4 Interview

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

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OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Informant Interview Questionnaire

ID NUMBER:

FORM CODE: IFE VERSION: A 9/11/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Month Day Year

0c. Event ID:

INSTRUCTIONS: The Informant Interview Form is completed for each informant for an out-of-hospital death as determined by the HCHS/SOL Event Investigation Summary. Event ID must be entered above, as described in the document, "General Instructions For Completing Paper Forms". Informant Number should be determined from the Event Investigation Summary Form. For "multiple choice" and "yes/no" type questions, circle the letter corresponding to the most appropriate response. If a letter is circle incorrectly, mark through it with an "X" and circle the correct response.

INFORMANT INTERVIEW TRACING INFORMATION

DECEDENT

Name: ________________________________________________________________________________

Address: ________________________________________________________________________________

________________________________________________________________________________

________________________________________________ _____________ ________________

City State Zip Code

Date of death: / / Age: ______ years

mm dd yyyy

Place of death: ___________________________________________________________________________

INFORMANT

Name: ________________________________________________________________________________

Address: ________________________________________________________________________________

________________________________________________________________________________

________________________________________________ _____________ ________________

City State Zip Code

Telephone: ( _ ) _- ______

Relationship to the deceased: ________________________________________________________________

RECORD OF CALLS
Day of Week	Date	Time	Notes	Code*	Int
S M T W R F S	MM/DD/YYY	A P
S M T W R F S	MM/DD/YYY	A P
S M T W R F S	MM/DD/YYY	A P
S M T W R F S	MM/DD/YYY	A P
S M T W R F S	MM/DD/YYY	A P
S M T W R F S	MM/DD/YYY	A P
S M T W R F S	MM/DD/YYY	A P
S M T W R F S	MM/DD/YYY	A P
S M T W R F S	MM/DD/YYY	A P
S M T W R F S	MM/DD/YYY	A P
S M T W R F S	MM/DD/YYY	A P
* RESULT CODES (CIRCLE THE FINAL SCREENING RESULT CODE) 1 Complete 5 Informant away or can't be found 2 Partially complete 6 Language barrier 3 Unknowledgable 7 No one home 4 Refusal 9 Other (specify in Notes)

INFORMANT INTERVIEW FORM (IFIC 1 of 16)

A. HISTORY 1. Before we get started could you please tell me what was your relationship to the deceased? {Respondent was deceased's} Spouse .....…… S Parent ...…...... P Daughter/Son ... C Other relative .. R Friend .…........ F Workmate ...... W Other .…......... O

"I'd like to ask you about ( )'s medical history. If you have any questions as we go along, please ask me." 2. First, think back to about one month before ( ) died. At that time, was he/she sick or ill, with his/her activities limited, or was he/she normally active for the most part? Sick/ill/limited activities .... R Normally Active ................ N Unknown ..................….... U

INFORMANT INTERVIEW FORM (IFIC 2 of 16)

3. Was ( ) being cared for at a nursing home, or at another place at the time of death? Yes, nursing home ......…. R Yes, at home ...........……. H Yes, assisted living ..…..... A Yes, Hospice facility ..…. F Go to Item 5 Yes, other .............……... O No ....................……….... N Unknown .............…….... U 4. Could you tell me the name and location of the nursing home? Specify Name, City, State Yes ...... Y Skip Name, City, State No ....... N [Place Name, City, State in notelog] Name _____________________________ _____________________________ City _____________________________ State _____________________________

5. Was ( ) hospitalized within the four weeks prior to death? Yes ....... Y Go to Item 9, No ........ N 3 Unknown ... U 6. What was the reason for hospitalization? {Circle (Y), (N), or (U) for each. Probe if not offered.} If no or Yes No Unknown unknown, go a. Heart attack to Item 9 or chest pain Y N U b. Heart surgery Y N U c. Other Y N U

INFORMANT INTERVIEW FORM (IFIC 3 of 16)

7. What was the date of the hospital admission? Month Day Year 8. Could you tell me the name and location of the hospital? Specify Name, City, State Yes .….. Y Skip Name, City, State No ..…... N [Place Name, City, State in notelog] Name ____________________________ ____________________________ City ____________________________ State ____________________________ 9. Was ( ) seen by a physician anytime in the last four weeks prior to death? Yes ....……. Y No ......…… N Go to Item 11 Unknown ... U

10. Could you tell me the name and address of this physician? Specify Name, City, State Yes ...... Y Skip Name, City, State No ....... N [Place Name, City, State in notelog] Name _____________________________ _____________________________ City _____________________________ State _____________________________ 11. Could you tell me the name and address of ( )'s usual physician? (If same as Q10 record as "same.") Specify Name, City, State Yes ...... Y Skip Name, City, State No ....... N [Place Name, City, State in notelog] Name ______________________________ ______________________________ City ______________________________ State ______________________________ 12. Before ( ) 's final illness, had he/she ever had pains in the chest from heart disease, for example angina pectoris? Yes ..……... Y Go to Item 14 No ...……... N Unknown ... U

