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pdfAPPENDIX C
DATA COLLECTION PROTOCOLS
LSP COST STUDY WORKSHEET #1: FACILITY LABOR COSTS
(Include staff working at the specific meal preparation or meal service facility.)
A.
NAME OF FACILITY
B.
NUMBER OF MEALS PREPARED OR SERVED PER WEEK
CONGREGATE
HOMEDELIVERED
PERSON OR
CATEGORY 1
PERSON OR
CATEGORY 2
Meals served to Title III participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Meals served in other programs to other persons . . . . . . . . . . . . . . . . . . . .
C.
LABOR USED
NAME OF PERSON OR CATEGORY
Actual salary or average salary for position
(enter 0 if volunteer ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Salary is per (year, week, hour)
Average percent fringe benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If volunteer, equivalent salary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total hours worked per week . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Breakdown of work timea
Hours on activities related only to congregate meals . . . . . . . . . . . . . .
Hours on activities related only to home-delivered meals . . . . . . . . . . .
Hours on activities related to both congregate and
home-delivered meals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hours on nonmeal-related activities . . . . . . . . . . . . . . . . . . . . . . . . . . .
a
Entries should add to total hours worked from previous line.
PERSON OR
CATEGORY 3
PERSON OR
CATEGORY 4
PERSON OR
CATEGORY 5
PERSON OR
CATEGORY 6
LSP COST STUDY WORKSHEET #2: MEAL DELIVERY LABOR COSTS
(Record labor costs associated with delivering meals to sites or to particpants' homes.)
A.
NAME OR DESCRIPTION OF ROUTE
B.
NUMBER OF MEALS DELIVERED PER WEEK
CONGREGATE
HOMEDELIVERED
PERSON OR
CATEGORY 1
PERSON OR
CATEGORY 2
Meals served to Title III participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Meals served to other persons . . . . . . . . . . . . . . . . . . . .
C.
LABOR USED
NAME OF PERSON OR CATEGORY
Actual salary or average salary for position
(enter 0 if volunteer ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Salary is per (year, week, hour)
Average percent fringe benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If volunteer, equivalent salary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total hours worked per week . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total hours spent on this delivery route per week . . . . . . . . . . . . . . . . . . . .
PERSON OR
CATEGORY 3
PERSON OR
CATEGORY 4
PERSON OR
CATEGORY 5
PERSON OR
CATEGORY 6
LSP COST STUDY WORKSHEET #3: ENTIRE NUTRITION PROJECT FOOD
OPERATIONS: NON-LABOR COSTS
(Note:
If any item (such as a space) can't be separated out between meal-related and nonmeal-related, report
the aggregate.)
COST COMPONENT
A.
COST PER WEEK
Payments to Vendors for Already-Prepared Food
Congregate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Home Delivered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B.
Food Ingredients for Meals Prepared at
Affiliated Central Kitchen or On-Site
Congregate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Home Delivered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C.
Purchase of Frozen Meals . . . . . . . . . . . . . . . . . . . . . . . . . . .
Congregate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Home Delivered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D.
Value of USDA Commodities Used . . . . . . . . . . . . . . . . . . . . . . . . . . .
E.
Value of Other Donated Food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
F.
Non-Food Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
G.
Rent or Space Costs
Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Central Kitchen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Central Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Additional Commodity Storage Costs . . . . . . . . . . . . . . . . . . . .
H.
Utility Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I.
Value of Donated Space and Utilities . . . . . . . . . . . . . . . . . . . . . . . .
J.
Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
K.
Gasoline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
L.
Other (SPECIFY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a
If the same food is used for congregate and home-delivered meals, a total is acceptable.
MEALS PER WEEK
NON-LABOR COSTS (continued)
EQUIPMENT VALUE
ESTIMATED REPLACEMENT
COST OF COMPARABLE
EQUIPMENT, BOUGHT NEW
Vehicles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Food Preparation and Service Equipment
Production Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Packaging Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Transport Equipment Other Than Vehiclesa . . . . . . . . . . . . . . . . . . .
Serving Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Building and Improvements (Enter "0" if No Buildings are Owned)
Office Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other (SPECIFY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a
Such as insulated containers for food transport.
VEHICLE USAGE
Transporting Food to Congregate Sites . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Transporting Participants to Congregate Sites . . . . . . . . . . . . . . . . . . . . . . .
Other Participant Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Home Delivery of Meals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
General and Administrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other (SPECIFY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PERCENTAGE OF
TOTAL VEHICLE
USE TIME
LSP COST STUDY WORKSHEET #4: CENTRAL ADMINISTRATIVE LABOR COSTS
(Include staff with central administrative responsibilities.)
A.
NAME OF NUTRITION PROJECT
B.
NUMBER OF MEALS PREPARED OR SERVED PER WEEK
CONGREGATE
HOMEDELIVERED
PERSON OR
CATEGORY 1
PERSON OR
CATEGORY 2
Meals served to Title III participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Meals served to other persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C.
LABOR USED
NAME OF PERSON OR CATEGORY
Actual salary or average salary for position
(enter 0 if volunteer ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Salary is per (year, week, hour)
Average percent fringe benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If volunteer, equivalent salary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total hours worked per week . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Breakdown of work timea
Hours on activities related only to congregate meals . . . . . . . . . . . . . .
Hours on activities related only to home-delivered meals . . . . . . . . . . .
Hours on activities related to both congregate and
home-delivered meals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hours on nonmeal-related activities . . . . . . . . . . . . . . . . . . . . . . . . . . .
a
Entries should add to total hours worked from previous line.
PERSON OR
CATEGORY 3
PERSON OR
CATEGORY 4
PERSON OR
CATEGORY 5
PERSON OR
CATEGORY 6
Mathematica Reference No.: 06669.202
National Evaluation of Title III-C
Services
Client Outcomes Survey
CAPI Questionnaire
May 23, 2012
INTRODUCTION
INTERVIEWER:
SELECT PARTICIPANT TYPE:
CONGREGATE NUTRITION PARTICIPANT ....................................................... 1
SET PTCPT = CM
HOME-DELIVERED NUTRITION PARTICIPANT ................................................ 2
SET PTCPT = HDM
CONGREGATE NUTRITION NONPARTICIPANT ............................................... 3
SET PTCPT = NON;
MATCH = CM
HOME-DELIVERED NUTRITION NONPARTICIPANT ........................................ 4
SET PTCPT = NON;
MATCH = HDM
INTERVIEWER:
WILL INTERVIEW BE CONDUCTED WITH A PROXY?
YES ....................................................................................................................... 1
SET PROXY
STATUS = Y
NO ......................................................................................................................... 0
SET PROXY
INTERVIEWER:
ENTER NAME OF PERSON
INTERVIEWER:
ENTER NAME OF PROGRAM
REQUIRED
IF PTCPT = CM OR HDM AND PROXY = N
INTRO1. My name is [NAME] and I am from Mathematica Policy Research. I am here on behalf of
the U.S. Department of Health and Human Services, Administration on Aging. I would
like your help with a survey to find out how the Administration on Aging can help meet
the needs of older Americans.
This survey has two parts. The first part of the survey is about your participation in the
nutrition program at [NAME OF PROGRAM SITE] and your satisfaction with aspects of
the nutrition program there. The second part of the survey is about what you ate and
drank over the past 24 hours. Your participation is voluntary but we would really like
your help. This survey is for research purposes only and will help to improve services
for older adults in the future. All of your answers will be kept strictly confidential. Your
eligibility for services from this and other programs will not be affected by your decision
to participate. The entire survey takes about 75 minutes to complete. We’ll mail you a
$50 gift card for completing the survey.
CONTINUE ........................................................................................................... 1
SKIP TO A1
REFUSED ............................................................................................................. r
Thank you for
your time
1
REQUIRED
IF PTCPT = CM OR HDM AND PROXY = Y
INTRO2. My name is [NAME] and I am from Mathematica Policy Research. I am here on behalf of
the U.S. Department of Health and Human Services, Administration on Aging. I would
like your help with completing a survey on behalf of [NAME OF PARTICIPANT]. The
purpose of the survey is to find out how the Administration on Aging can help meet the
needs of older Americans.
