3l = 12
IF (QWLL_3 = 13) THEN WLL_3m = 13
IF (QWLL_3 = 14) THEN WLL_3n = 14
IF (QWLL_3 = 15) THEN WLL_3o = 15
IF (QWLL_3 = 16) THEN WLL_3p = 16
IF (QWLL_3 = 17) THEN WLL_3q = 17
IF (QWLL_3 = 18) THEN WLL_3r = 18
IF (QWLL_3 = 19) THEN WLL_3s = 19
IF (QWLL_3 = 20) THEN WLL_3t = 20
IF (QWLL_3 = 21) THEN WLL_3u = 21
IF (QWLL_3 = 22) THEN WLL_3v = 22
IF (QWLL_3 = 23) THEN WLL_3w = 23
IF (QWLL_3 = 24) THEN WLL_3x = 24
IF (QWLL_3 = 25) THEN WLL_3y = 25
IF (QWLL_3 = 26) THEN WLL_3z = 26
IF (QWLL_3 = 27) THEN WLL_3aa = 27
IF (QWLL_3 = 28) THEN WLL_3ab = 28
IF (QWLL_3 = 29) THEN WLL_3ac = 29
IF (QWLL_3 = 30) THEN WLL_3ad = 30
IF (QWLL_3 = 31) THEN WLL_3ae = 31
IF (QWLL_3 = 32) THEN WLL_3af = 32
IF (QWLL_3 = 33) THEN WLL_3ag = 33
IF (QWLL_3 = 34) THEN WLL_3ah = 34
IF (QWLL_3 = 35) THEN WLL_3ai = 35
IF (QWLL_3 = 36) THEN WLL_3aj = 36
IF (QWLL_3 = 1) THEN SWLL3_a = 1
IF (QWLL_3 = 2) THEN SWLL3_b = 2
IF (QWLL_3 = 3) THEN SWLL3_c = 3
IF (QWLL_3 = 4) THEN SWLL3_d = 4
IF (QWLL_3 = 5) THEN SWLL3_e = 5
IF (QWLL_3 = 6) THEN SWLL3_f = 6
IF (QWLL_3 = 7) THEN SWLL3_g = 7
IF (QWLL_3 = 8) THEN SWLL3_h = 8
IF (QWLL_3 = 9) THEN SWLL3_i = 9
IF (QWLL_3 = 10) THEN SWLL3_j = 10
IF (QWLL_3 = 11) THEN SWLL3_k = 11
IF (QWLL_3 = 12) THEN SWLL3_l = 12
IF (QWLL_3 = 13) THEN SWLL3_m = 13
IF (QWLL_3 = 14) THEN SWLL3_n = 14
IF (QWLL_3 = 15) THEN SWLL3_o = 15
IF (QWLL_3 = 16) THEN SWLL3_p = 16
IF (QWLL_3 = 17) THEN SWLL3_q = 17
IF (QWLL_3 = 18) THEN SWLL3_r = 18
IF (QWLL_3 = 19) THEN SWLL3_s = 19
IF (QWLL_3 = 20) THEN SWLL3_t = 20
Ethnic Differences in Risk of Fracture and Related Vascular Events
Q: Q3_98c Asked annually on follow ups with sequence = 3, 5, 7, 9, 11, etc.
3.98c Since the last time we contacted you, has a doctor told you for the first time that you have a new broken, fractured or crushed bone?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
IF (Q3_98c = 1)
BrokeNew = 1
IF (SEQNO = 3) THEN Skip to Q3_98f
IF (SEQNO = 5) THEN Skip to Q3_98f
IF (SEQNO = 7) THEN Skip to Q3_98f
IF (SEQNO = 9) THEN Skip to Q3_98f
IF (SEQNO = 11) THEN Skip to Q3_98f
IF (SEQNO = 13) THEN Skip to Q3_98f
IF (SEQNO = 15) THEN Skip to Q3_98f
IF (SEQNO = 17) THEN Skip to Q3_98f
IF (SEQNO = 19) THEN Skip to Q3_98f
IF (SEQNO = 21) THEN Skip to Q3_98f
IF (SEQNO = 23) THEN Skip to Q3_98f
ENDIF
IF (Q3_98c > 1)
IF (SEQNO = 3) THEN Skip to QINST4
IF (SEQNO = 7) THEN Skip to QINST4
IF (SEQNO = 11) THEN Skip to QINST4
IF (SEQNO = 15) THEN Skip to QINST4
IF (SEQNO = 19) THEN Skip to QINST4
IF (SEQNO = 23) THEN Skip to QINST4
ENDIF
IF (SlpFlag = 0) THEN Skip to Sleep
IF (SlpFlag = 1) THEN Skip to Q4
Q: Q3_98f
3.98f Please tell me which bones you have broken, fractured or crushed since we last spoke to you:
MARK ALL THAT APPLY
01. Hip
02. Upper Leg, not hip
03. Pelvis
04. Knee, also know as patella
05. Lower leg or ankle
06. Foot, not just a toe
07. Tailbone, also known as coccyx
08. Spine or back, also know as vertebra
09. Lower arm or wrist
10. Hand, not just a finger
11. Elbow
12. Upper arm or shoulder
13. Jaw, nose, face and/or skull
14. Finger or toe
15. Ribs, chest or breastbone
16. Cervical spine or neck
17. Other, please specify: __________________________
18. Don't Know
IF (BrokeNew < 1)
IF (SEQNO = 3) THEN Skip to QINST4
IF (SEQNO = 7) THEN Skip to QINST4
IF (SEQNO = 11) THEN Skip to QINST4
IF (SEQNO = 15) THEN Skip to QINST4
IF (SEQNO = 19) THEN Skip to QINST4
IF (SEQNO = 23) THEN Skip to QINST4
ENDIF
IF (BrokeNew < 1)
IF (SlpFlag = 0) THEN Skip to Sleep
IF (SlpFlag = 1) THEN Skip to Q4
ENDIF
IF (Q3_98f = 01) THEN Bones1 = 1
IF (Q3_98f = 02) THEN Bones2 = 1
IF (Q3_98f = 03) THEN Bones3 = 1
IF (Q3_98f = 04) THEN Bones4 = 1
IF (Q3_98f = 05) THEN Bones5 = 1
IF (Q3_98f = 06) THEN Bones6 = 1
IF (Q3_98f = 07) THEN Bones7 = 1
IF (Q3_98f = 08) THEN Bones8 = 1
IF (Q3_98f = 09) THEN Bones9 = 1
IF (Q3_98f = 10) THEN Bones10 = 1
IF (Q3_98f = 11) THEN Bones11 = 1
IF (Q3_98f = 12) THEN Bones12 = 1
IF (Q3_98f = 13) THEN Bones13 = 1
IF (Q3_98f = 14) THEN Bones14 = 1
IF (Q3_98f = 15) THEN Bones15 = 1
IF (Q3_98f = 16) THEN Bones16 = 1
IF (Q3_98f = 17) THEN Bones17 = 1
IF (Q3_98f = 18) THEN S398f_a = 18
IF (Q3_98f = 01) THEN S398f_a = 01
IF (Q3_98f = 02) THEN S398f_b = 02
IF (Q3_98f = 03) THEN S398f_c = 03
IF (Q3_98f = 04) THEN S398f_d = 04
IF (Q3_98f = 05) THEN S398f_e = 05
IF (Q3_98f = 06) THEN S398f_f = 06
IF (Q3_98f = 07) THEN S398f_g = 07
IF (Q3_98f = 08) THEN S398f_h = 08
IF (Q3_98f = 09) THEN S398f_i = 09
IF (Q3_98f = 10) THEN S398f_j = 10
IF (Q3_98f = 11) THEN S398f_k = 11
IF (Q3_98f = 12) THEN S398f_l = 12
IF (Q3_98f = 13) THEN S398f_m = 13
IF (Q3_98f = 14) THEN S398f_n = 14
IF (Q3_98f = 15) THEN S398f_o = 15
IF (Q3_98f = 16) THEN S398f_p = 16
IF (Q3_98f = 17) THEN S398f_q = 17
IF (Q3_98f = 17) THEN Skip to Q3_98s
IF (Q3_98f 17) THEN Skip to Q3_98f1
Q: Q3_98s
Can you please tell me what bone you broke
INTERVIEWER: Enter UNKNOWN if not available.