INFORMANT INTERVIEW FORM (IFIC 4 of 16)

13. Did ( ) ever take nitroglycerin for this pain? Yes ...…….. Y No ....…….. N Unknown ... U 14. Did a doctor ever say that ( ) had a heart attack prior to his/her final illness? Yes ....….... Y No ......……. N Go to Item 16 Unknown ... U

15. Was ( ) hospitalized for a heart attack? Yes ...…..... Y No ....…….. N Unknown ... U 16. Did he/she ever have a coronary bypass operation, balloon angioplasty or some other operation or procedure to improve the circulation of blood to the heart? Yes ...…….. Y No ....…….. N Unknown ... U

INFORMANT INTERVIEW FORM (IFIC 5 of 16)

17. Did ( ) ever have any other heart disease or heart condition before his/her final illness? ┌────────Yes .....….. Y │ │ No .....……. N │ │ Unknown ... U │ └──If yes, specify: _______________________________ ___________________________________________ ___________________________________________ 18. Did ( ) ever have a stroke? Yes ....…... Y No .....…... N Go to Item 19b Unknown ... U

19.a. Did he/she have a stroke within four weeks of his/her final illness? Yes .....…… Y No .....……. N Unknown ... U b. Did he/she have a history of cigarette smoking? Yes .....…… Y No ......…… N Unknown ... U c. Did he/she have a history of diabetes? Yes ...…….. Y No ....…….. N Unknown ... U

INFORMANT INTERVIEW FORM (IFIC 6 of 16)

B. CIRCUMSTANCES SURROUNDING DEATH

Attach Event ID Label Here

"The next few questions are concerned with the circumstances surrounding ( )'s death."

20. Could you please tell me what you can of ( )'s general health, on the day he/she died, and of the death

itself?

┌───────Yes ..…….. Y

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│ No .....…… N

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│ Unknown ... U

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└───────Specify: _______________________________________________________________________________

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INFORMANT INTERVIEW FORM (IFIC 7 of 16)

"The next set of questions may go over some of what you have already told me. Although it may seem repetitious, I must ask these questions for consistency of information." 21. Were you present when ( ) died? Go to Item 25, Screen 8 Yes ....... Y No ……. N 22. Did anyone see or hear ( ) when he/she died? Go to Item 25, Screen 8 Yes ..……... Y No .....……. N Unknown ... U

23. Was anyone close enough to hear ( ) if he/she had called out? Go to Item 25, Screen 8 Yes ....... Y No ........ N Unknown ... U 24. How long after ( ) was last known to be alive was he/she found dead? {Enter the shortest interval known to be true} 5 minutes or less .…... A 1 hour or less .....….. B 24 hours or less ...….. C More than 24 hours .... D Unknown ............…... U

INFORMANT INTERVIEW FORM (IFIC 8 of 16)

25. Where was ( ) when he/she died? Home (or other private residence) ........ A Work .................................…………... B In a public building .................………. C On a bus or public transportation .….... D On the street .........................………… E In an automobile ...................………... F In a nursing home ..................……..... G In an emergency room ...............…..... H In an ambulance ...................……….... I In the hospital ......................…………. J Other ..............................…………..... O Unknown ........................………......... U

C. SYMPTOMS "The next few questions are concerned with any symptoms ( ) may have had shortly before he/she died." 26. Did ( ) experience pain or discomfort in his/her chest, left arm, or shoulder or jaw either just before death or within 3 days (72 hours) of death? Yes ...…….. Y Go to Item 30 No ....……. N Go to Item 30, Screen 10 Unknown ... U

INFORMANT INTERVIEW FORM (IFIC 9 of 16)

"The next set of questions deal specifically with the last episode of ( )'s pain or discomfort. The last episode is defined as starting at the time ( ) noticed discomfort that caused him/her to stop or change what he/she was doing." 27. Did ( )'s last episode of pain or discomfort specifically involve the chest? Yes ...…….. Y No .....……. N Unknown ... U

28. Did he/she take nitroglycerin because of this last episode of pain or discomfort? Yes .....…… Y No ......…… N Unknown ... U

INFORMANT INTERVIEW FORM (IFIC 10 of 16)

29. How long was it from the beginning of ( )'s last episode of pain or discomfort to the time he/she stopped breathing on his/her own? {Circle the shortest interval known to be true} 5 minutes or less .....……... A 10 minutes or less .....……. B 1 hour or less .........……… C 24 hours or less ........……. D More than 24 hours ......…. E Unknown .............……...... U

30. Within 3 days of death or just before ( ) died, did any of the following symptoms begin for the first time? {Circle (Y), (N) or (U) for each} Yes No Unknown a. Shortness of breath Y N U b. Dizziness Y N U c. Palpitations (pounding Y N U in the chest) d. Marked or increased Y N U fatigue,tiredness, or weakness e. Headache Y N U f. Sweating Y N U g. Paralysis Y N U h. Loss of speech Y N U i. Attack of indigestion Y N U or nausea or vomiting j. Other Y N U If Other, specify:_________________________________ _______________________________________________ _______________________________________________

INFORMANT INTERVIEW FORM (IFIC 11 of 16)

D. EMERGENCY MEDICAL CARE " The next few questions are concerned with emergency medical care ( ) may have received prior to or at the time of death. You may have already given this information in an answer to an earlier question. Since it is important to obtain information specifically on emergency medical care, I hope you don't mind if these questions seem repetitive."