This survey has two parts. The first part of the survey is about [NAME OF
PARTICIPANT]’s participation in the nutrition program at [NAME OF PROGRAM SITE]
and [his/her] satisfaction with aspects of the nutrition program there. The second part of
the survey is about what [he/she] ate and drank over the past 24 hours. Your
participation is voluntary but we would really like your help. This survey is for research
purposes only and will help to improve services for older adults in the future. All of your
answers will be kept strictly confidential. [NAME OF PARTICIPANT]’s eligibility for
services for this and other programs will not be affected by your decision to participate.
The entire survey takes about 75 minutes to complete. We’ll mail you a $50 gift card for
completing the survey.
For the remainder of the survey I would like you to answer as though you are [NAME OF
PARTICIPANT]. All of the following questions pertain to [him/her]. Please provide your
best estimate as to [his/her] own response or opinion.
CONTINUE ........................................................................................................... 1
SKIP TO A1
REFUSED ............................................................................................................. r
Thank you for
your time
REQUIRED
IF PTCPT = NON AND PROXY = N
INTRO3. My name is [NAME] and I am from Mathematica Policy Research. I am here on behalf of
the U.S. Department of Health and Human Services, Administration on Aging. I would
like your help with a survey to find out how the Administration on Aging can help meet
the needs of Older Americans.
This survey has two parts. The first part has some general questions, as well as
questions about your general health and dietary habits. The second part is about what
you ate and drank over the past 24 hours. Your participation is voluntary but we would
really like your help. This survey is for research purposes only and will help to improve
services for older adults in the future. All of your answers will be kept strictly
confidential. Your eligibility for services from this and other programs will not be
affected by your decision to participate. The entire survey takes about 55 minutes to
complete. We’ll mail you a $50 gift card for completing the survey.
CONTINUE ........................................................................................................... 1
SKIP TO A1
REFUSED ............................................................................................................. r
Thank you for
your time
2
REQUIRED
IF PTCPT = NON AND PROXY = Y
INTRO4. My name is [NAME] and I am from Mathematica Policy Research. I am here on behalf of
the U.S. Department of Health and Human Services, Administration on Aging. I would
like your help with completing a survey on behalf of [NAME OF PARTICIPANT]. The
purpose of the survey to find out how the Administration on Aging can help meet the
needs of older Americans.
This survey has two parts. The first part of the survey is about [NAME OF
PARTICIPANT]’s general health and dietary habits. The second part of the survey is
about what (he/she) ate and drank over the past 24 hours. Your participation is voluntary
but we would really like your help. This survey is for research purposes only and will
help to improve services for older adults in the future. All of your answers will be kept
strictly confidential. [NAME OF PARTICIPANT]’s eligibility for services for this and other
programs will not be affected by your decision to participate. The entire survey takes
about 55 minutes to complete. We’ll mail you a $50 gift card for completing the survey.
For the remainder of the survey I would like you to answer as though you were [NAME
OF PARTICIPANT]. All of the following questions pertain to [him/her]. Please provide
your best estimate as to [his/her] own response or opinion.
CONTINUE ........................................................................................................... 1
SKIP TO A1
REFUSED ............................................................................................................. r
Thank you for
your time
3
A. NUTRITION PROGRAM PARTICIPATION
PROGRAMMER BOX A1
CATI: CONTINUE IF PTCPT = CM OR HDM. IF PTCPT = NON, SKIP TO
SECTION B.
REQUIRED
IF PTCPT = CM
A_Intro:
A1.
My first questions are about [your/his/her] participation in the congregate nutrition
program at [NAME OF PROGRAM SITE].
During a typical week, how many days [do you/does he/does she] eat at [NAME OF
PROGRAM SITE] or another place like it?
|
|
| DAYS (0-999)
PER WEEK (Range 1-7) ....................................................................................... 1
PER MONTH (Range 1-31) .................................................................................. 2
PER YEAR (Range 1-99) ...................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF DAYS PER WEEK GT 7; I want to be sure I recorded your answer correctly. Did
you say [fill A1] days per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 DAYS PER WEEK.
HARD CHECK: IF DAYS PER MONTH GT 31; I want to be sure I recorded your answer correctly. Did
you say [fill A1] days per month? INTERVIEWER: ANSWER CANNOT EXCEED 31 DAYS PER
MONTH.
HARD CHECK: IF A1 GT 99; I want to be sure I recorded your answer correctly. Did you say [fill A1]
days? INTERVIEWER: ANSWER CANNOT EXCEED 99 DAYS.
HARD CHECK: IF A1 = 0; I want to be sure I recorded your answer correctly. Did you say [fill A1]
days? INTERVIEWER: ANSWER CANNOT BE 0.
4
REQUIRED
IF PTCPT = HDM
A_Intro:
A1.1
My first questions are about [your/his/her] participation in the home-delivered nutrition
program from [NAME OF PROGRAM SITE]. You may also know this as the meals-onwheels program from [NAME OF PROGRAM SITE].
During a typical week, how many days does [NAME OF PROGRAM SITE] or another
program like it deliver meals to [your/his/her] home?
|
|
| DAYS (0-999)
PER WEEK (Range 1-7) ....................................................................................... 1
PER MONTH (Range 1-31) .................................................................................. 2
PER YEAR (Range 1-99) ...................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF DAYS PER WEEK GT 7; I want to be sure I recorded your answer correctly. Did
you say [fill A1.1] days per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 DAYS PER
WEEK.
HARD CHECK: IF DAYS PER MONTH GT 31; I want to be sure I recorded your answer correctly. Did
you say [fill A1.1] days per month? INTERVIEWER: ANSWER CANNOT EXCEED 31 DAYS PER
MONTH.
HARD CHECK: IF A1.1 GT 99; I want to be sure I recorded your answer correctly. Did you say
[fill A1.1] days? INTERVIEWER: ANSWER CANNOT EXCEED 99 DAYS.
HARD CHECK: IF A1.1 = 0; I want to be sure I recorded your answer correctly. Did you say
[fill A1.1] days? INTERVIEWER: ANSWER CANNOT BE 0.
5
REQUIRED
IF PTCPT = CM
A2.
Thinking about meals [you eat/he eats/she eats] at [NAME OF PROGRAM SITE] or other
places like this, during a typical week, how many times per week [do you/does he/does
she] eat . . .
a. Breakfast there?
|
| TIMES (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF A2a GT 7; I want to be sure I recorded your answer correctly. Did you say
[fill A2a] times per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 TIMES PER WEEK.
b. Lunch there?
|
| TIMES (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF A2b GT 7; I want to be sure I recorded your answer correctly. Did you say
[fill A2b] times per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 TIMES PER WEEK
c. Dinner there?
|
| TIMES (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF A2c GT 7; I want to be sure I recorded your answer correctly. Did you say
[fill A2c] times per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 TIMES PER WEEK.
6
REQUIRED
IF PTCPT = HDM
A2.1
Thinking about meals [you receive/he receives/she receives] from [NAME OF PROGRAM
SITE, how many of each of the following meals [do you/does he/does she] receive during a
typical week?
a. Breakfast
|
| MEALS (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
MEALS ARE NOT DESIGNATED ........................................................................ 99
SKIP TO
UNDESIGNATED
MEALS
HARD CHECK: IF A2.1a GT 7; I want to be sure I recorded your answer correctly. Did you say
[fill A2.1a] meals per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 MEALS PER WEEK.
b. Lunch
|
| MEALS (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF A2.1b GT 7; I want to be sure I recorded your answer correctly. Did you say [fill
A2.1b] meals per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 MEALS PER WEEK.
c. Dinner
|
| MEALS (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF A2.1c GT 7; I want to be sure I recorded your answer correctly. Did you say
[fill A2.1c] meals per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 MEALS PER WEEK.
ASK ONLY IF RESPONDENT SAYS MEALS ARE NOT DESIGNATED:
d. Undesignated meals
|
|
| MEALS (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF A2.1d GT 10; I want to be sure I recorded your answer correctly. Did you say
[fill A2.1d] meals per week?
