6 survey

OMB#: 0925-0584

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 45 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 (0925-0584). Do not return the completed form to this address.

H

OMB#: 0925-0584

Exp. X/XX/XXXX

CHS/SOL Follow-up Interview Form

C

ontact Year 3

ID NUMBER:

FORM CODE: AFE VERSION: A 11/03/08

Contact Occasion

0

1

SEQ #

Acrostic:

Administrative Information

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

Instructions: See the detailed QxQ instructions for completion of the Annual Follow-up form.

INTRODUCTION

“Hello, my name is (interviewer name), and I am calling to follow up with (participant name) about the Hispanic Community Health Study / Study of Latinos (HCHS/SOL), a health study in which s/he is currently enrolled. Is s/he available?”

N o When would it be convenient to call back? ..............Thank you. I will call again.

Y es Hello, (participant name), this is (interviewer name) with the Hispanic Community Health Study / Study of Latinos. I’m calling to see how you have been since our last telephone interview with you and to update our HCHS/SOL records. Do you have a few minutes to speak on the phone?

No When would it be convenient to call back?.........Thank you. I will call again.

Yes We’d like to gather information about your general health and about specific medical conditions that you may have had since your visit to our clinic. I will ask you some questions about your health since our last telephone interview with you (date of last follow up phone interview). I want you to focus on what happened from (date of last follow up phone interview) until today.

1. Participant status:

Contacted and alive 0 Go to item 2 of this form

Contacted and refused interview 1 Go to Contact tracking, item 32

Not contacted, reported alive 2 Go to Contact tracking item 32

Not contacted, reported deceased 3 See Death investigation protocol

Unknown 4 Go to Contact tracking item 32

GENERAL HEALTH

2. Since our last telephone interview with you on (date), would you say, in general, your health is Excellent, Very good, Good, Fair, Poor, or Unsure? (read all response categories except Unsure)

Excellent 0 Very good 1 Good 2 Fair 3 Poor 4

HOSPITALIZED AND EMERGENCY DEPARTMENT EVENTS

“The following set of questions are about any hospital stays or visits to emergency rooms you may have had since our last telephone interview with you on (date).”

3. Since our last telephone interview with you on (date), have you at any time been admitted to a hospital?

No 0 Go to item 4

Yes 1

Unsure 2 Go to item 4

3a. What was the reason of this hospital stay? (do not read choices)

Myocardial infarction, heart attack 0

Angina, chest pain 1

Heart failure 2

Stroke or TIA 3

Peripheral vascular disease 4

Venous thrombosis or pulmonary embolism 5

COPD 6

Asthma 7

Other: 8 Specify: _______________

3b. What was the date of this hospitalization: / /

3c. What was the name of the hospital: _________________ Facility code:

3d. What was the address of this hospital: _________________ ; Don’t know 0

3e. Were you admitted to a hospital at any another time since your HCHS/SOL clinic visit?

No 0 Go to item 4

Yes 1 Data saved and screen refreshes to 3a.

4. Since our last telephone interview with you on (date), were you seen in an emergency room but not admitted to the hospital?

No 0 Go to item 5

Yes 1

Unsure 2 Go to item 5

4a. What was the reason of going to the emergency room? (do not read choices)

Myocardial infarction, heart attack 0

Angina, chest pain 1

Heart failure 2

Stroke or TIA 3

Peripheral vascular disease 4

Venous thrombosis or pulmonary embolism 5

COPD 6

Asthma 7

Other: 8 Specify: _______________

4b. What was the date of this visit: / /

4c. What was the name of the emergency room: _________ Facility code:

4d. What was the address of the emergency room: ____________ ; Don’t know 0

4e. Were you seen in an emergency room on any other occasion since your HCHS/SOL clinic visit?

No 0 Go to item 5

Yes 1 Data saved and screen refreshes to 4a.

OUT-PATIENT SELF-REPORTED CONDITIONS

“Now I would like to ask you about conditions that may have resulted in you seeing a doctor or health profession at a clinic or doctor’s office, but not actually being admitted to the hospital or visiting an emergency department/room.”