Ans_Len = 0
Ans_Len = Text Length of Q3_98s
IF (Ans_Len = 0)
Re Ask Q3_98s
ENDIF
Proceed to next question, Q3_98F
Q: Q3_98f# Asked for each bone break identified in Q_98f, use the # to identify the bone (1-17)
How did you break your bone listed in Q3_98f? For example, were you in a car accident or hit by a car? Did you fall down stairs? Did you fall from a height, like while standing on a ladder or chair? Did you fall or trip, like while walking or getting out of bed? Were you engaged in a sports activity, like skiing, horseback riding or climbing?
Mark all that apply
1. Car accident, hit by a car
2. Fall down stairs
3. Fall from a height, like while on a ladder
4. Fall or trip, like while walking or getting out of bed
5. Sports activity
6. Other, please specify:
8. Don't Know/Not Sure
9. Refused
NOTE: # indicates a number 1 – 17. This question will be repeated for each bone indicated in Q3_98f.
NOTE: if # is not = 17 do the following
IF (Bones# < 1) THEN Skip to Q3_98f(#+1)
Example # = 1. IF (Bones1 < 1) THEN Skip to Q3_98f2
NOTE: if # is = 17 do the following.
IF (Bones17 < 1)
IF (SEQNO = 3) THEN Skip to QINST4
IF (SEQNO = 7) THEN Skip to QINST4
IF (SEQNO = 11) THEN Skip to QINST4
IF (SEQNO = 15) THEN Skip to QINST4
IF (SEQNO = 19) THEN Skip to QINST4
IF (SEQNO = 23) THEN Skip to QINST4
ENDIF
NOTE: if # is = 17 do the following. Only for Bones17!
IF (Bones17 < 1)
IF (SlpFlag = 0) THEN Skip to Sleep
IF (SlpFlag = 1) THEN Skip to Q4
ENDIF
IF (Q3_98f# = 8) S398f#_a = 8
IF (Q3_98f# = 9) S398f#_a = 9
IF (Q3_98f# = 1) S398f#_a = 1
IF (Q3_98f# = 2) S398f#_b = 2
IF (Q3_98f# = 3) S398f#_c = 3
IF (Q3_98f# = 4) S398f#_d = 4
IF (Q3_98f# = 5) S398f#_e = 5
IF (Q3_98f# = 6) S398f#_f = 6
IF (Q3_98f# = 6) THEN Skip to Q3_f1s
IF (Q3_98f# 6) THEN Skip to Q3_f1a
Q: Q3f#s Use the # to identify the bone (1-17)
Can you please tell me how you broke your bone listed in Q3_98f? ____________________________
Ans_Len = 0
Ans_Len = Text Length of Q3_98f#s (where # = 1 – 17)
IF (Ans_Len = 0)
Re Ask Q3_98f#s
ENDIF
Q: Q3_f#a and Q3f#b Use the # to identify the bone (1-17)
What is the name of the facility where you had an X-ray or imaging scan, like an MRI or bone scan to diagnose this fracture?
Q3f#a Name of facility: _________________________________________
Q3f#b Location: _________________________________________________
INTERVIEWER: Please try to get as much information as you can. For location at least get city and state
DO NOT LEAVE BLANK. ENTER ANY INFORMATION OFFERED BY THE RESPONDENT. IF RESPONDENT DOES NOT KNOW OR REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Q3_98f#a (where # = 1 – 17)
IF (Ans_Len = 0)
Re Ask Q3_98f#a
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q3_98f#b (where # = 1 – 17)
IF (Ans_Len = 0)
Re Ask Q3_98f#b
ENDIF
Q: Q3_f#c Use the # to identify the bone (1-17)
IF (Intro < 5 AND IntroP3 < 2)
3.f1c What is the date you had the X-ray or imaging scan that diagnosed this fracture?
Enter date mm/dd/yyyy
01/01/7777 Don't Know/Not Sure
01/01/8888 Did not have an X-ray or imaging scan
01/01/9999 Refused
ENDIF
IF (INTRO > 4 OR IntroP3 > 1)
3.f1c What is the date you had the X-ray or imaging scan that diagnosed this fracture?
Enter date mm/dd/yyyy
01/01/7777 Don't Know/Not Sure
01/01/8888 Did not have an X-ray or imaging scan
01/01/9999 Refused
ENDIF
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
DATES ARE VERY IMPORTANT!!! AT THE VERY LEAST, GET MONTH and YEAR. PROBE USING LAST INTERVIEW DATE. If respondent unable to remember exact date, enter month and year and enter “01” for day.
IF (Q3_98f#c > system date)
IF (Q3_98f#c < 01/01/6666)
Re Ask Q3_98f#c
ENDIF
ENDIF
Sleep Apnea Module
These questions are not appropriate to ask a proxy; therefore
IF Intro > 4, Skip to Q4
IF IntroP3 > 1, Skip to Q4
IF SlpFlg = 1 and Seqno = 2, 4, 6, 8, 10, 12, 14, etc., Skip to Q4
IF SlpFlg = 0 and Seqno = 2, 4, 6, 8, 10, 12, 14, etc., Continue with Sleep Module
These questions are also not asked if this is a sequence during which the full cognitive battery is asked:
IF SlpFlg = 0 or is Blank and Seqno = 3, 7, 11, 15, 19, etc., Skip to QINST4
Q: Sleep
Now I want to ask you some questions about your sleep.
Some sleep problems have been linked to stroke and heart disease.
INTERVIEWER: PRESS ANY KEY TO CONTINUE
This isn’t really a question. It is just an introductory screen not requiring a specific answer.
Q: Slp1
Slp1
Sleep apnea is a condition where the upper airway closes or partially closes causing people to temporarily stop breathing while they are asleep. Have you been diagnosed with sleep apnea by a health care provider?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
If (Slp1 > 1) THEN Skip to Slp2
If Slp1 = 1, Proceed to next question, Slp1_1
Q: Slp1_1
Slp1_1
When you were diagnosed with sleep apnea, did you have an overnight sleep study? This could mean that you spent the night in a sleep lab or wore a special device at home to monitor your sleep and breathing.
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
Proceed to next question, Slp1_1a
Q: Slp1_1a
Slp1_1a
Did you receive any treatment for your sleep apnea?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
If (Slp1_1a > 1) THEN Skip to Slp2
If Slp1_1a = 1, Proceed to next question, Slp1_1b
Q: Slp1_1b
Slp1_1b
Have you received surgery to your throat or upper airway, such as removal of extra tissue to improve or eliminate snoring, to treat your sleep apnea?
1. Yes
2. No
8. Don't Know
9. Refused
Proceed to next question, Slp1_1c
Q: Slp1_1c
Slp1_1c
Do you sleep, or have you ever slept, with a mask, also known as a CPAP or BiPAP, to treat your sleep apnea?
1. Yes
2. No
8. Don't Know
9. Refused
If (Slp1_1c > 1) THEN Skip to Slp2
If Slp1_1c = 1, Proceed to next question, Slp1_1d
Q: Slp1_1d
Slp1_1d
On average, how many nights per week are you CURRENTLY using the mask?