HARD CHECK: IF A2.1d GT 21; I want to be sure I recorded your answer correctly. Did you say
[fill A2.1d] meals per week? INTERVIEWER: ANSWER CANNOT EXCEED 21 MEALS PER WEEK.
7
REQUIRED
IF A2.1 LUNCHES IS LT 5
A2.2
[Do you/Does he/Does she] receive fewer than five lunches a week because [you prefer/he
prefers/she prefers] it that way, or because [you/he/she] can only get fewer than five
lunches a week?
CODE ONE ONLY
PREFER IT THAT WAY ........................................................................................ 1
CANNOT GET MORE LUNCHES ........................................................................ 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = HDM
A2.3.
How long ago was the last time [NAME OF PROGRAM SITE] delivered a meal to
[your/his/her] home? You can tell me the number of days, weeks, months, or years.
INTERVIEWER:
|
|
IF RESPONDENT HAD A MEAL DELIVERED TODAY, PLEASE CODE
0 DAYS AGO
| (0-999)
DAYS AGO (Range 0-45) ..................................................................................... 1
WEEKS AGO (Range 1-30) .................................................................................. 2
MONTHS AGO (Range 1-13) ............................................................................... 3
YEARS AGO (Range 1-40) ................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF A2.3 GT 45; I want to be sure I recorded your answer correctly. Did you say
[fill A2.3]? INTERVIEWER: ANSWER CANNOT EXCEED 45.
HARD CHECK: IF WEEKS AGO GT 30; I want to be sure I recorded your answer correctly. Did you
say [fill A2.3] weeks ago? INTERVIEWER: ANSWER CANNOT EXCEED 30 WEEKS AGO.
HARD CHECK: IF MONTHS AGO GT 13; I want to be sure I recorded your answer correctly. Did you
say [fill A2.3] months ago? INTERVIEWER: ANSWER CANNOT EXCEED 13 MONTHS AGO.
HARD CHECK: IF YEARS AGO GT 40; I want to be sure I recorded your answer correctly. Did you
say [fill A2.3] years ago? INTERVIEWER: ANSWER CANNOT EXCEED 40 YEARS AGO.
HARD CHECK: IF WEEKS AGO = 0; I want to be sure I recorded your answer correctly. Did you say
[fill A2.3] weeks ago? INTERVIEWER: ANSWER CANNOT BE 0 WEEKS AGO.
HARD CHECK: IF MONTHS AGO = 0; I want to be sure I recorded your answer correctly. Did you
say [fill A2.3] months ago? INTERVIEWER: ANSWER CANNOT BE 0 MONTHS AGO.
HARD CHECK: IF YEARS AGO = 0; I want to be sure I recorded your answer correctly. Did you say
[fill A2.3] years ago? INTERVIEWER: ANSWER CANNOT BE 0 YEARS AGO.
8
REQUIRED
IF PTCPT = CM
A3.
Thinking back to 6 months ago (that is, last [CURRENT MONTH – 6 MONTHS]), did
[you/he/she] eat meals at the [NAME OF PROGRAM SITE] or other places like this more
often, less often, or about as often as [you do/he does/she does] now?
CODE ONE ONLY
MORE OFTEN ...................................................................................................... 1
LESS OFTEN ........................................................................................................ 2
ABOUT AS OFTEN ............................................................................................... 3
SKIP TO A5
DON’T KNOW ....................................................................................................... d
SKIP TO A5
REFUSED ............................................................................................................. r
SKIP TO A5
REQUIRED
IF A3 = 1
A4.
Why [do you/does he/does she] eat at [NAME OF PROGRAM SITE] more often than
[you/he/she] did 6 months ago?
PROBE:
That is, since last [CURRENT MONTH – 6 MONTHS].
CODE ALL THAT APPLY
HAVE NO ONE AT HOME TO EAT WITH ........................................................... 1
MADE FRIENDS AT MEAL SITE ......................................................................... 2
GOT INVOLVED IN ACTIVITIES AT MEAL SITE ................................................ 3
COSTS LESS TO EAT AT MEAL SITE THAN ELSEWHERE ............................. 4
THE MEAL SITE IS WARM AND INVITING ......................................................... 5
NO LONGER HAVE A PLACE TO PREPARE MEALS ........................................ 6
PHYSICALLY DIFFICULT TO MAKE OWN MEALS ............................................ 7
I LIKE THE KINDS OF FOODS THEY SERVE .................................................... 8
OTHER (PLEASE SPECIFY) ................................................................................ 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
9
REQUIRED
IF A3 = 2
A4.1
Why [do you/does he/does she] eat at [NAME OF PROGRAM SITE] less often than
[you/he/she] did 6 months ago?
PROBE:
That is, since last [CURRENT MONTH – 6 MONTHS].
CODE ALL THAT APPLY
HAVE FEW OR NO FRIENDS AT MEAL SITE .................................................... 1
HAVE OTHER PLACES TO EAT ......................................................................... 2
HAVEN’T GOTTEN INVOLVED OR NOT INTERESTED IN ACTIVITIES AT
MEAL SITE ........................................................................................................... 3
CAN’T AFFORD TO DONATE AT MEAL SITE .................................................... 4
SOMETIMES DIFFICULT TO GET TO MEAL SITE ............................................. 5
I FOUND THAT I DON’T ALWAYS LIKE THE KINDS OF FOODS THEY
SERVE .................................................................................................................. 6
STILL ABLE TO PREPARE OWN MEALS ........................................................... 7
OTHER (PLEASE SPECIFY) ................................................................................ 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM
A5.
When [you eat/he eats/she eats] at [NAME OF PROGRAM SITE], [are you/is he/is she] able
to take leftovers or seconds home with [you/him/her]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM
A6.
When [you go/he goes/she goes] to [NAME OF PROGRAM SITE], [do you/does he/does
she] ever get meals to take home to eat later? Please do not include leftovers [you/he/she]
might take home from a meal [you/he/she] ate at [NAME OF PROGRAM SITE].
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO A11
DON’T KNOW ....................................................................................................... d
SKIP TO A11
REFUSED ............................................................................................................. r
SKIP TO A11
10
REQUIRED
IF A6 = 1
A7.
How would [you/he/she] describe those take home meals? Are they full meals, just snacks,
supplements such as Ensure or Boost, or something else?
CODE ONE ONLY
FULL MEALS ........................................................................................................ 1
SNACKS ............................................................................................................... 2
SUPPLEMENTS ................................................................................................... 3
OTHER (PLEASE SPECIFY) ................................................................................ 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = HDM
A8.
How often [do you/does he/does she] eat the entire delivered meal in one sitting? Would
[you/he/she] say . . .
CODE ONE ONLY
Always, ................................................................................................................. 1
SKIP TO A10
Usually, ................................................................................................................ 2
SKIP TO A9
Sometimes, .......................................................................................................... 3
SKIP TO A9
Seldom, or ............................................................................................................ 4
SKIP TO A9
Never? .................................................................................................................. 5
SKIP TO A9
DON’T KNOW ....................................................................................................... d
SKIP TO A9
REFUSED ............................................................................................................. r
SKIP TO A9
REQUIRED
IF PTCPT = HDM AND A8 DNE 1
A9.
When [you do/he does/she does] not eat [your/his/her] entire delivered meal in one sitting,
do [you/he/she] usually eat all of what is left as another meal, eat only part of what is left
as another meal, or do you usually throw the rest of the meal away?
CODE ONE ONLY
ALL OF ANOTHER MEAL .................................................................................... 1
PART OF ANOTHER MEAL ................................................................................. 2
THROW IT AWAY ................................................................................................. 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
11
REQUIRED
IF PTCPT = HDM
A10.
[Do you/Does he/Does she] currently have any diet and nutritional supplements at home,
such as Ensure or Boost, that [NAME OF PROGRAM SITE] gave [you/him/her]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM OR HDM
A11.
[Do you/Does he/Does she] currently any emergency meals at home that the [NAME OF
PROGRAM SITE] gave [you/him/her]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF A11 = YES
A12.
How many emergency meals [do you/does he/does she] have from [NAME OF PROGRAM
SITE]? Your best estimate is fine.
|
|
| NUMBER OF MEALS (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF A12 = 0; I want to be sure I recorded your answer correctly. Did you say [fill A12]
meals? INTERVIEWER: ANSWER CANNOT BE 0.
