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pdfO. M. B. 0925-0281
Exp. //
ARIC
INFORMANT INTERVIEW FORM
Atherosclerosis Risk in Communities
EVENT ID:
SEQUENCE NUMBER:
LAST NAME:
FORM CODE:
I
F
I
VERSION: C DATE: 03/14/2013
INITIALS:
Public reporting burden for this collection of information is estimated to average 10 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 (0925-0281). Do not return the completed form
to this address.
INSTRUCTIONS: The Informant Interview Form is completed for each informant for an out-of-hospital death as determined by the ARIC Event Investigation
Summary. Event ID and Name 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
Name:
DECEDENT
________________________________________________________________________________
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
SMTWRFS
MM/DD/YYY
Time
Notes
Code*
A
P
SMTWRFS
MM/DD/YYY
A
P
SMTWRFS
MM/DD/YYY
A
P
SMTWRFS
MM/DD/YYY
A
P
SMTWRFS
MM/DD/YYY
A
P
SMTWRFS
MM/DD/YYY
A
P
SMTWRFS
MM/DD/YYY
A
P
SMTWRFS
MM/DD/YYY
A
P
SMTWRFS
MM/DD/YYY
A
P
SMTWRFS
MM/DD/YYY
A
P
SMTWRFS
MM/DD/YYY
A
P
* RESULT CODES (CIRCLE THE FINAL SCREENING RESULT CODE)
1
2
3
4
Complete
Partially complete
Unknowledgable
Refusal
5
6
7
9
Informant away or can't be found
Language barrier
No one home
Other (specify in Notes)
Int
INFORMANT INTERVIEW FORM (IFIC Screen 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}
"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?
Spouse .....…… S
Parent ...…...... P
)
Sick/ill/limited activities .... R
Daughter/Son ... C
Normally Active ................ N
Other relative .. R
Unknown ..................….... U
Friend .…........ F
Workmate ...... W
Other .…......... O
INFORMANT INTERVIEW FORM (IFIC Screen 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
5. Was (
) hospitalized
within the four weeks prior
to death?
Yes ....... Y
Yes, at home ...........……. H
Yes, assisted living ..…..... A
Go to Item 9,
Screen 3
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 _____________________________
No ........ N
Unknown ... U
6. What was the reason for hospitalization?
{Circle (Y), (N), or (U) for each. Probe if not
offered.}
If no or
unknown, go
to Item 9,
Screen 3
a. Heart attack
or chest pain
Yes No Unknown
Y
N
U
b. Heart surgery
Y
N
U
c. Other
Y
N
U
INFORMANT INTERVIEW FORM (IFIC Screen 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?
10. Could you tell me the name
and address of this physician?
Specify Name, City, State
Yes ...... Y
Skip Name, City, State
No ....... N
Specify Name, City, State
Yes .….. Y
[Place Name, City, State in notelog]
Skip Name, City, State
No ..…... N
Name _____________________________
_____________________________
[Place Name, City, State in notelog]
City _____________________________
Name ____________________________
State _____________________________
____________________________
City ____________________________
State ____________________________
9. Was (
) seen by a physician anytime
in the last four weeks prior to death?
Yes ....……. Y
Go to Item 11
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]
No ......…… N
Name ______________________________
Unknown ... U
______________________________
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,
Screen 4
No ...……... N
Unknown ... U
INFORMANT INTERVIEW FORM (IFIC Screen 4 of 16)
13. Did (
) ever take
nitroglycerin for this pain?
15. Was (
) hospitalized
for a heart attack?
Yes ...…….. Y
Yes ...…..... Y
No ....…….. N
No ....…….. N
Unknown ... U
Unknown ... U
14. Did a doctor ever say that
(
) had a heart
attack prior to his/her
final illness?
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
Go to Item 16
Yes ...…….. Y
No ......……. N
No ....…….. N
Unknown ... U
Unknown ... U
INFORMANT INTERVIEW FORM (IFIC Screen 5 of 16)
17. Did (
) ever have any other heart disease or
condition before his/her final illness?
heart
┌────────Yes .....….. Y
│
│
No .....……. N
│
│
Unknown ... U
│
└──If yes, specify: _______________________________
___________________________________________
___________________________________________
18. Did (
) ever have a stroke?
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
Yes ....…... Y
Go to Item 19b
No .....…... N
Unknown ... U
c. Did he/she have a history of diabetes?
Yes ...…….. Y
No ....…….. N
Unknown ... U
INFORMANT INTERVIEW FORM (IFIC Screen 6 of 16)
B. CIRCUMSTANCES SURROUNDING DEATH
"The next few questions are concerned with the circumstances surrounding (
20. Could you please tell me what you can of (
itself?
Attach Event ID Label Here
)'s death."
)'s general health, on the day he/she died, and of the death
┌───────Yes ..…….. Y
│
│
No .....…… N
│
│
Unknown ... U
│
│
└───────Specify: _______________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
INFORMANT INTERVIEW FORM (IFIC Screen 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 (
Go to Item 25,
Screen 8
) died?
