Form 3 Interview

The Hispanic Community Health Study/ Study of Latinos (HCHS/SOL)(NHLBI)

Interview Form Contact Yr3_English

Participants Follow-up Year 3 to 6

OMB: 0925-0584

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OMB#: 0925-0584

Exp. n/nn/nnnn





H

Public reporting burden for this collection of information is estimated to average 15 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.

CHS/SOL Follow-up Interview Form

Contact Year 3


ID NUMBER:









FORM CODE: FE3

VERSION: A

Contact

Occasion

0

3

SEQ #

0

1



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 (SOL), a health study in which s/he is currently enrolled. Is s/he available?


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


Yes Hello, (participant name), this is (interviewer name) with the Hispanic Community Health Study / Study of Latinos (SOL). I’m calling to see how you have been since your last telephone interview and to update our 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 in the past year. I will ask you some questions about your health since the last telephone interview with you on (date of last follow-up call). I want you to focus on what happened from (date of last follow-up call) until today.

  1. [GHE section for data entry screens begins here]

  1. Participant status (choose one):

Participant contacted and alive, agrees to interview 1 Go to item 2

Participant contacted and refused interview 2 Go to Contact tracking, item 49

Designated respondent contacted, reported alive 3 Go to Hospitalizations, item 3

Other respondent contacted, reported alive 4 Go to Contact tracking, item 49

Not contacted, reported deceased 5 Continue to 1a, below

Unknown 9 Go to Contact tracking, item 49

1a. What was the date of death? / /

1b. What city, state, and country did the death occur? _______________________________

1c. Do you know if (insert decedent’s name) was hospitalized or visited an emergency room for any reason since (date of last time interviewed) and his/her death?

No 0 End interview

Yes 1 Record date and name of each hospitalization and/or ER visit. End interview after last event is reported.

GENERAL HEALTH

  1. Since our last telephone interview with you on (date), would you say, in general, your health is Excellent, Very good, Good, Fair, Poor,?

Excellent 1 Very good 2 Good 3 Fair 4 Poor 5


[HOE section for data entry screens begins here]

  1. HOSPITALIZED AND EMERGENCY ROOM EVENTS


“The following questions are about any hospitalizations or visits to an emergency room you may have had since our last telephone interview with you on (date).” [ Note: This section will repeat depending upon number of reported events ]

  1. Since our last telephone interview with you on (date), have you at any time been admitted to a hospital or seen in an emergency room?

No 0 Go to item 5

Yes 1

Unsure 9 Go to item 5

“The next few questions are about one event, if there were more than one we would like to talk about each one separately, let’s start with the first event since our last telephone interview with you on (date).”

  1. Was this visit to the emergency room only, a hospital admission only, or a visit to the emergency room that resulted in being admitted to the hospital?

Emergency Department (only) 1

Hospital Admission (only) 2

Both 3

Unsure 9

4a. What was the main reason for going to the (insert emergency room or hospital) that day?

[Check one and 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

Chronic Obstructive Pulmonary Disease, emphysema, or chronic bronchitis 6

Asthma 7

Other: Specify: _____ 8

4b. What was the date of this event? / /

4c. What is the name of the medical facility?

4d. What is the address of this medical facility?

(Leave blank if unknown)

4e. For clarification of our records, under what name is this record?

4e1. First Name:

4e2. Second Name:

4e3. Last Name:

4e4. Maternal Last Name:

4f. Were you admitted to a hospital or seen at an ER at any another time since your last telephone interview?

No 0 Go to item 5

Yes 1 (Line entry saved, screen refreshes to a new series at item 4)


[OPE section for data entry screens begins here]

  1. 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 room.”

  1. Since our last telephone interview with you on (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 9 Go to item 6

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

5a. Breathing test or pulmonary function test?

No 0 Yes 1 Unsure 9


5b. Chest X-ray:

No 0 Yes 1 Unsure 9


5c. CT Scan of your chest:

No 0 Yes 1 Unsure 9


5d. 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 chronic bronchitis?