1. 1 night
2. 2 nights
3. 3 nights
4. 4 nights
5. 5 or more nights
6. 0 (no nights - no longer wears CPAP or BiPAP)
8. Don't know
9. Refused
INTERVIEWER: We are interested in learning how many nights per week the respondent wears the mask.
FOR PEOPLE WHO WORK NIGHTS, THIS COULD BE DURING THE DAY.
If (Slp1_1d = 6 OR Slp1_1d = 9) THEN Skip to Slp2
For all other answers to Slp1_1e, Proceed to next question, Slp1_1e
Q: Slp1_1e
Slp1_1e
On average, how many hours per night are you CURRENTLY using the mask?
1. 1 hour
2. 2 hours
3. 3 hours
4. 4 or more hours
5. 0 (no hours - no longer wears CPAP or BiPAP)
8. Don't know
9. Refused
INTERVIEWER: We are interested in learning how many hours the respondent wears the mask during his/her main sleeping period.
FOR PEOPLE WHO WORK NIGHTS, THIS COULD BE DURING THE DAY.
Proceed to next question, Slp2
Sleep Disordered Breathing Section
Q: Slp2
Slp2
Do you snore?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
If (Slp2 > 1) THEN Skip to Slp6
If Slp2 = 1, Proceed to next question, Slp3
Q: Slp3
Slp3
Is your snoring:
[read all possible answers to participant]
1. Slightly louder than breathing
2. As loud as talking
3. Louder than talking
4. Very loud; can be heard in adjacent rooms
8. Don't know/Not sure
9. Refused
Proceed to next question, Slp4
Q: Slp4
Slp4
How often do you snore?
[read all possible answers to participant]
1. Nearly every day
2. 3 to 4 nights per week
3. 1 to 2 nights per week
4. 1 to nights per month
5. Never or nearly never
8. Don't know/not sure
9. Refused
Proceed to next question, Slp5
Q: Slp5
Slp5
Has your snoring ever bothered other people?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
Proceed to next question, Slp6
Q: Slp6
Slp6
Has anyone ever noticed that you quit breathing during your sleep?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
If (Slp6 > 1) THEN Skip to Slp7
If Slp6 = 1, Proceed to next question, Slp6a
Q: Slp6a
Slp6a
How frequently have you been told this occurs, that is, that you quit breathing during your sleep?
1. Nearly every day
2. 3 to 4 times a week
3. 1 to 2 times a week
4. 1 to 2 times a month
5. Never or nearly never
8. Don't know/Not sure
9. Refused
Proceed to next question, Slp7
Excessive Daytime Sleepiness Section
Q: Slp7
Slp7
Do you feel tired or fatigued after your sleep?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
INTERVIEWER: We are interested in finding out if the respondent is tired or fatigued when it is time for them to get up or immediately afterward.
If (Slp7 > 1) THEN Skip to Slp8
If Slp7 = 1, Proceed to next question, Slp7a
Q: Slp7a
Slp7a
How often do you feel tired or fatigued after your sleep?
[read all possible answers to participants]
1. Nearly every day
2. 3 to 4 times a week
3. 1 to 2 times a week
4. 1 to 2 times a month
5. Never or nearly never
8. Don't know/Not sure
9. Refused
INTERVIEWER: We are interested in finding out if the respondent is tired or fatigued when it is time for them to get up or immediately afterward.
Proceed to next question, Slp8
Q: Slp8
Slp8
During your wake time, do you ever feel tired, fatigued, or not up to par?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
INTERVIEWER: We are interested in learning whether the respondent feels tired, fatigued or not up to par during their normal waking periods, for most people this would be during the day.
If (Slp8 > 1) THEN Skip to Slp9
If Slp8 = 1, Proceed to next question, Slp8a
Q: Slp8a
Slp8a
How often do you feel tired, fatigued, or not up to par during your wake time?
1. Nearly every day
2. 3 to 4 times a week
3. 1 to 2 times a week
4. 1 to 2 times a month
INTERVIEWER: We are interested in learning whether the respondent feels tired, fatigued or not up to par during their normal waking periods, for most people this would be during the day.
Proceed to next question, Slp9
Q: Slp9
Slp9
Have you ever nodded off or fallen asleep while driving a vehicle?
1. Yes
2. No
7. Not applicable - Does not drive a vehicle or does not drive often
8. Don't Know/Not Sure
9. Refused
If (Slp9 > 1) THEN Skip to Slp10
If Slp9 = 1, Proceed to next question, Slp9a
Q: Slp9a
Slp9a
How often does it occur?
[read possible answers to participant]
1. Nearly every day
2. 3 to 4 times a week
3. 1 to 2 times a week
4. 1 to 2 times a month
5. Never or nearly never
8. Don't know/not sure
9. Refused
Proceed to next question, Slp10
Sleep Duration and "Prescription Sleeping Pills" Section
Q: Slp10
Slp10
How many hours of sleep do you usually get at night, or during your main sleep period, on your work days?
____ Enter number of hours
77 Retired/Does Not Work
88 Don't Know/Not Sure
99 Refused
Slp10: Answer should be from 0 to 20, 77, 88, or 99
Proceed to next question, Slp11
Q: Slp11
Slp11
How many hours of sleep do you usually get at night, or during your main sleep period, on your NON-WORK days?
__ Enter number of hours
77 Retired/Does Not Work
88 Don't Know/Not Sure
99 Refused
Slp11: Answer should be from 0 to 20, 77, 88, or 99
Proceed to next question, Slp12
Q: Slp12
Slp12
How many days/nights in the last month have you used prescription sleeping pills?
__ Enter number of days/nights
88 Don't Know/Not Sure
99 Refused
INTERVIEWER: The key word here is "prescription", pills that are available only by doctor recommendation.
Slp12: Answer should be from 0 to 31, 88, or 99
Proceed to next question, Slp13
Q: Slp13
Slp13
How many days/nights in the last month have you used non-prescription, or over the counter sleeping pills?
This could include things like Tylenol or Advil PM.
__ Enter number of days/nights
88 Don't Know/Not Sure
99 Refused
Slp13: Answer should be from 0 to 31, 88, or 99
SlpFlag = 1
Proceed to next question, QINST4
Last iteration of WLL
Q: QINST4
Now let me play one last recording for you. Again there will be a few seconds delay before the recording begins. Listen carefully.
INTERVIEWER: The Screen will go blank for a few seconds and then the recorded instructions will begin.
INTERVIEWER: On the next screen as respondent lists
remembered words, if they pause for more than 15 secs
prompt with: "Do you remember any other words?"
