Form 2 Interview

OMB#: 0925-0584

Exp. n/nn/nnnn

H

Public reporting burden for this collection of information is estimated to average 35 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 2

ID NUMBER:

FORM CODE: FE2 VERSION: A

Contact Occasion

0

2

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.

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

1. Participant status (choose one):

Contacted and alive 1 Go to item 2

Contacted and refused interview 2 Go to Contact tracking, item 31a1

Not contacted, reported alive 3 Go to Contact tracking, item 31a1

Not contacted, reported deceased 4 Continue to 1a, below

Unknown 9 Go to Contact tracking, item 31a1

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

2. 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]

B. 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 ]

3. 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).”

4. 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]

C. 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.”

5. 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

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 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 2 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

7. 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: ______________________

8. 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: ______________________

9. 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]

D. SELF REPORT OF EVENTS SINCE BASELINE VISIT

“Now I would like to ask you about symptoms you may have had since your SOL center visit 2 years ago on (date).”

10. Since your SOL center visit on (date), has a doctor or health professional told you that you had atrial fibrillation?

No 0 Yes 1 Unsure 9

11. Since your SOL center visit on (date), has a doctor or health professional told you that you had heart failure?

No 0 Yes 1 Unsure 9

12. Since your SOL center visit 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

13. Since your SOL center visit on (date), do you often have swelling in your feet or ankles at the end of the day?

No 0 Yes 1 Unsure 9

14. Since your SOL center visit on (date), are there times when you wake up at night because of difficulty breathing?

No 0 Yes 1 Unsure 9

15. Since your SOL center visit 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

16. Since your SOL center visit 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

17. Since your SOL center visit on (date), are there times when you have difficulty breathing when you are not walking or active?

No 0 Yes 1 Unsure 9

18. Since your SOL center visit 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

19. Since your SOL center visit 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

20. Since your SOL center visit 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

21. Which statement best describes your current hearing (without a hearing aid)?

Excellent 0

Good 1

A little trouble 2

Moderate hearing trouble 3

A lot of trouble 4

Deaf 5

Refused 6

Don’t know 7

22. Since your SOL center visit on (date), has a doctor or health professional told you that you need a hearing aid?

No 0 Go to item 23

Yes 1

Unsure 9 Go to item 23

22a. Did you acquire a hearing aid?

No 0 Go to item 23

Yes 1

22b. How often do you wear it?

Always 0

Sometimes 1

Rarely 2

Never 3

23. When exposed to loud noise (by loud, we mean so loud that you had to speak in a raised voice to be heard) in the past year, how often have you worn hearing protection, such as earplugs or earmuffs while working?

None of the time 1

25% of the time 2

50% 3

75% 4

100% 5

Occasionally 6

Don’t know 9

24. When exposed to loud noise in the past year, how often have you worn hearing protection, such as earplugs, or earmuffs while outside of work, for example at sporting events or while participating in other noisy activities (using power tools, firearms, lawn mower, etc.)?

None of the time 1

25% of the time 2

50% 3

75% 4

100% 5

Occasionally 6

Don’t know 9

25. Since your SOL center visit on (date), have you had buzzing, ringing, or noise in your ears?

No 0 Go to item 26

Yes 1

Unsure 9 Go to item 26

25a. Does this noise usually last longer than 5 minutes?

No 0 Yes 1 Unsure 9

25b. Do you hear this noise only following very loud sounds? For example, concerts, shooting, or loud noise at work.

No 0 Yes 1 Unsure 9

26. Since your SOL center visit on (date), has a doctor or health professional told you that you have sleep apnea?

No 0 Go to item 27

Yes 1

Unsure 9 Go to item 27

26a. Has your sleep apnea been treated with any of the following? (check all that apply)

0 Surgery

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

2 Use of oxygen during sleep

3 A pressure machine such as CPAP or BILEVEL?

27. 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]

E. 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 to bring all these prescription medications to the telephone?”

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

No 0 Go to items 49

Yes 1

Participant refused 2 Go to items 49

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 with ‘medications you are currently taking’, that means medications you have been taken in the last 2 weeks.)