HARD CHECK: IF A12 GT 10; I want to be sure I recorded your answer correctly. Did you say
[fill A12] meals? INTERVIEWER: ANSWER CANNOT EXCEED 10 MEALS.
12
REQUIRED
IF PTCPT = CM OR HDM
A13.
If the [NAME OF PROGRAM SITE] wasn’t available to provide meals, how often would
(INSERT a-h) . . . Would you say most of the time, sometimes, or never?
CODE ALL THAT APPLY
MOST OF
THE TIME
SOMETIMES
NEVER
DON’T
KNOW
REFUSED
a. [You/He/She] cook for [yourself/himself/herself]?
1
2
3
d
r
b. Family or friends provide [you/him/her] with meals?
1
2
3
d
r
[You/He/She] eat at restaurants or have food
delivered from restaurants?
1
2
3
d
r
d. [You/He/She] eat meals that were easy to fix like
sandwiches, microwavable meals, or soups?
1
2
3
d
r
e. [You/He/She] eat meals that were ready to eat right
out of the package?
1
2
3
d
r
1
2
3
d
r
g. Eat foods saved from other meals?
1
2
3
d
r
h. [You/He/She] get food in some other way?
(PLEASE SPECIFY)
1
2
3
d
r
c.
f.
Skip meals or eat less than [you do/he does/she
does] now?
(STRING (30))
REQUIRED
IF PTCPT = CM
A14.
Excluding [NAME OF PROGRAM SITE], how many other places like [NAME OF PROGRAM
SITE] [do you/does he/does she] usually go for [your/his/her] meals? These could be
senior centers, senior lunch programs, or other congregate meals programs.
|
|
| NUMBER OF PLACES (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF A14 GT 10; I want to be sure I recorded your answer correctly. Did you say
[fill A14] places? INTERVIEWER: ANSWER CANNOT EXCEED 10 PLACES.
13
REQUIRED
IF PTCPT = HDM
A14.1 Excluding [NAME OF PROGRAM SITE], how many other similar places usually deliver
meals to [your/his/her] home?
|
|
| NUMBER OF PLACES (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF A14.1 GT 5; I want to be sure I recorded your answer correctly. Did you say
[fill A14.1] other places usually deliver meals to [your/his/her] home?
HARD CHECK: IF A14.1 GT 10; I want to be sure I recorded your answer correctly. Did you say
[fill A14.1] other places usually deliver meals to [your/his/her] home? INTERVIEWER: ANSWER
CANNOT EXCEED 10 OTHER PLACES.
REQUIRED
IF PTCPT = CM
A15.
How long ago did [you/he/she] first begin eating at a congregate meal site, senior center,
or senior lunch program for a meal?
PROBE:
|
|
You may answer in days, weeks, months, or years. Your best estimate is fine.
| (0-999)
DAYS AGO (Range 0-45) ..................................................................................... 1
WEEKS AGO (Range 1-30) .................................................................................. 2
MONTHS AGO (Range 1-13) ............................................................................... 3
YEARS AGO (Range 1-40) ................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF A15 GT 45; I want to be sure I recorded your answer correctly. Did you say
[fill A15]? INTERVIEWER: ANSWER CANNOT EXCEED 45.
HARD CHECK: IF WEEKS AGO GT 30; I want to be sure I recorded your answer correctly. Did you
say [fill A15] weeks ago? INTERVIEWER: ANSWER CANNOT EXCEED 30 WEEKS AGO.
HARD CHECK: IF MONTHS AGO GT 13; I want to be sure I recorded your answer correctly. Did you
say [FILL A15] months ago? INTERVIEWER: ANSWER CANNOT EXCEED 13 MONTHS AGO.
HARD CHECK: IF YEARS AGO GT 40; I want to be sure I recorded your answer correctly. Did you
say [fill A15] years ago? INTERVIEWER: ANSWER CANNOT EXCEED 40 YEARS AGO.
HARD CHECK: IF WEEKS AGO = 0; I want to be sure I recorded your answer correctly. Did you say
[fill A15] weeks ago? INTERVIEWER: ANSWER CANNOT BE 0 WEEKS AGO.
HARD CHECK: IF MONTHS AGO = 0; I want to be sure I recorded your answer correctly. Did you
say [fill A15] months ago? INTERVIEWER: ANSWER CANNOT BE 0 MONTHS AGO.
HARD CHECK: IF YEARS AGO = 0; I want to be sure I recorded your answer correctly. Did you say
[fill A15] years ago? INTERVIEWER: ANSWER CANNOT BE 0 YEARS AGO.
14
REQUIRED
IF PTCPT = HDM
A15.1 How long ago did [you/he/she] first receive a home-delivered meal?
PROBE:
|
|
You may answer in days, weeks, months, or years. Your best estimate is fine.
| (0-999)
DAYS AGO (Range 0-45) ..................................................................................... 1
WEEKS AGO (Range 1-30) .................................................................................. 2
MONTHS AGO (Range 1-13) ............................................................................... 3
YEARS AGO (Range 1-40) ................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF A15.1 GT 45; I want to be sure I recorded your answer correctly. Did you say
[fill A15.1]? INTERVIEWER: ANSWER CANNOT EXCEED 45.
HARD CHECK: IF WEEKS AGO GT 30; I want to be sure I recorded your answer correctly. Did you
say [fill A15.1] weeks ago? INTERVIEWER: ANSWER CANNOT EXCEED 30 WEEKS AGO.
HARD CHECK: IF MONTHS AGO GT 13; I want to be sure I recorded your answer correctly. Did you
say [fill A15.1] months ago? INTERVIEWER: ANSWER CANNOT EXCEED 13 MONTHS AGO.
HARD CHECK: IF YEARS AGO GT 40; I want to be sure I recorded your answer correctly. Did you
say [fill A15.1] years ago? INTERVIEWER: ANSWER CANNOT EXCEED 40 YEARS AGO.
HARD CHECK: IF WEEKS AGO = 0; I want to be sure I recorded your answer correctly. Did you say
[fill A15.1] weeks ago? INTERVIEWER: ANSWER CANNOT BE 0 WEEKS AGO.
HARD CHECK: IF MONTHS AGO = 0; I want to be sure I recorded your answer correctly. Did you
say [fill A15.1] months ago? INTERVIEWER: ANSWER CANNOT BE 0 MONTHS AGO.
HARD CHECK: IF YEARS AGO = 0; I want to be sure I recorded your answer correctly. Did you say
[fill A15.1] years ago? INTERVIEWER: ANSWER CANNOT BE 0 YEARS AGO.
15
REQUIRED
IF PTCPT = CM
A16.
How did [you/he/she] first learn about the nutrition program like the one at [NAME OF
PROGRAM SITE]?
CODE ALL THAT APPLY
FROM ANOTHER PERSON ................................................................................. 1
MEDICAL DOCTOR.............................................................................................. 2
MEDICAL PERSONNEL OTHER THAN A DOCTOR .......................................... 3
SOCIAL WORKER ................................................................................................ 4
FAMILY MEMBER ................................................................................................ 5
FRIEND ................................................................................................................. 6
NEWSPAPER, TV, RADIO, INTERNET ............................................................... 7
POSTERS, SOMETHING IN THE MAIL ............................................................... 8
ANNOUNCEMENT IN CLUB OR CHURCH ......................................................... 9
REFERRED BY A COMMUNITY-BASED AGENCY (HOSPITAL, SOCIAL
SERVICES AGENCY, ETC.) ................................................................................ 10
OTHER (PLEASE SPECIFY) ................................................................................ 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
16
REQUIRED
IF PTCPT = HDM
A16.1 How did [you/he/she] first learn about the home-delivered nutrition program like the one at
[NAME OF PROGRAM SITE]?