INTERVIEWER: HIT NEXT TO CONTINUE
IF (Intro > 4) THEN Skip to Q4
IF (SlpFlag = 1)
IF (seqno = 1) THEN Skip to Q4
IF (seqno = 2) THEN Skip to Q4
IF (seqno = 4) THEN Skip to Q4
IF (seqno = 5) THEN Skip to Q4
IF (seqno = 6) THEN Skip to Q4
IF (seqno = 8) THEN Skip to Q4
IF (seqno = 9) THEN Skip to Q4
IF (seqno = 10) THEN Skip to Q4
IF (seqno = 12) THEN Skip to Q4
IF (seqno = 13) THEN Skip to Q4
IF (seqno = 14) THEN Skip to Q4
IF (seqno = 16) THEN Skip to Q4
IF (seqno = 17) THEN Skip to Q4
IF (seqno = 18) THEN Skip to Q4
IF (seqno = 20) THEN Skip to Q4
IF (seqno = 21) THEN Skip to Q4
IF (seqno = 22) THEN Skip to Q4
IF (seqno = 24) THEN Skip to Q4
IF (seqno = 25) THEN Skip to Q4
IF (seqno = 26) THEN Skip to Q4
ENDIF
IF (SlpFlag = 0)
IF (seqno = 1) THEN Skip to Sleep
IF (seqno = 2) THEN Skip to Sleep
IF (seqno = 4) THEN Skip to Sleep
IF (seqno = 5) THEN Skip to Sleep
IF (seqno = 6) THEN Skip to Sleep
IF (seqno = 8) THEN Skip to Sleep
IF (seqno = 9) THEN Skip to Sleep
IF (seqno = 10) THEN Skip to Sleep
IF (seqno = 12) THEN Skip to Sleep
IF (seqno = 13) THEN Skip to Sleep
IF (seqno = 14) THEN Skip to Sleep
IF (seqno = 16) THEN Skip to Sleep
IF (seqno = 17) THEN Skip to Sleep
IF (seqno = 18) THEN Skip to Sleep
IF (seqno = 20) THEN Skip to Sleep
IF (seqno = 21) THEN Skip to Sleep
IF (seqno = 22) THEN Skip to Sleep
IF (seqno = 24) THEN Skip to Sleep
IF (seqno = 25) THEN Skip to Sleep
IF (seqno = 26) THEN Skip to Sleep
ENDIF
Q: QWLL_4
INTERVIEWER: Press F6 to begin playing recorded instructions Play segment 4
Press F7 to end playing recorded instructions
MARK THE WORDS AS THE RESPONDENT NAMES THEM IF THE RESPONDENT
REPEATS A WORD, USE THE SECOND AND THIRD COLUMNS. IF THE
RESPONDENT NAMES A WORD NOT ON THE LIST, MARK IT AS "UNLISTED"
Butter
Arm
Shore
Letter
Queen
Cabin
Pole
Ticket
Grass
Engine
None
Unlisted
Could not hear recording
Refused
INTERVIEWER: HIT NEXT TO CONTINUE
NOTE TO PROGRAMMERS: We need to be able to capture the order in which the words were repeated and if the respondent repeated a word more than once, up to 3 times
IF (SlpFlag = 1)
IF (SEQNO = 1) THEN Skip to Q4
IF (SEQNO = 2) THEN Skip to Q4
IF (SEQNO = 4) THEN Skip to Q4
IF (SEQNO = 5) THEN Skip to Q4
IF (SEQNO = 6) THEN Skip to Q4
IF (SEQNO = 8) THEN Skip to Q4
IF (SEQNO = 9) THEN Skip to Q4
IF (SEQNO = 10) THEN Skip to Q4
IF (SEQNO = 12) THEN Skip to Q4
IF (SEQNO = 13) THEN Skip to Q4
IF (SEQNO = 14) THEN Skip to Q4
IF (SEQNO = 16) THEN Skip to Q4
IF (SEQNO = 17) THEN Skip to Q4
IF (SEQNO = 18) THEN Skip to Q4
IF (SEQNO = 20) THEN Skip to Q4
IF (SEQNO = 21) THEN Skip to Q4
IF (SEQNO = 22) THEN Skip to Q4
IF (SEQNO = 24) THEN Skip to Q4
ENDIF
IF (SlpFlag = 0)
IF (SEQNO = 1) THEN Skip to Sleep
IF (SEQNO = 2) THEN Skip to Sleep
IF (SEQNO = 4) THEN Skip to Sleep
IF (SEQNO = 5) THEN Skip to Sleep
IF (SEQNO = 6) THEN Skip to Sleep
IF (SEQNO = 8) THEN Skip to Sleep
IF (SEQNO = 9) THEN Skip to Sleep
IF (SEQNO = 10) THEN Skip to Sleep
IF (SEQNO = 12) THEN Skip to Sleep
IF (SEQNO = 13) THEN Skip to Sleep
IF (SEQNO = 14) THEN Skip to Sleep
IF (SEQNO = 16) THEN Skip to Sleep
IF (SEQNO = 17) THEN Skip to Sleep
IF (SEQNO = 18) THEN Skip to Sleep
IF (SEQNO = 20) THEN Skip to Sleep
IF (SEQNO = 21) THEN Skip to Sleep
IF (SEQNO = 22) THEN Skip to Sleep
IF (SEQNO = 24) THEN Skip to Sleep
ENDIF
IF (QWLL_4 = 1) THEN WLL_4a = 1
IF (QWLL_4 = 2) THEN WLL_4b = 2
IF (QWLL_4 = 3) THEN WLL_4c = 3
IF (QWLL_4 = 4) THEN WLL_4d = 4
IF (QWLL_4 = 5) THEN WLL_4e = 5
IF (QWLL_4 = 6) THEN WLL_4f = 6
IF (QWLL_4 = 7) THEN WLL_4g = 7
IF (QWLL_4 = 8) THEN WLL_4h = 8
IF (QWLL_4 = 9) THEN WLL_4i = 9
IF (QWLL_4 = 10) THEN WLL_4j = 10
IF (QWLL_4 = 11) THEN WLL_4k = 11
IF (QWLL_4 = 12) THEN WLL_4l = 12
IF (QWLL_4 = 13) THEN WLL_4m = 13
IF (QWLL_4 = 14) THEN WLL_4n = 14
IF (QWLL_4 = 15) THEN WLL_4o = 15
IF (QWLL_4 = 16) THEN WLL_4p = 16
IF (QWLL_4 = 17) THEN WLL_4q = 17
IF (QWLL_4 = 18) THEN WLL_4r = 18
IF (QWLL_4 = 19) THEN WLL_4s = 19
IF (QWLL_4 = 20) THEN WLL_4t = 20
IF (QWLL_4 = 21) THEN WLL_4u = 21
IF (QWLL_4 = 22) THEN WLL_4v = 22
IF (QWLL_4 = 23) THEN WLL_4w = 23
IF (QWLL_4 = 24) THEN WLL_4x = 24
IF (QWLL_4 = 25) THEN WLL_4y = 25
IF (QWLL_4 = 26) THEN WLL_4z = 26
IF (QWLL_4 = 27) THEN WLL_4aa = 27
IF (QWLL_4 = 28) THEN WLL_4ab = 28
IF (QWLL_4 = 29) THEN WLL_4ac = 29
IF (QWLL_4 = 30) THEN WLL_4ad = 30
IF (QWLL_4 = 31) THEN WLL_4ae = 31
IF (QWLL_4 = 32) THEN WLL_4af = 32
IF (QWLL_4 = 33) THEN WLL_4ag = 33
IF (QWLL_4 = 34) THEN WLL_4ah = 34
IF (QWLL_4 = 35) THEN WLL_4ai = 35
IF (QWLL_4 = 36) THEN WLL_4aj = 36
IF (QWLL_4 = 1) THEN SWLL4_a = 1
IF (QWLL_4 = 2) THEN SWLL4_b = 2
IF (QWLL_4 = 3) THEN SWLL4_c = 3
IF (QWLL_4 = 4) THEN SWLL4_d = 4
IF (QWLL_4 = 5) THEN SWLL4_e = 5
IF (QWLL_4 = 6) THEN SWLL4_f = 6
IF (QWLL_4 = 7) THEN SWLL4_g = 7
IF (QWLL_4 = 8) THEN SWLL4_h = 8
IF (QWLL_4 = 9) THEN SWLL4_i = 9
IF (QWLL_4 = 10) THEN SWLL4_j = 10
IF (QWLL_4 = 11) THEN SWLL4_k = 11
IF (QWLL_4 = 12) THEN SWLL4_l = 12
IF (QWLL_4 = 13) THEN SWLL4_m = 13
IF (QWLL_4 = 14) THEN SWLL4_n = 14
IF (QWLL_4 = 15) THEN SWLL4_o = 15
IF (QWLL_4 = 16) THEN SWLL4_p = 16
IF (QWLL_4 = 17) THEN SWLL4_q = 17
IF (QWLL_4 = 18) THEN SWLL4_r = 18
IF (QWLL_4 = 19) THEN SWLL4_s = 19
IF (QWLL_4 = 20) THEN SWLL4_t = 20
Proceed to next question, CESD_1
CESD-4 Depression and Cohen’s Perceived Stress Scale
These next questions are about how you might have felt or behaved recently. Please tell me how often you felt this way during the past week.