#	(a) Medication UPC / NDC		Medication name (b)
29.
	(c) Strength	(d) Units
30.
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32.
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33.
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34.
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35.
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38.
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#	(a) Medication UPC		Medication name (b)
39.
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40.
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41.
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42.
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46.
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47.
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48.
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“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.”

49. 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 item50

Yes 1

Unsure 9 Go to item 50

49a. What dose do you take?

81 mg per day of aspirin 0

325 mg per day of aspirin 1

Other 2 specify: _________________

F. OTHER ITEMS

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

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

Never smoker 0 (Go to item 52)

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

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

No 0 Go to item 52

Yes 1

Unsure 9 Go to item 52

51a. On average, about how many cigarettes a day do you smoke?

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

Married 0

Widow (er) 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 SOL study. Now, I’d just like to make sure our records are up to date.

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

53. 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”.

53. Current home address*

53.A.1. PO Box, Box &/or Route and Number
53.B.1. Street Number Prefix
53.B.2. Street Number
53.B.3. Street Number Suffix
53.C.1. Street Name Prefix
53.C.2. Street Name
53.C.3. Street Name Type
53.C.4. Street Name Suffix
53.D.1. Unit Type
53.D.2. Unit Type Identifier
53.D.3. Unit Subtype
53.D.4. Unit Subtype Identifier
53.E.1. Other
53.F.1. City

53.G.1. County
53.H.1. State
53.I.1. Country/Territory (Select code from list)
53.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 53.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 53.E.1.

IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER IT IN 53.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE ACTUAL HOME LOCATION IN 53.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 53.E.1.

54. Primary Phone Number: () -

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

Morning 1

Afternoon 2

Evening 3

56. Secondary Phone Number: () -

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

Morning 1

Afternoon 2

Evening 3

Local Contact 1

58. a. Title: _______________ b. First Name:

c. Second Name:

d. Last Name:

e. Maternal Last Name: ______________________________________

59. Relationship: __________________

60. Current home address of primary 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						–

*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 160.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.

61. Telephone: () -

Local Contact 2

62. a. Title: _______________ b. First Name:

c. Middle/Second Name:

d. Paternal Last Name:

e. Maternal Last Name: ______________________________________

63. Relationship: __________________

64. Current home address of secondary 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						–

65. 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 64.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 64.E.1.

IF THE ONLY KNOWN HOME ADDRESS IS A POST OFFICE BOX, BOX, OR ROUTE AND NUMBER, ENTER IT IN 64.A.1., BUT ALSO ENTER THE NAME OF THE INTERSECTION OR STREET CLOSEST TO THE ACTUAL HOME LOCATION IN 64.C.2. AND THE NAME OF THE BUILDING OR LOCATION IN 64.E.1.

Local Contact 3

66. a. Title: _______________ b. First Name:

c. Middle/Second Name:

d. Paternal Last Name:

e. Maternal Last Name: ______________________________________

67. Relationship: __________________

68. Current home address of third contact*

68.A.1. PO Box, Box &/or Route and Number
68.B.1. Street Number Prefix
68.B.2. Street Number
68.B.3. Street Number Suffix
68.C.1. Street Name Prefix
68.C.2. Street Name
68.C.3. Street Name Type
68.C.4. Street Name Suffix
68.D.1. Unit Type
68.D.2. Unit Type Identifier
68.D.3. Unit Subtype
68.D.4. Unit Subtype Identifier
68.E.1. Other
68.F.1. City
68.G.1. County
68.H.1. State
68.I.1. Country/Territory (Select code from list)
68.J.1. Zip Code						–

69. Telephone: () -

70. 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:

F. 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 53, 60, 64, 68

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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