CODE ALL THAT APPLY
FROM ANOTHER PERSON ................................................................................. 1
MEDICAL DOCTOR.............................................................................................. 2
MEDICAL PERSONNEL OTHER THAN A DOCTOR .......................................... 3
SOCIAL WORKER ................................................................................................ 4
FAMILY MEMBER ................................................................................................ 5
FRIEND ................................................................................................................. 6
NEWSPAPER, TV, RADIO, INTERNET ............................................................... 7
POSTERS, SOMETHING IN THE MAIL ............................................................... 8
ANNOUNCEMENT IN CLUB OR CHURCH ......................................................... 9
REFERRED BY A COMMUNITY-BASED AGENCY (HOSPITAL, SOCIAL
SERVICES AGENCY, ETC.) ................................................................................ 10
OTHER (PLEASE SPECIFY) ................................................................................ 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM OR HDM
A17.
[Were you/Was he/Was she] on a waiting list before [you were/he was/she was] able to
take part in the [NAME OF PROGRAM SITE] nutrition program?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO B1
DON’T KNOW ....................................................................................................... d
SKIP TO B1
REFUSED ............................................................................................................. r
SKIP TO B1
17
REQUIRED
IF A17 = 1
A18.
How long [were you/was he/was she] on the waiting list before [you/he/she] received a
program meal? You can tell me the number of days, weeks, months, or years.
|
|
| (0-999)
DAYS (Range 1-99) .............................................................................................. 1
WEEKS (Range 1-20) ........................................................................................... 2
MONTHS (Range 1-12) ........................................................................................ 3
YEARS (Range 1-5) .............................................................................................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF A18 GT 99; I want to be sure I recorded your answer correctly. Did you say
[fill A2.3]? INTERVIEWER: ANSWER CANNOT EXCEED 99.
HARD CHECK: IF WEEKS GT 20; I want to be sure I recorded your answer correctly. Did you say
[fill A18] weeks? INTERVIEWER: ANSWER CANNOT EXCEED 20 WEEKS.
HARD CHECK: IF MONTHS GT 12; I want to be sure I recorded your answer correctly. Did you say
[fill A18] months? INTERVIEWER: ANSWER CANNOT EXCEED 12 MONTHS.
HARD CHECK: IF YEARS GT 5; I want to be sure I recorded your answer correctly. Did you say
[fill A18] years? INTERVIEWER: ANSWER CANNOT EXCEED 5 YEARS.
HARD CHECK: IF A18 = 0; I want to be sure I recorded your answer correctly. Did you say
[fill A18]? INTERVIEWER: ANSWER CANNOT BE 0.
18
B. OTHER SERVICES
PROGRAMMER BOX B1
CATI: CONTINUE IF PTCPT = CM, HDM, OR NON.
REQUIRED
IF PTCPT = CM OR HDM
B1.
In the past 6 months, other than meals from [NAME OF PROGRAM SITE], [have you/has
he/has she] gotten other types of help or services from either [NAME OF PROGRAM SITE],
[NAME OF AREA AGENCY ON AGING], or some other agency or provider?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO B3
DON’T KNOW ....................................................................................................... d
SKIP TO B3
REFUSED ............................................................................................................. r
SKIP TO B3
REQUIRED
IF PTCPT = NON
B1.1
In the past 6 months, [have you/has he/has she] gotten any help or received any services
from [NAME OF AREA AGENCY ON AGING] or some other agency?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO C1
DON’T KNOW ....................................................................................................... d
SKIP TO C1
REFUSED ............................................................................................................. r
SKIP TO C1
19
REQUIRED
IF B1 OR B1.1 =1
B2.
In the past 6 months . . .
YES
NO
DON’T
KNOW
REFUSED
a. [Have you/Has he/Has she] participated in an adult day
care program?
1
0
d
r
b. [Have you/Has he/Has she] received personal care services
for help with dressing or bathing?
1
0
d
r
1
0
d
r
d. Did a nutritional counselor give [you/him/her] individual
advice on what [you/he/she] should eat?
1
0
d
r
e. [Have you/Has he/Has she] received case management
services in which a case manager set up in-home services
for [you/him/her] such as homemaker or personal care
services, or called to see how [you are/he is/she is] doing?
1
0
d
r
1
0
d
r
g. Did [you/he/she] participate in a support group to talk with
other people who have the same kind of problems [you
have/he has/she has]?
1
0
d
r
h. [Have you/Has he/Has she] received homemaker or
housekeeping services to help with light housework,
preparing meals, or shopping?
1
0
d
r
1
0
d
r
c.
f.
i.
Did [a visiting nurse or therapist come to [your/his/her]
home to provide physical, occupational, or speech therapy?
[Have you/Has he/Has she] received free or discounted
housing?
[Have you/Has he/Has she] received chore services to help
with heavier housecleaning or yard work?
20
REQUIRED
IF PTCPT = CM
B3.
In the past 6 months, [have you/has he/has she] attended a class or lecture about any of
the following at [NAME OF PROGRAM SITE]?
YES
NO
DON’T
KNOW
REFUSED
a. A specific chronic disease (e.g., Diabetes, heart disease)?
1
0
d
r
b. Nutrition or healthy eating habits?
1
0
d
r
c.
1
0
d
r
d. Health insurance or Medicare Part D?
1
0
d
r
e. How to manage [your/his/her] medications?
1
0
d
r
f.
1
0
d
r
Safety issues such as falls prevention?
How to manage [your/his/her] finances?
REQUIRED
IF PTCPT = CM
B3.1
Thinking about other activities at [NAME OF PROGRAM SITE], in the past 6 months
[have you/has he/has she] . . .
YES
NO
DON’T
KNOW
REFUSED
a. Participated in an exercise or fitness class there?
1
0
d
r
b. Received assistance in finding employment there?
1
0
d
r
1
0
d
r
1
0
d
r
c.
Received legal services such as help with making a will or
understanding a bill or other legal matter there?
d. Received counseling about your housing situation or
problems with your housing there?
21
C. SERVICES, ACTIVITIES, AND TRANSPORTATION
PROGRAMMER BOX C1
CATI: CONTINUE IF PTCPT = CM, HDM, or NON.
REQUIRED
IF PTCPT = CM
C_Intro:
C1.
The next questions are about how [you get/he gets/she gets] to and from [NAME OF
PROGRAM SITE].
During the past 30 days, [have you/has he/has she] done any of the following to get to or
from [NAME OF PROGRAM SITE]? Did you . . .
a. Drive [yourself/himself/herself]?
YES
NO
DON’T
KNOW
REFUSED
NOT APPLICABLE
(SITE IN BUILDING
WHERE
PARTICIPANT
RESIDES)
1
0
d
r
n
SKIP TO C5
b. Share a ride with a friend or family
member but were not the driver?
1
0
d
r
n
Use private transportation such as a
taxi, limousine, or car service?
1
0
d
r
n
d. Use public transportation such as buses,
light rail transit, trains, subways,
community shuttles or jitneys?
1
0
d
r
n
e. Use para transportation such as ADA
transit or Dial-A Ride transit?
1
0
d
r
n
1
0
d
r
n
1
0
d
r
n
c.
f.
Use specialized transportation such as
nutrition program or senior program
sponsored bus/van/car, church or faithbased program bus/van/car, or volunteer
driver?
g. Use some other form of transportation
such as walking, biking, or using a
scooter?
22
REQUIRED
IF C1e OR C1f = 1
C2.
During the past 30 days, how often did [you/he/she] use para or special transportation to
get to and from [NAME OF PROGRAM SITE]?
|
|
| (0-999) TIMES
PER DAY (Range 1-5) .......................................................................................... 1
PER WEEK (Range 1-25) ..................................................................................... 2
PER MONTH (Range 1-50) .................................................................................. 3
PER YEAR (Range 1-99) ...................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF C2 GT 99; I want to be sure I recorded your answer correctly. Did you say
[fill C2]? INTERVIEWER: ANSWER CANNOT EXCEED 99.
HARD CHECK: IF PER DAY GT 5; I want to be sure I recorded your answer correctly. Did you say
[fill C2] times per day? INTERVIEWER: ANSWER CANNOT EXCEED 5 TIMES PER DAY.
HARD CHECK: IF PER WEEK GT 25; I want to be sure I recorded your answer correctly. Did you
say [fill C2] times per week? INTERVIEWER: ANSWER CANNOT EXCEED 25 TIMES PER WEEK.
