Form 1 AFU Year 3

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

AFU Y3_1-14-2014_English

AFU Year 3

OMB: 0925-0584

Document [pdf]

Download: pdf | pdf

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.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL Follow-up Interview Form
V2-Contact Year 3
FORM CODE: FE3
VERSION:1, 1/14/2014

ID NUMBER:

Contact
Occasion

SEQ #

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):
Participant contacted and alive, agrees to interview 1

Go to item 2

Participant contacted and refused interview

Go to Contact tracking, item 49

Designated respondent contacted, reported alive

Go to Hospitalizations, item 3

Other respondent contacted, reported alive

Go to Contact tracking, item 49

Not contacted, reported deceased

Continue to 1a, below

Unknown

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.

FORM CODE: FE3
VERSION: 1, 1/14/2014

ID NUMBER:

Contact
Occasion

SEQ #

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?
Go to item 5
No
0
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: _____

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)

AFU Y3_1-14-2014_English.doc

Page 2 of 17

FORM CODE: FE3
VERSION: 1, 1/14/2014

ID NUMBER:

Contact
Occasion

SEQ #

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

(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

AFU Y3_1-14-2014_English.doc

Page 3 of 17

FORM CODE: FE3
VERSION: 1, 1/14/2014

ID NUMBER:

Contact
Occasion

SEQ #

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
Yes 1
Unsure 9
No 0
6b. Chest X-ray
No 0

Yes 1

Unsure 9

6c. CT Scan of your chest
Yes 1
No 0

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
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?
Go to item 8
No
0
Yes
1
Go to item 8
Unsure
9
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: ____________________________________

AFU Y3_1-14-2014_English.doc

Page 4 of 17

ID NUMBER:

FORM CODE: FE3
VERSION: 1, 1/14/2014

Contact
Occasion

SEQ #

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
Specify: _______________________________
Other
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
“Now I would like to ask you about symptoms you may have had since our last telephone interview with you
on (date).”
10. 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

AFU Y3_1-14-2014_English.doc

Page 5 of 17

ID NUMBER:

FORM CODE: FE3
VERSION: 1, 1/14/2014

Contact
Occasion

SEQ #

11. Since our last telephone interview with you on (date), has a doctor or health professional told you that
you had heart failure?
Yes 1
Unsure 9
No
0
12. 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
13. 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
14. 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
15. 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
16. 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
17. 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
18. 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?
Yes 1
Unsure 9
No
0
19. 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
20. Since our last telephone interview with you on (date), have you had wheezing or whistling in your
chest?
Go to item 21
No
0
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?

AFU Y3_1-14-2014_English.doc

Page 6 of 17

FORM CODE: FE3
VERSION: 1, 1/14/2014

ID NUMBER:

Yes 1

Contact
Occasion

SEQ #

Unsure 9

21. 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?
22. How often do you snore now?
Never
Rarely (1-2 nights a week)
Sometimes (3-5 nights a week)
Always or almost always (6-7 nights a week)
Don’t know

1
2
3
4
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 bring all these prescription medications to the telephone?”
23. (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.)
#
24.

25.

(a) Medication UPC / NDC
(c) Strength

(d) Units

AFU Y3_1-14-2014_English.doc

Medication name (b)

Page 7 of 17

FORM CODE: FE3
VERSION: 1, 1/14/2014

ID NUMBER:

#
26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

(a) Medication UPC / NDC
(c) Strength

(d) Units

AFU Y3_1-14-2014_English.doc

Contact
Occasion

SEQ #

Medication name (b)

Page 8 of 17

FORM CODE: FE3
VERSION: 1, 1/14/2014

ID NUMBER:

(a) Medication UPC / NDC

Contact
Occasion

SEQ #

Medication name (b)

37.

38.

39.

40.

41.

42.

43.

(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.”
44. 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
325 mg per day of aspirin
Other

0
1
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.

AFU Y3_1-14-2014_English.doc

Page 9 of 17

ID NUMBER:

FORM CODE: FE3
VERSION: 1, 1/14/2014

Contact
Occasion

SEQ #

F. 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

G. 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”.
49. 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.3. Street Number Suffix

49.C.1. Street Name Prefix
49.C.2. Street Name

49.C.3. Street Name Type
49.C.4. Street Name Suffix

AFU Y3_1-14-2014_English.doc

Page 10 of 17

FORM CODE: FE3
VERSION: 1, 1/14/2014

ID NUMBER:

Contact
Occasion

SEQ #

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.F.1. City

49.G.1. County
49.H.1. State
49.I.1. Country/Territory (Select code from list)
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.

50. Primary Phone Number:

(

)

51. What is the best time of day to reach you at this number?
Morning
1
Afternoon
2
Evening
3
52. Secondary Phone Number:

(

)

53. What is the best time of day to reach you at this number?
Morning
1
Afternoon
2
Evening
3

AFU Y3_1-14-2014_English.doc

Page 11 of 17

ID NUMBER:

FORM CODE: FE3
VERSION: 1, 1/14/2014

Contact
Occasion

SEQ #

Local Contact 1 (primary contact)

a. Title:

b. First Name:

c. Middle/Second Name:

d. Paternal Last Name:

e. Maternal Last Name:

55. Relationship:
56. 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

AFU Y3_1-14-2014_English.doc

Page 12 of 17

FORM CODE: FE3
VERSION: 1, 1/14/2014

ID NUMBER:

Contact
Occasion

SEQ #

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.

57. Telephone:

(

)

Local Contact 2 (secondary contact)
58. a. Title:

b. First Name:

c. Middle/Second Name:
d. Paternal Last Name:
e. Maternal Last Name:
59. Relationship:

AFU Y3_1-14-2014_English.doc

Page 13 of 17

ID NUMBER:

FORM CODE: FE3
VERSION: 1, 1/14/2014

Contact
Occasion

SEQ #

60. 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

AFU Y3_1-14-2014_English.doc

–

Page 14 of 17

FORM CODE: FE3
VERSION: 1, 1/14/2014

ID NUMBER:

61. Telephone:

(

)

Contact
Occasion

SEQ #

*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

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 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

AFU Y3_1-14-2014_English.doc

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FORM CODE: FE3
VERSION: 1, 1/14/2014

ID NUMBER:

Contact
Occasion

SEQ #

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:

(

–

)

66. 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:

H. 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”

AFU Y3_1-14-2014_English.doc

Page 16 of 17

FORM CODE: FE3
VERSION: 1, 1/14/2014

ID NUMBER:

Contact
Occasion

SEQ #

Location Codes for Questions 45, 49, 56, 60, 64
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46

AFU Y3_1-14-2014_English.doc

Afghanistan
Anguilla
Antigua and
Barbuda
Argentina
Aruba
Australia
Austria
Bangladesh
Belgium
Belize
Bolivia
Brazil
Canada
Chile
China
Colombia
Costa Rica
Cuba
Czech Republic
Denmark
Dominican
Republic
Ecuador
El Salvador
Finland
France
Germany
Great Britain
Greece
Guam
Guatemala
Haiti
Holland
Honduras
Hungary
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Japan
Korea
Lebanon
Malaya
Mexico

47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
99

New Zealand
Nicaragua
Norway
Pakistan
Panama
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Russia
South Africa
Spain
Sweden
Switzerland
United States
Uruguay
Venezuela
Virgin Islands
Other
Unknown/refused

Page 17 of 17

File Type	application/pdf
File Modified	2014-05-30
File Created	2014-05-30