5. Since our last telephone interview with you (date), has a doctor or health professional told you that you had emphysema, chronic bronchitis, or chronic obstructive pulmonary disease (COPD)? This does not include doctor’s visits for tuberculosis or TB.

No 0 Go to item 6

Yes 1

Unsure 2 Go to item 6

5a. Did your doctor or healthcare professional order any of the following tests to help make the diagnosis?

i. Breathing test or pulmonary function test?

No 0 Yes 1 Unsure 2

ii. Chest X-ray:

No 0 Yes 1 Unsure 2

iii. CT Scan of your chest:

No 0 Yes 1 Unsure 2

5b. Were you told by a doctor or health professional that you were having an attack, worsening, or an exacerbation of your emphysema, chronic obstructive pulmonary disease (COPD), or bronchitis?

No 0 Go to item 6

Yes 1

Unsure 2 Go to item 6

i. Did the doctor or health care professional prescribe a change in your medication, such as increasing your inhalers, oxygen or pills for your lungs or prescribing a steroid pill for your lungs?

No 0 Yes 1 Unsure 2

6. Since our last telephone interview with you on (date), has a doctor or health professional told you that you had asthma?

No 0 Go to item 7

Yes 1

Unsure 2 Go to item 7

6a. Did your doctor or healthcare professional order any of the following tests to help make the diagnosis?

i. Breathing test or pulmonary function test?

No 0 Yes 1 Unsure 2

ii. Chest X-ray:

No 0 Yes 1 Unsure 2

iii. CT Scan of your chest:

No 0 Yes 1 Unsure 2

6b. Were you told by a doctor or health professional that you were having an attack, worsening, or an exacerbation of your asthma?

No 0 Go to item 7

Yes 1

Unsure 2 Go to item 7

i. Did the doctor or health care professional prescribe a change in your medication, such as increasing your inhalers, oxygen or pills for your lungs or prescribing a steroid pill for your lungs?

No 0 Yes 1 Unsure 2

7. Since our last telephone interview with you on (date), has a doctor or health professional told you that you had atrial fibrillation?

No 0

Yes 1

Unsure 2

8. Since our last telephone interview with you on (date), has a doctor or health professional told you that you had heart failure?

No 0

Yes 1

Unsure 2

NO # 9 (will renumber)

10. Has a doctor ever said that you have a blood clot in your leg vein or lung requiring blood thinning medicine?

No 0

Yes 1

11. Since your HCHS/SOL clinic visit on (date), has a doctor or health professional told you that you had diabetes or high sugar in the blood?

No 0 Go to item 12

Yes 1

Unsure 2 Go to item 12

11a. Did the doctor recommend any new or different treatments?

No 0 Go to item 12

Yes 1

Unsure 2 Go to item 12

i.What treatment was recommended?

(Do not prompt for specific response. Mark all that apply)

Pills 0

Insulin Alone 1

Insulin and pills 2

Referred for eye exam 3

Advice to change diet 4

Advice to stop smoking 5

Advice to increase excercise 6

Other: 7 Specify: _______

12. Since your HCHS/SOL clinic visit on (date), has a doctor or health professional told you that you had high blood pressure or hypertension?

No 0 Go to item 13

Yes 1

Unsure 2 Go to item 13

12a. Did the doctor recommend any new or different treatments?

No 0 Go to item 13

Yes 1

Unsure 2 Go to item 13

i. What treatment was recommended?

(Do not prompt for specific response. Mark all that apply)

Start new medicine 0

Increase dose of existing medicine 1

Advice to lose weight 2

Advice to change diet 3

Advice to stop smoking 4

Advice to increase exercise 5

Other 6 specify ________________

13. Since your HCHS/SOL clinic visit on (date), has a doctor or health professional told you that you had high blood cholesterol?

No 0 Go to item 14

Yes 1

Unsure 2 Go to item 14

13a. Did the doctor recommend any new or different treatments?

No 0 Go to item 14

Yes 1

Unsure 2 Go to item 14

i. What treatment was recommended?