HARD CHECK: IF PER MONTH GT 50 1; I want to be sure I recorded your answer correctly. Did you
say [fill C2] times per month? INTERVIEWER: ANSWER CANNOT EXCEED 50 TIMES PER MONTH.
HARD CHECK: IF C2 = 0; I want to be sure I recorded your answer correctly. Did you say [fill C2]?
INTERVIEWER: ANSWER CANNOT BE 0.
REQUIRED
IF ANY C1B-G = 1
C3.
How easy is it to obtain transportation to the [NAME OF PROGRAM SITE]? Would
[you/he/she] say . . .
CODE ONE ONLY
Very easy, ............................................................................................................ 1
Somewhat easy, .................................................................................................. 2
Not too easy, or ................................................................................................... 3
Not easy at all? .................................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
23
REQUIRED
IF C1e OR C1f = 1
C4.
If the transportation service [you use/he uses/she uses] to get to and from [NAME OF
PROGRAM SITE] was not available, would [you/he/she] go . . .
CODE ONE ONLY
About as often as now, ....................................................................................... 1
Somewhat less often, ......................................................................................... 2
A lot less often, or ............................................................................................... 3
Wouldn’t go at all? .............................................................................................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM, OR NON
C5.
During the past year, [have you/has he/has she] used any of the following transportation
services to go to the store, bank, doctor’s office, or some other place?
YES
NO
DON’T
KNOW
REFUSED
a. Para transportation such as ADA transit or Dial-A Ride
transit?
1
0
d
r
b. Specialized transportation such as a senior program
sponsored bus/van/car, church or faith-based program
bus/van/car, or volunteer driver?
1
0
d
r
REQUIRED
IF C5a OR C5b = 1
C6.
Where did the transportation service take [you/him/her]?
CODE ALL THAT APPLY
Grocery shopping, .............................................................................................. 1
Other types of shopping,.................................................................................... 2
Doctor or other health care visit, ....................................................................... 3
Bank or other errand, or ..................................................................................... 4
Some place else? (PLEASE SPECIFY) .............................................................. 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
24
D. RECREATIONAL AND SOCIAL ACTIVITIES
PROGRAMMER BOX D1
CATI: CONTINUE IF PTCPT = CM. IF PTCPT = HDM OR NON, SKIP TO
SECTION E.
D_Intro:
The next questions are about recreational and social activities [you/he/she] may
participate in at [NAME OF PROGRAM SITE].
REQUIRED
IF PTCPT = CM
D1.
In general, how satisfied [are you/is he/is she] with opportunities [you have/he has/she
has] to spend time with other people at [NAME OF PROGRAM SITE]? Would [you/he/she]
say [you are/he is/she is] . . .
CODE ONE ONLY
Very satisfied, ...................................................................................................... 1
Somewhat satisfied,............................................................................................ 2
Not too satisfied, or ............................................................................................ 3
Not at all satisfied? ............................................................................................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM
D2.
[Do you/Does he/Does she] spend a lot of time, some time, just a little time, or no time
participating in other activities or receiving other services at the [NAME OF PROGRAM
SITE] meal site?
CODE ONE ONLY
A LOT OF TIME .................................................................................................... 1
SOME TIME .......................................................................................................... 2
JUST A LITTLE TIME ........................................................................................... 3
NO TIME ............................................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
25
REQUIRED
IF PTCPT = CM
D3.
How long [do you /does he/does she] usually stay at the [NAME OF PROGRAM SITE] meal
site each time [you go/he goes/she goes]? Please include the time [you spend/he
spent/she spent] getting a meal.
|
|
| (0-999)
MINUTES (1-90) ................................................................................................... 1
HOURS (1-10) ....................................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF D3 GT 90; I want to be sure I recorded your answer correctly. Did you say
[fill D3]? INTERVIEWER: ANSWER CANNOT EXCEED 90.
HARD CHECK: IF HOURS GT 10; I want to be sure I recorded your answer correctly. Did you say
[fill D3] hours? INTERVIEWER: ANSWER CANNOT EXCEED 10 HOURS.
HARD CHECK: IF D3 = 0; I want to be sure I recorded your answer correctly. Did you say [fill D3]?
INTERVIEWER: ANSWER CANNOT BE 0.
26
E. INFORMATION AND REFERRAL, OTHER SERVICES
PROGRAMMER BOX E1
CATI: CONTINUE IF PTCPT = CM OR HDM. IF PTCPT = NON,
CONTINUE IF B1.1 = 1. ELSE, SKIP TO SECTION J.
REQUIRED
IF PTCPT = CM OR HDM
E_Intro:
The next set of questions are about services, help, or information [you/he/she] may
receive from [NAME OF PROGRAM SITE].
REQUIRED
IF PTCPT = NON
E_Intro:
The next set of questions are about services, help, or information [you/he/she] may
receive from [NAME OF AREA AGENCY ON AGING] or another organization.
REQUIRED
IF PTCPT = CM OR HDM
E1.
During the past year, did someone from the [NAME OF PROGRAM] provide information or
refer [you/him/her] to places to learn about financial, social, or health services that are
available or tell [you/him/her] how to get the help [you need/he needs/she needs]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO F1
DON’T KNOW ....................................................................................................... d
SKIP TO F1
REFUSED ............................................................................................................. r
SKIP TO F1
REQUIRED
IF PTCPT = NON
E1.1
During the past year, did someone from [NAME OF AREA AGENCY ON AGING] or another
organization provide information or refer [you/him/her] to places to learn about financial,
social, or health services that are available or tell [you/him/her] how to get the help [you
need/he needs/she needs]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO J1
DON’T KNOW ....................................................................................................... d
SKIP TO J1
REFUSED ............................................................................................................. r
SKIP TO J1
27
REQUIRED
IF E1 = 1
E2.
How often did [you/he/she] seek out this kind of information or help from the [NAME OF
PROGRAM] in the past year?
|
|
| TIMES (0-999)
PER WEEK (Range 1-7) ....................................................................................... 1
PER MONTH (Range 1-31) .................................................................................. 2
PER YEAR (Range 1-90) ...................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF E2 GT 90; I want to be sure I recorded your answer correctly. Did you say [fill E2]
times? INTERVIEWER: ANSWER CANNOT EXCEED 90 TIMES.
HARD CHECK: IF PER WEEK GT 7; I want to be sure I recorded your answer correctly. Did you say
[fill E2] times per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 TIMES PER WEEK.
HARD CHECK: IF PER MONTH GT 31; I want to be sure I recorded your answer correctly. Did you
say [fill E2] times per month? INTERVIEWER: ANSWER CANNOT EXCEED 31 TIMES PER MONTH.
HARD CHECK: IF E2 = 0; I want to be sure I recorded your answer correctly. Did you say [fill E2]
times? INTERVIEWER: ANSWER CANNOT BE 0.
REQUIRED
IF E1.1 = 1
E2.1
How often did [you/he/she] seek out this kind of information or help from [NAME OF AREA
AGENCY ON AGING] or another organization in the past year?
|
|
| TIMES (0-999)
PER WEEK (Range 1-7) ....................................................................................... 1
PER MONTH (Range 1-31) .................................................................................. 2
PER YEAR (Range 1-90) ...................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF E2.1 GT 90; I want to be sure I recorded your answer correctly. Did you say
[fill E2.1] times? INTERVIEWER: ANSWER CANNOT EXCEED 90 TIMES.
HARD CHECK: IF PER WEEK GT 7; I want to be sure I recorded your answer correctly. Did you say
[fill E2.1] times per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 TIMES PER WEEK.
HARD CHECK: IF PER MONTH GT 31; I want to be sure I recorded your answer correctly. Did you
say [fill E2.1] times per month? INTERVIEWER: ANSWER CANNOT EXCEED 31 TIMES PER
MONTH.
HARD CHECK: IF E2.1 = 0; I want to be sure I recorded your answer correctly. Did you say
[fill E2.1] times? INTERVIEWER: ANSWER CANNOT BE 0.
28
REQUIRED
IF E1 OR E1.1 = 1
E3.
[Were you/was he/was she] looking for information or a referral to any of the following . . .