Q: CESD_1
1 During the past week, would you say you felt depressed less than one day, one to two days, three to four days or five to seven days?
1 less than 1 day
2 1-2 days
3 3-4 days
4 5-7 days
8 Don't Know/Not Sure
9 Refused
Proceed to next question, CESD_2
Q: CESD_2
2. During the past week, would you say that you felt lonely less than one day, one to two days, three to four days, or five to seven days?
1 less than 1 day
2 1-2 days
3 3-4 days
4 5-7 days
8 Don't Know/Not Sure
9 Refused
Proceed to next question, CESD_3
Q: CESD_3
3. During the past week would you say that you had crying spells less than one day, one to two days, three to four days, or five to seven days?
1 less than 1 day
2 1-2 days
3 3-4 days
4 5-7 days
8 Don't Know/Not Sure
9 Refused
Proceed to next question, CESD_4
Q: CESD_4
4 During the past week, would you say that you felt sad less than one day, one to two days,
three to four days, or five to seven days?
1 less than 1 day
2 1-2 days
3 3-4 days
4 5-7 days
8 Don't Know/Not Sure
9 Refused
Proceed to next question, QALLOW
Permission to Record Responses to Letter Fluency and Animal Naming
Q: QALLOW
I am now going to ask some questions that
ask you to use your memory.
For scoring purposes I would like to record
your responses if you allow it.
Do I have your permission to record your responses to
these next two questions?
1. YES
2. NO
INTERVIEWER: IF RESPONDENT DECLINES, SURVEY SHOULD PROCEED TO
FIRST UNRECORDED COGNITIVE QUESTION, MOCA_1
IF (QALLOW = 2) THEN Skip to MOCA_1
Proceed to next question, LetterF
Word Fluency Cognitive Test
LETTER_F
I will say a letter of the alphabet. Then I want you to give me as many words as you can that begin with that letter, as quickly as you can. For instance, if I say "B", you might give me "bad, battle, bed...". I do not want you to use words that are proper names such as "Boston, Bob, or Buick". Also, do not use the same word again with a different ending such as "eat" and "eating". Any questions?...You will have a full 60 seconds to think of words. Begin when I say the letter. The letter is "F". Go ahead.
INTERVIEWER: To begin recording, press F8
Time for 60 seconds
To stop recording, press F9
PAUSES of 15 seconds or more, repeat basic instruction: "Tell me as many words as you can think of that begin with the letter F." The FIRST word MUST start with "F". For any word that doesn't start with "F", say "No, say words that start with the letter F as in FOOD." EXCEPTION - OK if the word starts with "PH" and is NOT the FIRST word.
DO NOT STOP TIMING UNTIL 60 SECONDS ARE UP
Do_Wav = 1
Proceed to next question, QKIT1 and QKIT2
ANIMAL NAMING
Q: QKIT1
QKITCHEN
I am going to tell you the names of some things you can find
in a kitchen: spoons, knives, plates, faucet. Can you think
of other things in the kitchen?
1.
2.
INTERVIEWER: If the respondent names things that are NOT commonly Found in the kitchen, repeat the instruction, "What are the things you would find in the kitchen, things like spoons, plates, faucet?" If the
participant still does not understand or gives incorrect responses, enter "INCORRECT" and skip to close of survey.
Ans_Len = 0
Ans_Len = Text Length of QKIT1
IF (Ans_Len = 0)
RE ASK QKIT1
ENDIF
Ans_Len = 0
Ans_Len = Text Length of QKIT2
IF (Ans_Len = 0)
RE ASK QKIT2
ENDIF
Proceed to next question, QAnim
Q: QAnim
Good. Now, tell me as many ANIMALS as you can. Name them as
Quickly as possible. Begin now. For purposes of the study, I must
allow you the full 60 seconds.
INTERVIEWER: If there is a pause of 15 seconds or more, repeat the instruction:
“Tell me as many animal names as you can”
Do_Wav = 1
Proceed to next question, MOCA_1
MOCA (Montreal Cognitive Assessment)
Q: MOCA_1
1. I am going to name five objects. Please wait until I say all five words, then repeat them. Remember what they are because I am going to ask you to name them again in a few minutes, but please do not write anything down. Please repeat these words for me:
face, velvet, church, daisy, red
INTERVIEWER: Mark each word respondent repeats correctly
1. Face
2. Velvet
3. Church
4. Daisy
5. Red
8. Could not repeat any of the words
9. Refused
IF (MOCA_1 = 1) THEN MOCA1_a = 1
IF (MOCA_1 = 2) THEN MOCA1_b = 2
IF (MOCA_1 = 3) THEN MOCA1_c = 3
IF (MOCA_1 = 4) THEN MOCA1_d = 4
IF (MOCA_1 = 5) THEN MOCA1_e = 5
Proceed to next question, MOCA_2
Q: MOCA_2
2. I am going to read the same list for a second time. Try to remember as many words as you can, including words you said the first time.
INTERVIEWER: Mark each word respondent repeats correctly
1. Face
2. Velvet
3. Church
4. Daisy
5. Red
8. Could not repeat any of the words
9. Refused
INTERVIEWER: After respondent has named as many words as he/she can remember, say
“I will ask you to recall those words again at the end of the test.”
IF (MOCA_2 = 1) THEN MOCA2_a = 1
IF (MOCA_2 = 2) THEN MOCA2_b = 2
IF (MOCA_2 = 3) THEN MOCA2_c = 3
IF (MOCA_2 = 4) THEN MOCA2_d = 4
IF (MOCA_2 = 5) THEN MOCA2_e = 5
Proceed to next question, MOCA_3
Q: MOCA_3
3. Now, please tell me the date today.
Today's date = Name of month, dd, yyyy
Interviewer: If respondent does not give complete date, prompt by saying, "tell me the exact date including month, day and year."
Mark all correct responses
1. Month correct
2. Date correct
3. Year correct
4. None correct
IF (MOCA_3 = 1) THEN MOCA3_a = 1
IF (MOCA_3 = 2) THEN MOCA3_b = 2
IF (MOCA_3 = 3) THEN MOCA3_c = 3
Proceed to next question, MOCA_4
Q: MOCA_4
4. Please tell me the day of the week.
Today is: Day of the week
1. Correct
2. Incorrect
Proceed to next question, MOCA_5
Q: MOCA_5
5. Please tell me your permanent or primary street address:
ADDRESS = Insert street address from file
1. Same
2. Different
INTERVIEWER: If they also give the city, tell them you'll be asking for that information next.
IF (MOCA_5 = 1) THEN Skip to MOCA_6
Proceed to next question, MOCA_5a
Q: MOCA_5a
INTERVIEWER: Please type the address participant gave
_________________________________________________________
Ans_Len = 0
Ans_Len = Text Length of MOCA_5a
IF (Ans_Len = 0)
RE ASK MOCA_5a
ENDIF
Proceed to next question, MOCA_6
Q: MOCA_6
6. Please tell me what city your permanent or primary address is in
CITY = Insert city address from file
1. Same
2. Different
IF (MOCA_6 = 1) THEN Skip to MOCA_7
Proceed to next question, MOCA_6a
Q: MOCA_6a
INTERVIEWER: Please type the city name participant gave
________________________________________________________
Ans_Len = 0
Ans_Len = Text Length of MOCA_6a
IF (Ans_Len = 0)
RE ASK MOCA_6a
ENDIF
Proceed to next question, MOCA_7
Q: MOCA_7
I read some words to you earlier, which I asked you to remember. Tell me as many of those words as you can remember.
INTERVIEWER: Mark each word respondent repeats correctly
1. Face
2. Velvet
3. Church
4. Daisy
5. Red
8. Could not repeat any of the words
9. Refused
IF (MOCA_7 = 1) THEN MOCA7_a = 1
IF (MOCA_7 = 2) THEN MOCA7_b = 2
IF (MOCA_7 = 3) THEN MOCA7_c = 3
IF (MOCA_7 = 4) THEN MOCA7_d = 4
IF (MOCA_7 = 5) THEN MOCA7_e = 5
Proceed to next question, Q4
Medical Visits and Hospital Stays Not Reported Earlier in Survey
Q: Q4
Original Respondent:
You mentioned earlier that you had visited a doctor's office, clinic or hospital for
List already recorded reasons for medical visits
If no medical visits recorded, Skip to Paragraph below
Other than being treated for this condition (these conditions), how many times have you stayed in a hospital, nursing home or rehab, visited an emergency room or had an out-patient procedure since we last talked to you?
Proxy, Original Respondent ill:
You mentioned earlier that Insert Name from Sample File is currently ill and has seen a doctor for
List already recorded reasons for medical visits Other than being treated for this condition (these conditions), how many times has he/she stayed in a hospital, nursing home or rehab, visited an emergency room or had an out-patient procedure since we last talked to him/her
Proxy, Original Respondent in the hospital:
You mentioned earlier that Insert Name from Sample File is currently in the hospital and has been seen for
List already recorded reasons for medical visits. Other than being treated for this condition (these conditions), how many times has he/she stayed in a hospital, nursing home or rehab, visited an emergency room or had an out-patient procedure since we last talked to him/her?
Proxy, Original Respondent in a nursing home
You mentioned earlier that Insert Name from Sample File is currently in a nursing home and has been seen for List already recorded reasons for medical visits. Other than being treated for this condition (these conditions), how many times has he/she stayed in a hospital, nursing home or rehab, visited an emergency room or had an out-patient procedure since we last talked to him/her?
Proxy, Original Respondent deceased
You mentioned earlier that Insert Name from Sample File has passed away and had been seen for
List already recorded reasons for medical visits. Other than being treated for this condition (these conditions), how many times had he/she stayed in a hospital, nursing home or rehab, visited an emergency room or had an out-patient procedure since we last talked to him/her?
How many times have you/has he/has she stayed over night in a Hospital, nursing home or rehabilitation center,visited an emergency room or had an out-patient procedure since we last talked to you?
Enter number
777 Don't Know/Not Sure
999 Refused
INTERVIEWER: PLEASE NOTE THAT WE WANT SEPARATE NUMBERS OF STAYS. IF A
PERSON WAS ADMITTED TO THE HOSPITAL AND STAYED 5 DAYS, THAT COUNTS AS
ONLY ONE VISIT.
If there are no known additional visits to a hospital/nursing home/emergency room or out patient procedure, Skip to Q11_9
VisNums = Number of items in Vislist
IF (Q4 = 0) THEN Skip to QMEDREL
IF (Q4 = 777) THEN Skip to QMEDREL
IF (Q4 = 999) THEN Skip to QMEDREL
IF (Q4 > 0)
Medrel = Medrel + 1
ENDIF
Proceed to next question, Q5 series
Q5 Series asks about each additional medical visit up to five
Q5_1a - 5_1d = Stay #1
Q5_2a - 5_2d = Stay #2
Q5_3a - 5_3d = Stay #3
Q5_4a – 5_4d = Stay #4
Q5_5a – 5_5d = Stay #5
Q: Q5_#a
For each time you/he/she stayed as a patient in a hospital, nursing home or rehabilitation center, I need to know the reason, the name and location of where you/he/she stayed, the date and the name of the doctor who treated you/him/her. I will ask for each of these one at a time.
Let's start with the first time you/he/she stayed overnight as a patient in a hospital, nursing home or rehabilitation
center since we last spoke to you/him/her?
What was the reason you/he/she were/was admitted?
1. Stroke/brain aneurysm/TIA
2. Heart-related condition
3. Cancer
4. Other Specify: __________________________
5. Broken, crushed or fractured bones
8. Don't Know/Not Sure
9. Refused
IF (Q5_#a = 1) THEN Skip to Q5_#a1
IF (Q5_#a = 3) THEN Skip to Q5_#a1
IF (Q5_#a = 2) THEN Skip to Q5_#spec
IF (Q5_#a = 4) THEN Skip to Q5_#spec
IF (Q5_#a = 5) THEN Skip to Q5_Bone#
IF (Q5_#a = 8) THEN Skip to Q5_#a1
IF (Q5_#a = 9) THEN Skip to Q5_#a1
Q: Q5_Bone# Use # to identify (1-5)
Please tell me which bones you have broken, fractured or crushed since we last spoke to you:
Interviewer: MARK ALL THAT APPLY
01. Hip
02. Upper Leg, not hip
03. Pelvis
04. Knee, also know as patella
05. Lower leg or ankle
06. Foot, not just a toe
07. Tailbone, also known as coccyx
08. Spine or back, also know as vertebra
09. Lower arm or wrist
10. Hand, not just a finger
11. Elbow
12. Upper arm or shoulder
13. Jaw, nose, face and/or skull
14. Finger or toe
15. Ribs, chest or breastbone
16. Cervical spine or neck
17. Other Specify:
18. Don't Know
IF (Q5_Bone# = 17) THEN Skip to Q5_Bon#s
IF (Q5_Bone# 17) THEN Skip to Q5_#a1
Q: Q5_Bon#s Use # to identify (1-5)
Can you please tell me how you broke your upper leg?
Ans_Len = 0
Ans_Len = Text Length of Q5_Bon#s
IF (Ans_Len = 0)
RE ASK Q5_Bon#s
ENDIF
Skip to Q5_#a1
Q: Q5_#spec Use # to identify (1-5)
Please specify reason for stay/visit: ________________________________________________
Ans_Len = 0
Ans_Len = Text Length of Q5_#spec
IF (Ans_Len = 0)
RE ASK Q5_#spec
ENDIF
Proceed to next question, Q5_#a1
Q: Q5_#a1 Use # to identify (1-5)
Was this in-patient, out-patient or an emergency room visit?
1. In-patient
2. Out-patient
3. Emergency room
8. Don't Know/Not Sure
9. Refused
Proceed to next question, Q5_#b and Q5_#b1
Q: Q5_#b and Q5_#b1 Use # to identify (1-5)
What was the name and location of the facility?
Q5_#b Name of Facility: ___________________________________________
Q5_#b1 Location: ___________________________________________
DO NOT LEAVE THIS SCREEN BLANK.
IF RESPONDENT DOES NOT KNOW OR CANNOT REMEMBER, ENTER "UNKNOWN."
INTERVIEWER: Please note!! Probe for correct and complete names. Use only two letter abbreviations for state name. Ask respondent to spell facility and city names for you.
Ans_Len = 0
Ans_Len = Text Length of Q5_#b
IF (Ans_Len = 0)
RE ASK Q5_#b
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q5_#b1
IF (Ans_Len = 0)
RE ASK Q5_#b1
ENDIF
Proceed to next question, Q5_#c
Q: Q5_#c Use # to identify (1-5)
IF (Intro < 5 AND IntroP3 = 1)
What was the name of the doctor who treated you at that time?
ENDIF
IF (Intro > 4 OR IntroP3 > 1)
What was the name of the doctor who treated him/her at that time?
ENDIF
Name of doctor: _____________________________________________________________
DO NOT LEAVE THIS SCREEN BLANK.
IF RESPONDENT DOES NOT KNOW OR CANNOT REMEMBER, ENTER "UNKNOWN."
Ans_Len = 0
Ans_Len = Text Length of Q5_#c
IF (Ans_Len = 0)
RE ASK Q5_#c
ENDIF
Proceed to next question, Q5_#d
Q: Q5_#d Use # to identify (1-5)
On what date were you/was he/was she admitted?
_________ Enter date mm/dd/yyyy
01/01/7777 Don't Know/Not Sure
01/01/9999 Refused
INTERVIEWER: Respondent was recruited on mm/dd/yyyy
This should be the ## month follow-up
Last recorded contact with respondent: mm/dd/yyyy
DATES ARE VERY IMPORTANT!!! AT THE VERY LEAST, GET MONTH and YEAR. PROBE USING LAST INTERVIEW DATE
IF (Q5_#d > System Date)
IF (Q5_#d < 01/01/7777)
RE ASK Q5_#d
ENDIF
ENDIF
IF (Q4 = #) THEN Skip to QMEDREL
Medical Release Information
Q: QMEDREL If we do not need to request copies of medical records, Skip to QStay
When you/he/she agreed to participate in this project, you/he/she gave us general permission to get copies of medical records if we needed to. However, doctors and hospitals may not release information without recently signed permission forms. In the next few weeks we may send new medical release forms. Please sign and date the new form and return it in the self addressed, stamped envelope that we will enclose.
INTERVIEWER: The confidentiality and security of medical records
is required by law and the REGARDS staff safeguard
any records that are requested with multiple security
precautions.
Medical records are requested only for conditions that may be related to heart disease or stroke. However, for the study to be consistent, we have medical records professionals who determine which records will be requested. This statement is read to everyone who has been hospitalized, been to an emergency room, had an out patient procedure or stayed in a rehabilitation facility.
INTERVIEWER: Press any key to continue
If we are speaking with the original respondent, Skip to QAddver
IF (medrel = 0) THEN Skip to QAddver
IF (Qdead < 1)
IF (Qincap < 1) THEN Skip to QAddver
END IF
Surrogate contact information for sending medical release forms
Q: Surro
Are you the correct person to send these forms to?
1. Yes
2. No
8. Don't Know/Not Sure
9. Refused
IF (Surro = 1) THEN Skip to Surro1a
Proceed to next question, SurroFN and SurroLN
Q: SurroFN and SurroLN
Who should we send these forms to?
SurroFN First Name: ___________________________________________
SurroLN Last Name: ___________________________________________
Ans_Len = 0
Ans_Len = Text Length of SurroFN
IF (Ans_Len = 0)
Re Ask SurroFN
ENDIF
Ans_Len = 0
Ans_Len = Text Length SurroLN
IF (Ans_Len = 0)
Re Ask SurroLN
ENDIF
Proceed to next question, Surro1a and Surro1b
Q: Surro1a and Surro1b
And what address should these forms be sent to?
Surro1a Street _________________________________________________
Surro1b City _________________________________________________
Ans_Len = 0
Ans_Len = Text Length of Surro1a
IF (Ans_Len = 0)
Re Ask Surro1a
ENDIF
Ans_Len = 0
Ans_Len = Text Length Surro1b
IF (Ans_Len = 0)
Re Ask Surro1b
ENDIF
Proceed to next question, Surro1c
Q: Surro1c
And that address is in what state?
Enter code for appropriate state ____________
AL = Alabama ME = Maine OH = Ohio
AR = Arkansas MD = Maryland OK = Oklahoma
AZ = Arizona MA = Massachusetts OR = Oregon
CA = California MI = Michigan PA = Pennsylvania
CO = Colorado MN = Minnesota RI = Rhode Island
CT = Connecticut MS = Mississippi SC = South Carolina
DE = Delaware MO = Missouri SD = South Dakota
FL = Florida MT = Montana TN = Tennessee
GA = Georgia NE = Nebraska TX = Texas
IA = Iowa NV = Nevada UT = Utah
ID = Idaho NH = New Hampshire VT = Vermont
IL = Illinois NJ = New Jersey VA = Virginia
IN = Indiana NM = New Mexico WA = Washington
KS = Kansas NY = New York DC = Washington, D.C.
KY = Kentucky NC = North Carolina WV = West Virginia
LA = Louisiana ND = North Dakota WI = Wisconsin
WY = Wyoming
Ans_Len = 0
Ans_Len = Text Length of Surro1c
IF (Ans_Len = 0)
Re Ask Surro1c
ENDIF
Proceed to next question, Surro1d
Q: Surro1d
And lastly, I'll need the zip code: ______________________
Proceed to next question, Surro1e
Q: Surro1e
INTERVIEWER: Just to verify, you entered that the respondent lives in
Is this correct?
1. Yes
2. No
IF (Surro1e = 2) THEN Skip to Surro1c
Proceed to next question, Surro1f
Q: Surro1f
And to help us in the future, can you give me the phone where it is best to reach you/person to be contacted?
Start with the area code: ______________________________________
INTERVIEWER: If phone number is unknown enter 999-999-9999
Ans_Len = 0
Ans_Len = Text Length of Surro1f
IF (Ans_Len = 0)
Re Ask Surro1f
ENDIF
Skip to QStay
Verifying Contact Information for Original Respondent
Q: QAddver
Let me verify that we have the correct mailing address:
Insert mailing address from file
Is this address correct?
1. Yes
2. No
IF (QAddver = 1) THEN Skip to QStay
Proceed to next question, Qaddcor
Q: Qaddcor
Please give me the correct address:
Let's start with the correct street number and name:
Street: ________________________________________
INTERVIEWER: Please note: on this screen enter the street name and number only.
Please ask respondent to spell any name you are at all unsure of.
Ans_Len = 0
Ans_Len = Text Length of Qaddcor
IF (Ans_Len = 0)
Re Ask Qaddcor
ENDIF
Proceed to next question, Qaddcor2
Q: Qaddcor2
Now, please give me the correct city name. To prevent errors, I must ask you to please spell it for me.
City: _______________________________________
INTERVIEWER: Please note: enter only the city name on this screen.
Ans_Len = 0
Ans_Len = Text Length of Qaddcor2
IF (Ans_Len = 0)
Re Ask Qaddcor2
ENDIF
Proceed to next question, Qaddcor3
Q: Qaddcor3
And that address is in what state?
Enter code for appropriate state _______
AL = Alabama ME = Maine OH = Ohio
AR = Arkansas MD = Maryland OK = Oklahoma
AZ = Arizona MA = Massachusetts OR = Oregon
CA = California MI = Michigan PA = Pennsylvania
CO = Colorado MN = Minnesota RI = Rhode Island
CT = Connecticut MS = Mississippi SC = South Carolina
DE = Delaware MO = Missouri SD = South Dakota
FL = Florida MT = Montana TN = Tennessee
GA = Georgia NE = Nebraska TX = Texas
IA = Iowa NV = Nevada UT = Utah
ID = Idaho NH = New Hampshire VT = Vermont
IL = Illinois NJ = New Jersey VA = Virginia
IN = Indiana NM = New Mexico WA = Washington
KS = Kansas NY = New York DC = Washington, D.C.
KY = Kentucky NC = North Carolina WV = West Virginia
LA = Louisiana ND = North Dakota WI = Wisconsin
WY = Wyoming
Ans_Len = 0
Ans_Len = Text Length of Qaddcor3
IF (Ans_Len = 0)
Re Ask Qaddcor3
ENDIF
Proceed to next question, Qaddcor4
Q: QAddcor4
And lastly, I'll need your zip code: ______________________
Proceed to next question, Qaddcor5
Q: QAddcor5
INTERVIEWER: Just to verify, you entered that the respondent lives in:
Is this correct?
1. Yes
2. No
IF (QAddcor5 = 2) THEN Skip to QAddcor3
Proceed to next question, QStay
Q: QStay If original follow up was completed with a proxy due to illness or incapacity, Skip to QStay1
We will be calling again in about six months to check in with you and see how you've been doing. Is the phone number where we've reached you today most likely going to be your phone number in six months?
