Form #1 Form #1 Telephone Verification Script

Assisted Living

Provider Information Tool

For Consumer Education

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Script for Verification of ALF Mailing Address and

Name of Administrator/Executive Director

Good morning/afternoon. My name is _______________ and I am calling from the University of North Carolina on behalf of the U.S. Agency for Healthcare Research and Quality (AHRQ).

We are conducting research for AHRQ and would like to mail some important materials to the Administrator/Executive Director of your assisted living community.

As such, I would like to verify the mailing address of the community and the name of the Administrator/Executive Director.

Please know that provision of this information is completely voluntary.

[BASED UPON RESPONDENT’S INITIAL TELEPHONE GREETING, VERIFY (WITHOUT ASKING THE RESPONDENT) THE NAME OF THE FACILITY AND RECORD ANY FACILITY NAME CHANGES BELOW:]

________________________________________________________________

Is the mailing address of your community ­­­­­________ [READ THE FACILITY ADDRESS AS PRINTED BELOW AND RECORD ANY CHANGES]:

Preprinted facility name, address and telephone number

Abt SRBI ID # XX-XXX

What is the name of your current Administrator/Executive Director?

__________________________________________________________________

T

RESULT CODE – CIRCLE ALL THAT APPLY:

1. No changes to facility name and address

2. Facility name changed

3. Facility address changed

4. Refused to verify address

5. Refused to provide name of administer

6. Out-of-business/Could not locate the facility

hank you very much. I appreciate your help with this effort.”

Public reporting burden for this collection of information is estimated to average 1 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.