No 0 Go to item 6

Yes 1

Unsure 9 Go to item 6

5e. 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 9

  1. 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 9 Go to item 7

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

6a. Breathing test or pulmonary function test

No 0 Yes 1 Unsure 9

6b. Chest X-ray

No 0 Yes 1 Unsure 9

6c. CT Scan of your chest

No 0 Yes 1 Unsure 9

6d. 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 9 Go to item 7


6e. 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 9

  1. Since our last telephone interview with you 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 8

Yes 1

Unsure 9 Go to item 8

7a. Did the doctor recommend any new or different treatments?

No 0 Go to item 8

Yes 1

Unsure 9 Go to item 8

7b.What treatment was recommended? (Do not prompt for specific response. Mark all that apply)

Pills

Insulin Alone

Insulin and pills

Referred for eye exam

Advice to change diet

Advice to stop smoking

Advice to increase exercise

Other Specify: ____________________________________

  1. Since our last telephone interview with you on (date), has a doctor or health professional told you that you had high blood pressure or hypertension?

No 0 Go to item 9

Yes 1

Unsure 9 Go to item 9

8a. Did the doctor recommend any new or different treatments?

No 0 Go to item 9

Yes 1

Unsure 9 Go to item 9

8b. What treatment was recommended? (Do not prompt for specific response. Mark all that apply)

Start new medicine

Increase dose of existing medicine

Advice to lose weight

Advice to change diet

Advice to stop smoking

Advice to increase exercise

Other Specify: _______________________________

  1. Since our last telephone interview with you on (date), has a doctor or health professional told you that you had high blood cholesterol?

No 0 Go to item 10

Yes 1

Unsure 9 Go to item 10

9a. Did the doctor recommend any new or different treatments?

No 0 Go to item 10

Yes 1

Unsure 9 Go to item 10

9b. What treatment was recommended? (Do not prompt for specific response. Mark all that apply.)

Start new medicine

Increase dose of existing medicine

Advice to lose weight

Advice to change diet

Advice to stop smoking

Advice to increase exercise

Other Specify: _________________________________

[EVE section for data entry screens begins here]

  1. SELF REPORT OF EVENTS SINCE BASELINE VISIT

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

  1. 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 9

  1. 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 9

  1. Since our last telephone interview with you on (date), has a doctor or health professional told you that you had a blood clot in your leg vein or lung requiring blood thinning medicine?

No 0 Yes 1 Unsure 9

  1. 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 9

  1. 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 9

  1. Since our last telephone interview with you on (date), are there times when you have been troubled by shortness of breath when hurrying on level ground or walking up a slight hill?

No 0 Yes 1 Unsure 9

  1. 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 9

  1. 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 9

  1. 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 9

  1. Since our last telephone interview with you on (date), 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 9

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

No 0 Go to item 21

Yes 1

Unsure 9 Go to item 21

20a. Have you had an attack of wheezing or whistling in the chest that has made you feel short of breath?

No 0 Yes 1 Unsure 9

  1. Since our last telephone interview with you on (date), has a doctor or health professional told you that you have sleep apnea?

No 0 Go to item 22

Yes 1

Unsure 9 Go to item 22

21a. Has your sleep apnea been treated with any of the following? (check all that apply)

Surgery

Use of a dental appliance during sleep (a device put in your mouth at night that moves the jaws open)

Use of oxygen during sleep

A pressure machine such as CPAP or BILEVEL?

  1. How often do you snore now?

Never 1

Rarely (1-2 nights a week) 2

Sometimes (3-5 nights a week) 3

Always or almost always (6-7 nights a week) 4

Don’t know 9


[MEE section for data entry screens begins here]

  1. MEDICATIONS

“Now I would like to ask about the prescription medications you currently use. By currently I mean in the past two weeks. Can you bring all these prescription medications to the telephone?”

  1. (Interviewer: Do not ask) Does the participant have medications to report?

No 0 Go to items 44

Yes 1

Participant refused 2 Go to items 44

Please read the names of all the medications prescribed by a doctor. This includes pills, liquid medications, skin patches, inhalers, injections and suppositories. Please do not include over the counter medications unless prescribed by a doctor. (If they ask what do we mean by ‘medications you are currently taking’, that means medications you have taken in the last 2 weeks.)