YES
NO
DON’T
KNOW
REFUSED
a. An adult day care program?
1
0
d
r
b. Personal care services for help with dressing or bathing?
1
0
d
r
1
0
d
r
d. A nutritional counselor who would give [you/him/her]
individual advice on what [you/he/she] should eat?
1
0
d
r
e. Case management services in which a case manager
would set up in-home services for [you/him/her] such as
homemaker or personal care services, or calls to see how
[you are/he is/she is] doing?
1
0
d
r
1
0
d
r
g. Homemaker or housekeeping services to help with light
housework, preparing meals, or shopping?
1
0
d
r
h. Chore services to help with heavier housecleaning or yard
work?
1
0
d
r
i.
Housing assistance?
1
0
d
r
j.
Transportation services?
1
0
d
r
c.
f.
A visiting nurse or therapist that would come to your home
to provide physical, occupational, or speech therapy?
A support group to talk with other people who have the
same kind of problems [you have/he has/she has]?
REQUIRED
IF E1 = 1
E4.
During the past year, when [you/he/she] sought out information about services or help
from [NAME OF PROGRAM] staff and were referred to an agency other than [NAME OF
PROGRAM SITE], did the program staff ever . . .
YES
NO
DON’T
KNOW
REFUSED
a. Give [you/him/her] printed information, brochures,
applications, or phone numbers?
1
0
d
r
b. Fill out or help [you/him/her] to fill out an application or
paperwork for services?
1
0
d
r
1
0
d
r
d. Accompany [you/him/her] to the other agency?
1
0
d
r
e. Provide or arrange for transportation to the other agency?
1
0
d
r
1
0
d
r
c.
f.
Make an appointment for [you/him/her] at the other agency
or notify them that [you were/he was/she was] coming?
Follow-up with [you/him/her] to see that [you were/he
was/she was] served by the other agency?
29
REQUIRED
IF E1 = 1
E5.
Overall, how helpful was the program staff in getting [you/him/her] the information,
services, help, or benefits [you were/he was/she was] looking for? Were they . . .
CODE ONE ONLY
Very helpful, ......................................................................................................... 1
Somewhat helpful, .............................................................................................. 2
Not too helpful, or ............................................................................................... 3
Not at all helpful? ................................................................................................ 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF E1 = 1
E6.
Has [NAME OF PROGRAM] staff ever given [you/him/her] information or helped
[you/him/her] with making decisions on Medicare Part D, the prescription drug benefit?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
30
F. HELPFULNESS OF PROGRAM
PROGRAMMER BOX F1
CATI: CONTINUE IF PTCPT = CM OR HDM. IF PTCPT = NON, SKIP TO
SECTION J.
REQUIRED
IF PTCPT = CM OR HDM
F1.
Overall, how helpful has [NAME OF PROGRAM]’s nutrition program been? Would
[you/he/she] say it has. . .
CODE ONE ONLY
Helped [you/him/her] a lot, ................................................................................. 1
Helped [you/him/her] somewhat,....................................................................... 2
Helped [you/him/her] a little, .............................................................................. 3
Didn’t help [you/him/her], or .............................................................................. 4
Made things worse?............................................................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM OR HDM
F2.
Has [NAME OF PROGRAM SITE]’s nutrition program . . .
YES
NO
DON’T
KNOW
REFUSED
a. Helped [you/him/her] eat healthier foods?
1
0
d
r
b. Improved [your/his/her] health?
1
0
d
r
1
0
d
r
d. Helped [you/him/her] achieve or maintain a healthy weight?
1
0
d
r
e. Helped [you/him/her] to live independently and stay in
[your/his/her] home?
1
0
d
r
c.
Helped [you/him/her] follow the special diet that is
prescribed by [your/his/her] doctor or dietician?
31
G. VOLUNTEER WORK FOR [NAME OF PROGRAM SITE] NUTRITION PROGRAM
PROGRAMMER BOX G1
CATI: CONTINUE IF PTCPT = CM. IF PTCPT = HDM, SKIP TO SECTION
H. IF PTCPT = NON, SKIP TO SECTION J.
G_Intro:
The next set of questions are about volunteer work for [NAME OF PROGRAM SITE]’s
nutrition program.
REQUIRED
IF PTCPT = CM
G1.
[Do you/Does he/Does she] do volunteer work for [NAME OF PROGRAM SITE]’s nutrition
program?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO H1
DON’T KNOW ....................................................................................................... d
SKIP TO H1
REFUSED ............................................................................................................. r
SKIP TO H1
REQUIRED
IF G1 = 1
G2.
How often [do you/does he/does she] do volunteer work for [NAME OF PROGRAM SITE]’s
nutrition program?
|
|
| TIMES (0-999)
PER WEEK (Range 1-7) ....................................................................................... 1
PER MONTH (Range 1-31) .................................................................................. 2
PER YEAR (Range 1-90) ...................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF G2 GT 90; I want to be sure I recorded your answer correctly. Did you say
[fill G2] times? INTERVIEWER: ANSWER CANNOT EXCEED 90 TIMES.
HARD CHECK: IF PER WEEK GT 7; I want to be sure I recorded your answer correctly. Did you say
[fill G2] times per week? INTERVIEWER: ANSWER CANNOT EXCEED 7 TIMES PER WEEK.
HARD CHECK: IF PER MONTH GT 31; I want to be sure I recorded your answer correctly. Did you
say [fill G2] times per month? INTERVIEWER: ANSWER CANNOT EXCEED 31 TIMES PER MONTH.
HARD CHECK: IF G2 = 0; I want to be sure I recorded your answer correctly. Did you say [fill G2]
times? INTERVIEWER: ANSWER CANNOT BE 0.
32
REQUIRED
IF G1 = 1
G3.
On average, how long [do you/does he/does she] volunteer each time [you do/he does/she
does] volunteer work?
PROBE:
|
|
Your best estimate is fine.
| (0-999)
MINUTES (Range 1-90) ........................................................................................ 1
HOURS (Range 1-10) ........................................................................................... 2
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF G3 GT 90; I want to be sure I recorded your answer correctly. Did you say
[fill G3]? INTERVIEWER: ANSWER CANNOT EXCEED 90.
HARD CHECK: IF HOURS GT 10; I want to be sure I recorded your answer correctly. Did you say
[fill G3] hours? INTERVIEWER: ANSWER CANNOT EXCEED 10 HOURS.
HARD CHECK: IF G3 = 0; I want to be sure I recorded your answer correctly. Did you say [fill G3]?
INTERVIEWER: ANSWER CANNOT BE 0.
REQUIRED
IF G1 = 1
G4.
[Do you/Does he/Does she] do volunteer work for the congregate nutrition program, the
home-delivered nutrition program, or both programs?
CODE ONE ONLY
CONGREGATE NUTRITION PROGRAM ............................................................ 1
HOME-DELIVERED NUTRITION PROGRAM ..................................................... 2
BOTH NUTRITION PROGRAMS ......................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
33
H. IMPRESSIONS OF THE NUTRITION PROGRAM
PROGRAMMER BOX H1
CATI: CONTINUE IF PTCPT = CM OR HDM. IF PTCPT = NON, SKIP TO
SECTION J.
H_Intro:
The next questions are about [your/his/her] general impression of the [NAME OF
PROGRAM].
REQUIRED
IF PTCPT = CM
H1.
Overall, how would [you/he/she] rate the nutrition program at [NAME OF PROGRAM SITE]?
Would [you/he/she] say it is . . .
CODE ONE ONLY
Excellent, ............................................................................................................. 1
Very good, ............................................................................................................ 2
Good, .................................................................................................................... 3
Fair, or .................................................................................................................. 4
Poor? .................................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = HDM
H1.1
Overall, how would [you/he/she] rate [NAME OF PROGRAM SITE]’s home-delivered
nutrition program? Would [you/he/she] say it is . . .
CODE ONE ONLY
Excellent, ............................................................................................................. 1
Very good, ............................................................................................................ 2
Good, .................................................................................................................... 3
Fair, or .................................................................................................................. 4
Poor? .................................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
34
REQUIRED
IF PTCPT = CM OR HDM
H1.2
Which of the following best describes the meals provided by [NAME OF PROGRAM SITE]?