31. Was a physician, ambulance, or other emergency medical team called? Yes ....…… . Y No .....……. N Go to Item 35 Unknown ... U 32. Was (the physician, ambulance, or EMS team) called because of symptoms ( ) was having or after he/she was already dead? Symptoms ....... S Go to Item 35 Already Dead ... D

INFORMANT INTERVIEW FORM (IFIC 12 of 16)

33. How long was it from the time the last episode of symptoms started to the time that medical assistance was called for? {Circle the shortest interval known to be true} 5 minutes or less ....…. A 10 minutes or less ...... B 1 hour or less .......….. C 6 hours or less .....….. D 24 hours or less ...….. E More than 24 hours .... F Unknown ..............…. U

34. How long was it from the time that medical care was called to the time when it arrived? {Circle the shortest interval known to be true} 5 minutes or less .....…… A 10 minutes or less .....….. B 1 hour or less ........…….. C 6 hours or less ........……. D 24 hours or less .......…… E More than 24 hours .....… F Unknown ................…… U Did not come ..........…… X

INFORMANT INTERVIEW FORM (IFIC 13 of 16)

35. Were resuscitation measures, such as closed chest massage or CPR, attempted at the time? Yes ...…….. Y Go to Item 38 Screen 14 No ...…..…. N Unknown .... U 36. Who started the resuscitation or CPR? Bystander, non‑health professional ..... A M.D. .......................…………….......... B Ambulance attendant, paramedic, or other health professional ..……...... C Fireman or policeman .……................. D Other ...........................……………..... O Unknown .............................………… U

37. Where was resuscitation or CPR started? Home (or other private residence) ...........… A Work .........................…….. B Public place ................…… C Ambulance or other emergency vehicle .... D Go to Item 39 Emergency room ................. E Hospital ......……................. F Other ....................……........ O Unknown .......................…. U

INFORMANT INTERVIEW FORM (IFIC 14 of 16)

38. Was ( ) taken to a hospital? Yes ....…….. Y No ......……. N Go to Item 40 Unknown .... U 39. Could you tell me the name and location of this hospital? Specify Name, City, State Yes ...... Y Skip Name, City, State No ....... N [Place Name, City, State in notelog] Name _______________________________ City __________________________ State __________________________

E. ADDITIONAL INFORMATION 40. Is there someone else whom we could contact, who might know more about the circumstances surrounding ( )'s death or his/her usual state of health? Yes ....……. Y Read "final script" then go to Item 43, Screen 15 No ......…… N Unknown .... U 41. Could you tell me the name, address, and telephone number of this person? Specify Name, City, State, Phone Yes .... Y Skip Name, City, State, Phone No ..... N [Place Name, City, State, Phone in notelog] Name ___________________________________ City ___________________________________ State ___________________________________ Phone ___________________________________

INFORMANT INTERVIEW FORM (IFIC 15 of 16)

42. How was he/she related to the deceased? Spouse ..........…… S Parent ..........……. P Daughter/Son .….. C Other relative …... R Friend ..........……. F Workmate .....…... W Other ..........…….. O [Read "final script",then go to Item 43]

F. RELIABILITY {To be completed immediately after the interview} 43. Did the respondent frequently contradict himself/herself or give information that he/she would have no way of knowing? ...... Yes Y No N 44. Did the respondent seem to be reluctant to answer questions and thus might not have given all the information the interviewer would wish to know? ................. Yes Y No N

INFORMANT INTERVIEW FORM (IFIC 16 of 16)

45. On the basis of these questions, give your rating of reliability of the interview. ......... Good G Fair F Poor P 46. Would you like to add other details concerning the quality of the interview? Yes ....... Y No ........ N If Yes, specify: ____________________________ _________________________________________ _________________________________________ 47. Informant agreed to provide consent to gather further information? Yes ............…… Y No ............…….. N Not applicable ... A If Yes, specify _________________________________ ______________________________________________ ______________________________________________

G. ADMINISTRATIVE INFORMATION 48. Date of data collection: Month Day Year 49. Method of data collection: Computer ....... C Paper Form ..... P 5 0. Code number of the person completing this form. ....….. 5 1. Result Code: