Appendix C

Form Approved

Resident Name: __________________________
Staff Name:________________________

OMB No. 0935-XXXX
Exp. Date XX/XX/2010

(Black out names after completion of ID check)

Collaborative Studies of Long-Term Care:
Collaborative Studies of Long-Term Care:
Falls Prevention Program in Assisted Living
Screening for Mental Well-Being
inC.
Assisted
Living
Staff Interview
(STF)
B. Staff Interview
7-31-2007
(STF)

Facility ID:

Resident ID:

Staff ID:

Interviewer ID:
Date
completed:
M

M

D

D

Y

Y

Developed / adapted for the Collaborative Studies of Long-Term Care
Cecil G. Sheps Center for Health Services Research
University of North Carolina at Chapel Hill
Do not use without permission

Public reporting burden for this collection of information is estimated to average 10 minutes per response, the
estimated time required to complete the survey. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance
Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036,
Rockville, MD 20850.

Staff Information
1. What is your job title at this facility?

2. How long have you been in this current position?

3. How long have you worked at this facility?
4. What is your highest level of education completed?

…1 Direct care staff
…2 Supervisor
…1 Other (specify)________________________
___ ___ years ___ ___months

___ ___ years ___ ___months

…1 Junior High or Middle School
…2 Some high school
…3 High school grad or GED
…3 2-year college or associate’s degree
…4 Some college (no degree)
…5 4-year college degree or higher

5a. Which of the following certifications or licensures do you hold?
Check all that apply:
1. RN

…0 No …1 Yes

2. LPN

…0 No …1 Yes

3. CNA or Certified Personal Care Assistant

…0 No …1 Yes

4. Medication assistant

…0 No …1 Yes

6. What is your sex? [DO NOT ASK]
7. What year were you born?

8. Is English your first language?

…1 Male

…2

Female

___ ___ ___ ___
…0 No …1 Yes
If NO, what is:____________________]

9. Are you Hispanic or Latino/Latina?
[code 7 for don’t know; 8 for refusal]

10. What is your race? Please select one or more?
[record all that the respondent identifies with;
code 7 for don’t know; 8 for refusal]

…0 No …1 Yes
…1 American Indian or Alaska Native
…2 Asian
…3 Native Hawaiian or Other Pacific Islander
…4 Black or African American
…5 White

2