1. Yes Skip to QInst4
2. No, phone number will change
3. No, address will change
4. No, both address and phone will change
IF (Qdead > 0) THEN Skip to QClose
IF (Qincap > 0) THEN Skip to QStay1
IF (QStay = 1)
IF (PrxCall 1)
IF (QPhyA_1 = 1) THEN Skip to QPhyA_2
IF (QPhyA_1 1) THEN Skip to QClose
ENDIF
IF (PrxCall = 1) THEN Skip to QClose
ENDIF
IF (QStay = 2) THEN Skip to Q6moadd4
Proceed to next question, Q6moadd
Q: Q6moadd , Q6moadd1, Q6moadd2, Q6moadd3, Q6moadd4
Please give me the phone number and address where you think you will be best reached in about six months.
Q6moadd Address:
Q6moadd1 City:
Q6moadd2 State:
Q6moadd3 Zip:
Q6moadd4 Phone
Ans_Len = 0
Ans_Len = Text Length of Q6moadd
IF (Ans_Len = 0)
Re Ask Q6moadd
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q6moadd1
IF (Ans_Len = 0)
Re Ask Q6moadd1
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q6moadd2
IF (Ans_Len = 0)
Re Ask Q6moadd2
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q6moadd3
IF (Ans_Len = 0)
Re Ask Q6moadd3
ENDIF
Ans_Len = 0
Ans_Len = Text Length of Q6moadd4
IF (Ans_Len = 0)
Re Ask Q6moadd4
ENDIF
IF (PrxCall 1)
IF (QPhyA_1 = 1) THEN Skip to QPhyA_2
IF (QPhyA_1 1) THEN Skip to QClose
ENDIF
IF (PrxCall = 1) THEN Skip to QClose
Q: QStay1
As a part of the study we will call again in six months to see how Insert Name from Sample File
is doing. Will he/she be able to complete a telephone survey in six months?
1. Yes, recovery is a possibility
2. No
8. Don't Know/Not Sure
9. Refussed
IF (QStay1 = 1) THEN Skip to QStay1a
IF (QStay1 > 1) THEN Skip to QStay2
Q: QStay1a
Is Insert Phone number from Sample File the phone number most likely going to be his/her phone number in six months?
If (QStay1a = 2) THEN Skip to Q6moadd4
Q: QStay2
May we contact you at that time?
1. Yes
2. No, please contact person receiving Med Release forms
3. No, please contact someone else.
4. No, please do not contact us again.
IF (Surro=1)
IF (QStay2 = 1) THEN Skip to QClose
ENDIF
IF (QStay2 = 2) THEN Skip to QClose
IF (QStay2 = 4) THEN Skip to QClose
IF (Surro > 1)
IF (QStay2 = 1) THEN Skip to QStay4a
ENDIF
Q: QStay3a and QStay3b
Who should we contact in six months to check on how Insert Name from Sample File is doing?
QStay3a First Name: ____________________________________
QStay3b Last Name: ____________________________________
Ans_Len = 0
Ans_Len = Text Length of QStay3a
IF (Ans_Len = 0)
Re Ask QStay3a
ENDIF
Ans_Len = 0
Ans_Len = Text Length of QStay3b
IF (Ans_Len = 0)
Re Ask QStay3b
ENDIF
Q: QStay4a, QStay4b and QStay4c
Please give me home, work, and cell numbers if possible
QStay4a Home ____________________
QStay4b Work ____________________
Qstay4c Cell ____________________
INTERVIEWER: If there are no cell or work numbers enter 999-999-9999
Skip to QClose
Ans_Len = 0
Ans_Len = Text Length of QStay4a
IF (Ans_Len = 0)
Re Ask QStay4a
ENDIF
Ans_Len = 0
Ans_Len = Text Length of QStay4b
IF (Ans_Len = 0)
Re Ask QStay4b
ENDIF
Ans_Len = 0
Ans_Len = Text Length of QStay4c
IF (Ans_Len = 0)
Re Ask QStay4c
ENDIF
IF (PrxCall = 0)
IF (QPhyA_1 = 1) THEN Skip to QPhyA_2
ENDIF
Skip to QClose
Continuation of Physical Activity Module Questions
Q: QPhyA_2 Asked only if response to QPhyA_1 is “Yes” , if QPhyA_1 = “No” Skip to Close
Since you are able to be active, we'd like to invite you to help us further understand the relationship between physical activity and stroke by wearing a very small, lightweight physical activity monitor for one week. It doesn't matter what your current physical activity level is.
If you say "yes", an activity monitor will be mailed to you within the next day or so. The activity monitor includes a time-sensitive recording device with a limited charge on it so it is important that you begin wearing the device within a day or so of receiving it. Wear it for seven consecutive days and keep a list of activities that you do during that time.
Is this something that you could and would be interested in doing now?
1. Yes
2. Not at this time, but potentially later
3. No
INTERVIEWER - IF PARTICIPANT SAYS NO, THEN SAY "NO PROBLEM".
IF (QPhyA_2 = 1) PA_Flag = 1
IF (QPhyA_2 = 2) PA_Flag = 0
IF (QPhyA_2 = 3) PA_Flag = 1
Proceed to next question, QPhyA_2a
Q: QPhyA_2a
INTERVIEWER: Please enter any additional comments the respondent volunteered regarding the Physical Activity question. Enter NONE if the respondent had no comments at all.
Ans_Len = 0
Ans_Len = Text Length of QPhyA_2a
IF (Ans_Len = 0)
Re Ask QPhyA_2a
ENDIF
IF (QPhyA_2 = 1) THEN Skip to QPhyA_3
IF (QPhyA_2 1)
Skip to QClose
ENDIF
Q: QPhyA_3
PhyA.3 Asked only if response to QPhyA_2 is Yes, If QPhyA_2 = No, Skip to Close
Thank you for agreeing to participate. A consent form, the activity monitor, a recording sheet, and instructions will be sent to you in the next few days. Once you receive the package, simply follow the
instructions, or call the REGARDS toll free telephone number if you need any help. Once you have finished wearing the monitor for 7 days, return the materials to us in the pre-stamped envelope.
INTERVIEWER - PRESS '1' KEY TO CONTINUE.
Conclusion and Additional Notes
Q: QClose and QClose1
Thank you again for participating in this important research project. I appreciate the time you've spent on the phone with me today on this important project.
INTERVIEWER: Please enter your i.d number ###
Please enter your station number ##
CallLen = Time difference between CallTime and System Time
IF (CallLen < 0)
CallLen = 0
ENDIF
IF (CallLen > 9999)
CallLen = 9999
ENDIF
FUDate = System Date
EndDte = System Date
DISPOS = 36
Q: SpAtt
INTERVIEWER: Please enter any additional comments the respondent volunteered regarding the study including the original survey, in home exam, paper surveys they were asked to fill out and receipt of their check. Also include any comments regarding the cognitive tests, additional medical conditions, or comments in general.
These comments are very important and will be used by the team recovering medical records and the group analyzing the cognitive testing results. Please be accurate and thorough, but as brief as possible.
Enter NONE if you have no comments at all.
Ans_Len = 0
Ans_Len = Text Length of SpAtt
IF (Ans_Len = 0)
Re Ask SpAtt
ENDIF
Q: Finish
THIS CONCLUDES THE INTERVIEW
IF (DISPOS = 36)
End Call
ENDIF
IF (Sorry5a = 1)
DISPOS = 72
End Call
ENDIF
IF (Sorry15a = 1)
DISPOS = 75
End Call
ENDIF
IF (Sorry15a = 1)
DISPOS = 75
End Call
ENDIF
IF (QDead1 = 99990101)
DISPOS = 72
End Call
ENDIF
................
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