#

(a) Medication UPC / NDC

Medication name (b)


(c) Strength

(d) Units





(c) Strength

(d) Units






(c) Strength

(d) Units





(c) Strength

(d) Units





(c) Strength

(d) Units





(c) Strength

(d) Units





(c) Strength

(d) Units





(c) Strength

(d) Units





(c) Strength

(d) Units





(c) Strength

(d) Units


(c) Strength

(d) Units





(c) Strength

(d) Units





(c) Strength

(d) Units






(c) Strength

(d) Units





(c) Strength

(d) Units





(c) Strength

(d) Units





(c) Strength

(d) Units





(c) Strength

(d) Units





(c) Strength

(d) Units





(c) Strength

(d) Units




“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.”

  1. 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 Go to item 45

Yes 1

Unsure 9 Go to item 45


44a. What dose do you take?

81 mg per day of aspirin 0

325 mg per day of aspirin 1

Other 2 specify: _________________________________


Thank you so much for answering these questions. We greatly appreciate your participation in the SOL study. Now, I’d just like to make sure our records are up to date.


  1. PLACE OF BIRTH [CBE section for data entry screens begins here.]


Where were you born?

45. Country/Territory (Select location code from list)


46. State/Province



















47. Municipality



















48. City or Town



















  1. PARTICIPANT TRACKING [CIE section for data entry screens begins here.]

Interviewer: Current tracking information from SOL database is shown below. Record tracking information changes reported during the interview in the space provided.

“It is very important for this study to be able to reach you in the future. Although you provided your contact information at the time of your visit, in order to keep our records up to date please provide us with your current home address. All information you give us in strictly confidential and will not be shared with anyone else”.

  1. Current home address*

49.A.1. PO Box, Box &/or Route and Number
























49.B.1. Street Number Prefix









49.B.2. Street Number







49.B.2. Street Number






49.B.3. Street Number Suffix









49.C.1. Street Name Prefix









49.C.2. Street Name







49.C.2. Street Name



















49.C.3. Street Name Type








49.C.4. Street Name Suffix









49.D.1. Unit Type








49.D.2. Unit Type Identifier









49.D.3. Unit Subtype









49.D.4. Unit Subtype Identifier








49.E.1. Other







49.E.1. Other






49.F.1. City







49.F.1. City



















49.G.1. County







49.G.1. County






49.H.1. State






49.I.1. Country/Territory (Select code from list)







49.I.1. Country/Territory (Select code from list)






49.J.1. Zip Code






–

49.J.1. Zip Code





*IF THE PARTICIPANT LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE HOME LOCATION IN 49.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 49.E.1.


IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER IT IN 49.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE ACTUAL HOME LOCATION IN 49.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 49.E.1.

  1. Primary Phone Number: () -

  2. What is the best time of day to reach you at this number?

Morning 1

Afternoon 2

Evening 3

  1. Secondary Phone Number: () -

  2. What is the best time of day to reach you at this number?

Morning 1

Afternoon 2

Evening 3

Local Contact 1 (primary contact)

54 a. Title: b. First Name:

c. Middle/Second Name:

d. Paternal Last Name:

e. Maternal Last Name:

  1. Relationship:

  2. Current home address of primary contact*

56.A.1. PO Box, Box &/or Route and Number
























56.B.1. Street Number Prefix









56.B.2. Street Number













56.B.3. Street Number Suffix









56.C.1. Street Name Prefix









56.C.2. Street Name


























56.C.3. Street Name Type








56.C.4. Street Name Suffix










56.D.1. Unit Type








56.D.2. Unit Type Identifier









56.D.3. Unit Subtype









56.D.4. Unit Subtype Identifier








56.E.1. Other




















56.F.1. City


























56.G.1. County













56.H.1. State






56.I.1. Country/Territory (Select code from list)













56.J.1. Zip Code






–






*IF THE PERSON LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE HOME LOCATION IN 56.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 56.E.1.


IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER IT IN 56.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE ACTUAL HOME LOCATION IN 56.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 56.E.1.

  1. Telephone: () -


Local Contact 2 (secondary contact)

  1. a. Title: b. First Name:

c. Middle/Second Name:

d. Paternal Last Name:

e. Maternal Last Name:

  1. Relationship:

  2. Current home address of secondary contact*

60.A.1. PO Box, Box &/or Route and Number
























60.B.1. Street Number Prefix









60.B.2. Street Number













60.B.3. Street Number Suffix









60.C.1. Street Name Prefix









60.C.2. Street Name


























60.C.3. Street Name Type








60.C.4. Street Name Suffix









60.D.1. Unit Type








60.D.2. Unit Type Identifier









60.D.3. Unit Subtype









60.D.4. Unit Subtype Identifier








60.E.1. Other













60.F.1. City


























60.G.1. County













60.H.1. State






60.I.1. Country/Territory (Select code from list)













60.J.1. Zip Code






–






  1. Telephone: () -


*IF THE PERSON LIVES AT SEVERAL LOCATIONS, ENTER WHERE HE OR SHE LIVES MOST. IF THE EXACT ADDRESS IS UNKNOWN, ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE HOME LOCATION IN 60.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 60.E.1.


IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER IT IN 60.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE ACTUAL HOME LOCATION IN 60.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 60.E.1.


Local Contact 3

  1. a.Title: b. First Name:

c. Middle/Second Name:

d. Paternal Last Name:

e. Maternal Last Name:

  1. Relationship:

  2. Current home address of third contact*

    64.A.1. PO Box, Box &/or Route and Number
























    64.B.1. Street Number Prefix









    64.B.2. Street Number













    64.B.3. Street Number Suffix









    64.C.1. Street Name Prefix









    64.C.2. Street Name


























    64.C.3. Street Name Type








    64.C.4. Street Name Suffix









    64.D.1. Unit Type








    64.D.2. Unit Type Identifier









    64.D.3. Unit Subtype









    64.D.4. Unit Subtype Identifier








    64.E.1. Other













    64.F.1. City


























    64.G.1. County













    64.H.1. State






    64.I.1. Country/Territory (Select code from list)













    64.J.1. Zip Code






    –





  3. Telephone: () -

  4. For this portion of the call, I have one more question. What is the name of your physician or other health care provider (HCP)?”

a. Name:

b. Address:

c. City: , State: , Zip Code:

  1. END OF THIS PORTION OF THE CALL

“Thank you for answering the questions about your health. We wish to continue to stay in touch with you and will be contacting you again next year”


Location Codes for Questions 45, 49, 56, 60, 64


  1. Afghanistan

  2. Anguilla

  3. Antigua and Barbuda

  4. Argentina

  5. Aruba

  6. Australia

  7. Austria

  8. Bangladesh

  9. Belgium

  10. Belize

  11. Bolivia

  12. Brazil

  13. Canada

  14. Chile

  15. China

  16. Colombia

  17. Costa Rica

  18. Cuba

  19. Czech Republic

  20. Denmark

  21. Dominican Republic

  22. Ecuador

  23. El Salvador

  24. Finland

  25. France

  26. Germany

  27. Great Britain

  28. Greece

  29. Guam

  30. Guatemala

  31. Haiti

  32. Holland

  33. Honduras

  34. Hungary

  35. India

  36. Indonesia

  37. Iran

  38. Iraq

  39. Ireland

  40. Israel

  41. Italy

  42. Japan

  43. Korea

  44. Lebanon

  45. Malaya

  46. Mexico

  47. New Zealand

  48. Nicaragua

  49. Norway

  50. Pakistan

  51. Panama

  52. Paraguay

  53. Peru

  54. Philippines

  55. Poland

  56. Portugal

  57. Puerto Rico

  58. Russia

  59. South Africa

  60. Spain

  61. Sweden

  62. Switzerland

  63. United States

  64. Uruguay

  65. Venezuela

  66. Virgin Islands

  67. Other

99 Unknown/refused

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File TitleHISPANIC COMMUNITY HEALTH STUDY
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