23. Was anyone close enough to hear (
if he/she had called out?
Go to Item 25,
Screen 8
)
Yes ....... Y
No ........ N
Yes ....... Y
Unknown ... U
No ……. N
22. Did anyone see or hear (
Go to Item 25,
Screen 8
) when he/she died?
Yes ..……... Y
No .....……. N
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
Unknown ... U
1 hour or less .....….. B
24 hours or less ...….. C
More than 24 hours .... D
Unknown ............…... U
INFORMANT INTERVIEW FORM (IFIC Screen 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
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
In a nursing home ..................……..... G
In an emergency room ...............…..... H
In an ambulance ...................……….... I
In the hospital ......................…………. J
Other ..............................…………..... O
Unknown ........................………......... U
Go
GototoItem
Item30,
30,
Screen
10
Screen 10
No ....……. N
Unknown ... U
INFORMANT INTERVIEW FORM (IFIC Screen 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."
28. Did he/she take nitroglycerin
because of this last episode
of pain or discomfort?
Yes .....…… Y
27. Did (
)'s last episode of pain or
discomfort specifically involve the chest?
No ......…… N
Unknown ... U
Yes ...…….. Y
No .....……. N
Unknown ... U
INFORMANT INTERVIEW FORM (IFIC Screen 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?
30. Within 3 days of death or just
before (
) died, did
any of the following symptoms
begin for the first time?
{Circle the shortest interval known to be true}
5 minutes or less .....……...
A
10 minutes or less .....…….
B
1 hour or less .........………
{Circle (Y), (N) or (U) for each}
Yes
No
Unknown
a. Shortness of breath
Y
N
U
C
b. Dizziness
Y
N
U
24 hours or less ........…….
D
Y
N
U
More than 24 hours ......….
E
c. Palpitations (pounding
in the chest)
Unknown .............……......
U
d. Marked or increased
fatigue,tiredness, or
weakness
Y
N
U
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
or nausea or vomiting
Y
N
U
j. Other
Y
N
U
If Other, specify:_________________________________
_______________________________________________
_______________________________________________
INFORMANT INTERVIEW FORM (IFIC Screen 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,
Screen 13
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,
Screen 13
Already Dead ... D
INFORMANT INTERVIEW FORM (IFIC Screen 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 Screen 13 of 16)
35. Were resuscitation measures, such as closed chest
massage or CPR, attempted at the time?
37. Where was resuscitation or CPR started?
Home (or other
Yes ...…….. Y
private residence) ...........… A
No ...…..…. N
Go to Item
38,
Screen 14
Work .........................…….. B
Unknown .... U
Public place ................…… C
Ambulance or
36. Who started the resuscitation or CPR?
Bystander, non-health professional ..... A
M.D. .......................…………….......... B
Ambulance attendant, paramedic,
other emergency vehicle .... D
Go to Item
39,
Screen 14
or other health professional ..……...... C
Emergency room ................. E
Hospital ......……................. F
Other ....................……........ O
Unknown .......................…. U
Fireman or policeman .……................. D
Other ...........................……………..... O
Unknown .............................………… U
INFORMANT INTERVIEW FORM (IFIC Screen 14 of 16)
38. Was (
) taken to a hospital?
E. ADDITIONAL INFORMATION
Yes ....…….. Y
Go to Item 40
No ......……. N
Unknown .... U
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
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 _______________________________
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
City
__________________________
[Place Name, City, State, Phone in notelog]
State
__________________________
Name ___________________________________
City
___________________________________
State ___________________________________
Phone ___________________________________
INFORMANT INTERVIEW FORM (IFIC Screen 15 of 16)
42. How was he/she related to the deceased?
Spouse ..........…… S
F. RELIABILITY
{To be completed immediately after the interview}
Parent ..........……. P
Daughter/Son .….. C
Other relative …... R
Friend ..........……. F
43. Did the respondent frequently
contradict himself/herself or
give information that he/she
would have no way of knowing? ...... Yes
Y
No
N
Workmate .....…... W
Other ..........…….. O
[Read "final script",then go to Item 43]
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 Screen 16 of 16)
45. On the basis of these
questions, give your
rating of reliability
of the interview. ......... Good
G. ADMINISTRATIVE INFORMATION
G
Fair
F
Poor
P
48. Date of data collection:
Month
46. Would you like to add
other details concerning
the quality of the interview?
Day
49. Method of data collection:
Yes ....... Y
No ........ N
If Yes, specify: ____________________________
Computer ....... C
Paper Form ..... P
_________________________________________
_________________________________________
47. Informant agreed to provide
consent to gather further
information?
50. Code number of the person
completing this form. ....…..
51. Result Code:
Yes ............…… Y
No ............…….. N
Not applicable ... A
If Yes, specify _________________________________
______________________________________________
______________________________________________
Year
| File Type | application/pdf |
| Author | Jacqueline Wright |
| File Modified | 2014-03-10 |
| File Created | 2013-11-18 |