(Do not prompt for specific response. Mark all that apply)

Start new medicine 0

Increase dose of existing medicine 1

Advice to lose weight 2

Advice to change diet 3

Advice to stop smoking 4

Advice to increase exercise 5

Other 6 specify ________________

SELF REPORT OF SIGNS AND SYMPTOMS

“Now I would like to ask you about symptoms you may have had since our last telephone interview with you.”

14. Since our last telephone interview with you on (date), do you often have swelling in your feet or ankles at the end of the day?

No 0

Yes 1

Unsure 2

15. Since our last telephone interview with you on (date), are there times when you wake up at night because of difficulty breathing?

No 0

Yes 1

Unsure 2

16. Since our last telephone interview with you on (date), are there times when you have trouble breathing or shortness of breath when walking at ordinary pace on level ground?

No 0

Yes 1

Unsure 2

17. Since our last telephone interview with you on (date), are there times when you stop for breath when walking at your own pace on level ground?

No 0

Yes 1

Unsure 2

17a. Do you ever have to stop for breath after walking about 100 yards (or after a few minutes) on level ground?

No 0

Yes 1

Does not apply 2

18. Since our last telephone interview with you on (date), are there times when you have difficulty breathing when you are not walking or active?

No 0

Yes 1

Unsure 2

19. Since our last telephone interview with you on (date), have you had a cough on most days or nights of the week during at least 3 months in a row?

No 0

Yes 1

Unsure 2

20. Since our last telephone interview with you on (date), d have you brought up phlegm from your chest on most days or nights of the week during at least 3 months in a row?

No 0

Yes 1

Unsure 2

21. Since our last telephone interview with you on (date), have you had wheezing or whistling in your chest?

No 0 Go to item 22

Yes 1

Unsure 2 Go to item 22

21a. Have you had an attack of wheezing or whistling in the chest that has made you feel short of breath?

Yes 0 No 1 Unsure 2

NEUROCOGNITIVE FUNCTION

23. “Now I will ask you some questions and give you a couple of short tasks that will require memory and concentration. First, I will ask you some questions that ask you to use your memory. I am going to say three words. Please wait until I have said 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.” Please repeat these words for me: BLUE - PEAR - SOFA.

23a. Number of presentations necessary for the participant to repeat the words:

Presentation 0

Presentations 1

Presentations 2

Incorrect 3

Not Attempted/Disability 4

Not Attempted/Refusal 5

Not Not attempted /

Correct Incorrect attempted Refused

(0) (1) (2) (3)

23b. What year is this?

23c. What month is this?

23d. What is the day of the week?

23e. Now, what were those three

words I asked you to remember?

i. Blue

ii. Pear

iii. Sofa

24. “Next, I am going to read a list of words. I want you to listen carefully and try to remember the words as I read them. When I stop, I would like you to recall as many of the words as you can. You may know some of the words by a different name, but I want you to try to remember the exact words I say. You will not be able to remember all of the words so just do the best you can. You do not have to recall the words in the same order that I read them. The words are…”

After reading the list, say: Now tell me all of the words you can remember.

After the participant's response, provide one prompt for additional words before going to the next trial.

Mark all words either 0 if recalled or 1 if not recalled.

Words a. (Trial 1) b. (Trial 2) c. (Trial 3) Distracter Words d. (Trial 5)

i. Cabbage Eggs Cabbage

ii. Ladle Pot Ladle

iii. Coffee Milk Coffee

iv. Beets Cherries Beets

v. Dictionary Bowl Dictionary

vi. Cocoa Cheese Cocoa

vii. Beans Lettuce Beans

viii. Strainer Spoon Strainer

ix. Oranges Water Oranges

x. Corn Fish Corn

xi. Newspaper Pen Newspaper

xii. Juice Peach Juice

xiii. Asparagus Cookies Asparagus

xiv. Pan Notebook Pan

xv. Tea Onions Tea

(Trial 2)

“I am going to read the same list of words to you again. I want you to try to remember as many of the words as you can, including those you have recalled before. When I stop I want you to tell me as many of the words as you can remember.”

After reading the list say: “Now tell me all of the words you can remember.”

After the participant's response, provide one prompt for additional words before going to the next trial.

(Trial 3)

“I will read the same words once more. Listen carefully and when I finish tell me as many of the words as you can remember.”

After reading the list say: “Now tell me all of the words you can remember.”

After the participant's response, provide one prompt for additional words before going to the next trial.

Distracter

“I am going to read you a different list of words. This time, I want you to repeat each word out loud after I read it.”

(Trial 5) Immediately after the participant repeats the last word from the distracter list say: “Now, I want you to tell me as many of the words from the first list that I read to you as you can remember.”

Do not repeat the first list. After the participant's response, provide one prompt for additional words.

25. “On this next task, I will say a letter. Then I want you to tell me as many different words as you can think of, as fast as you can, that begin with that letter. You may tell me words in English or Spanish so long as they are different words. Leave out names of people, names of places, and numbers. So, if I were to say "T," you would not say words like 'Thomas,' 'Texas,' or the number 'Ten.' But you could say words like ‘table,' 'take,' or 'turtle.'”

“Also, do not use the same word again with a different ending. For example, if you said 'take,' then you could not say 'takes,' or 'taking.' These would all be considered the same word.”

“Are you ready?” Pause

Allow one minute for each letter (F and A).

(If the participant discontinues before the end of the minute, encourage him/her to try to think of more words. If there is a silence of 15 seconds, repeat the basic instructions and the letter. Inadmissible words include proper nouns, variations, plurals, and repetitions)

25a. “Tell me as many words as you can that start with the letter F. I will tell you when to stop. Ready, go.” (Begin timing)

Record the number of words:

25b. “That was great. Now, tell me as many words as you can that start with the letter A. I will tell you when to stop. Ready, go.” (Begin timing)

Record the number of words:

MEDICATIONS

“Now I would like to ask about the prescription medications you currently use. Can I ask you to bring all the prescription medications you are taking to the telephone?”

26. (do not ask) Does the participant have medications to report?

No 0 Skip to item 28

Yes 1

Participant refused 2 Skip to item 28

27. Please read the names of all the medications prescribed by a doctor. This includes pills, liquid medications, skin patches, inhalers, and injections. Please do not include over the counter medications unless prescribed by a doctor. (If asked, currently taking applies to medications taken in the past two weeks.)

a. _____________________________

b. _____________________________

c. _____________________________

d. _____________________________

“Next, I would like to ask you about your regular use of aspirin. By regular use, I mean taking aspirin every other day or more frequently.”

28. Are you NOW taking aspirin, or a medicine containing aspirin, on a regular basis? This does NOT include Tylenol or Advil or Motrin, ibuprofen.

No 0 Skip to item 29

Yes 1

Participant refused 2 Skip to item 29

28a. What dose do you take?

81 mg per day of aspirin 0

325 mg per day of aspirin 1

Other 2 specify: _________________

OTHER ITEMS

“Next I would like to ask you some other final questions.”

29. Which of the following best describes your current cigarette smoking status?

Never smoker 0 Skip to item 31

Former smoker, quit more than 1 year ago 1

Former smoker, quit less than 1 year ago 2

Current smoker 3

Don’t know 4

30. Have you smoked cigarettes during the last 30 days?

No 0 Skip to item 31

Yes 1

Participant refused 2 Skip to item 31

30a. On average, about how many cigarettes a day do you smoke?

31. Please tell me which of the following best describes your marital status?

Married 0

Widowed 1

Divorced 2

Separated 3

Single 4

Living with partner 5

“Thank you so much for answering these questions. We greatly appreciate your participation in the HCHS/SOL study. Should you have any questions, please feel free to call us at the clinic at (telephone number). Before we hang up, I’d just like to make sure our records are up to date. Could you please tell me if the following information I have is still correct?”

PARTICIPANT TRACKING

32. Current tracking information from HCHS/SOL database is shown below. Record tracking information changes reported during the interview in the space provided.

a. Participant Tracking: Changes:

Current data to be shown here Record changes here

b. Contacts/proxies: Changes:

Current data to be shown here Record changes here

c. Health care providers: Changes:

Current data to be shown here Record changes here