CODE ONE ONLY
There is a set menu that does not give [me/him/her] any choice of food
items, .................................................................................................................... 1
[I have/He has/She has] a choice of different complete meal options
(e.g., Meal A or Meal B), or ................................................................................. 2
[I have/He has/She has] a choice of different food items within the
meal (e.g., Choice of entrée, choice of vegetables, fruit, dessert, salad
bar)........................................................................................................................ 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM
H2.
What [do you/does he/does she] like most about the [NAME OF PROGRAM SITE]’s
nutrition program? Would [you/he/she] say the . . .
CODE ONE ONLY
Food,..................................................................................................................... 1
Other services, .................................................................................................... 2
Participants, ......................................................................................................... 3
Staff, ..................................................................................................................... 4
Activities, ............................................................................................................. 5
Location, or .......................................................................................................... 6
Something else? (PLEASE SPECIFY) .............................................................. 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
35
REQUIRED
IF PTCPT = HDM
H2.1
What [do you/does he/does she] like most about the [NAME OF PROGRAM SITE]’s
nutrition program? Would [you/he/she] say the . . .
CODE ONE ONLY
Food,..................................................................................................................... 1
Delivery staff, or .................................................................................................. 2
Something else? (PLEASE SPECIFY) .............................................................. 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM
[PROGRAMMER: EXCLUDE RESPONSES GIVEN TO H2 FROM H3]
H3.
What [do you/does he/does she] like least about the [NAME OF PROGRAM SITE]’s
nutrition program? Would [you/he/she] say the . . .
CODE ONE ONLY
Food,..................................................................................................................... 1
Services, .............................................................................................................. 2
Participants, ......................................................................................................... 3
Staff, ..................................................................................................................... 4
Activities, ............................................................................................................. 5
Location, or .......................................................................................................... 6
Something else? (PLEASE SPECIFY) .............................................................. 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
36
REQUIRED
IF PTCPT = HDM
[PROGRAMMER: EXCLUDE RESPONSES GIVEN TO H2.1 FROM H3.1]
H3.1
What [do you/does he/does she] like least about the [NAME OF PROGRAM SITE]’s
nutrition program? Would [you/he/she] say the . . .
CODE ONE ONLY
Food,..................................................................................................................... 1
Delivery staff, or .................................................................................................. 2
Something else? (PLEASE SPECIFY) ............................................................... 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM OR HDM
H6.
How would [you/he/she] rate the [NAME OF PROGRAM SITE]’s staff overall? Would
[you/he/she] say they are . . .
CODE ONE ONLY
Excellent, ............................................................................................................. 1
Very good, ............................................................................................................ 2
Good, .................................................................................................................... 3
Fair, or .................................................................................................................. 4
Poor? .................................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
37
REQUIRED
IF PTCPT = CM OR HDM
Next I’m going to read you some statements about [NAME OF PROGRAM SITE]’s nutrition
program.
H7.
Think about all the foods [you receive/he receives/she receives] from [NAME OF
PROGRAM SITE]’s nutrition program. Would [you/he/she] say [you are/he is/she is]
always, usually, sometimes, seldom, or never satisfied . . .
ALWAYS
USUALLY
SOMETIMES
SELDOM
NEVER
DON’T
KNOW
REFUSED
a. with the way the food
tastes?
1
2
3
4
5
d
r
b. with the way the food
smells?
1
2
3
4
5
d
r
1
2
3
4
5
d
r
d. with the variety of food?
1
2
3
4
5
d
r
e. that hot foods are hot and
cold foods are cold?
1
2
3
4
5
d
r
that you get foods that
[you like/he likes/she
likes]?
1
2
3
4
5
d
r
g. that [your/his/her] special
dietary needs or
restrictions are met?
1
2
3
4
5
d
r
h. with the amount of food
[you receive/he receives/
she receives]?
1
2
3
4
5
d
r
1
2
3
4
5
d
r
c.
f.
with the way the food
looks?
(PTCPT = CM):
i.
with the tables and table
settings?
38
REQUIRED
IF PTCPT = CM OR HDM
H8.
[Do you/Does he/Does she] like the meals that [you get/he gets/she gets] from [NAME OF
PROGRAM SITE]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM
H9.
[Are you/Is he/Is she] greeted when [you arrive/he arrives/she arrives] at [NAME OF
PROGRAM SITE]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = HDM
H10.
How often does the meal arrive at the scheduled time? Would [you/he/she] say . . .
CODE ONE ONLY
Always, ................................................................................................................. 1
Usually, ................................................................................................................ 2
Sometimes, .......................................................................................................... 3
Seldom, or ............................................................................................................ 4
Never? .................................................................................................................. 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
39
REQUIRED
IF PTCPT = HDM
H11.
How often does the person who delivers [your/his/her] meals stay and spend some time
talking with [you/him/her]? Would [you/he/she] say . . .
CODE ONE ONLY
Always, ................................................................................................................. 1
Usually, ................................................................................................................ 2
Sometimes, .......................................................................................................... 3
Seldom, or ............................................................................................................ 4
Never? .................................................................................................................. 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = HDM
H12.
How often is the person who delivers [your/his/her] meals pleasant? Would [you/he/she]
say . . .
CODE ONE ONLY
Always, ................................................................................................................. 1
Usually, ................................................................................................................ 2
Sometimes, .......................................................................................................... 3
Seldom, or ............................................................................................................ 4
Never? .................................................................................................................. 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM OR HDM
H13.
Would [you/he/she] recommend [NAME OF PROGRAM SITE]’s nutrition program to
[your/his/her] friends or relatives?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
40
I. MEAL CONTRIBUTIONS
PROGRAMMER BOX I1
CATI: CONTINUE IF PTCPT = CM OR HDM. IF PTCPT = NON, SKIP TO
SECTION J.
I_Intro:
The next set of questions are about monetary contributions to the nutrition program at
[NAME OF PROGRAM SITE].
REQUIRED
IF PTCPT = CM OR HDM
I1.
[Do you/Does he/Does she] make monetary contributions to [NAME OF PROGRAM SITE]’s
nutrition program?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO J1
DON’T KNOW ....................................................................................................... d
SKIP TO J1
REFUSED ............................................................................................................. r
SKIP TO J1
REQUIRED
IF I1 = 1
I2.
Does the program have a suggested amount that [you/he/she] should contribute for each
meal?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO I4
DON’T KNOW ....................................................................................................... d
SKIP TO I4
REFUSED ............................................................................................................. r
SKIP TO I4
REQUIRED
IF I2 = 1
I3.
[Do you/Does he/Does she] think the suggested amount [you are/he is/she is] asked to
contribute is too much, too little, or about right?
CODE ONE ONLY
TOO MUCH ........................................................................................................... 1
TOO LITTLE .......................................................................................................... 2
ABOUT RIGHT ...................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
41
REQUIRED
IF I1 = 1
I4.
[Do you/Does he/Does she] decide for [yourself/himself/herself] how much to contribute
for each meal?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF I1 = 1
I5.
[Do you/Does he/Does she] feel pressured to contribute for each meal?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
42
J. EATING BEHAVIOR, DIET AND FOOD PREPARATION
PROGRAMMER BOX I1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER
QUESTIONS IN SECTION J.
J_Intro:
The next questions are about the meals [you eat/he eats/she eats] each day.
REQUIRED
IF PTCPT = CM, HDM OR NON
J1.
In total, how many different meals do you usually eat each day? Please include meals you
eat at home or away from home.
ENTER MEALS PER DAY .................................................................................... 0
NOT REGULAR, EAT WHEN HUNGRY .............................................................. 99
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF J1 = 0
J1_Meals. ENTER NUMBER OF MEALS PER DAY
|
| MEALS PER DAY (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF J1_Meals = 0; I want to be sure I recorded your answer correctly. Did you say
[fill J1_Meals] meals per day? INTERVIEWER: ANSWER CANNOT BE 0
HARD CHECK: IF J1_Meals GT 7; I want to be sure I recorded your answer correctly. Did you say
[fill J1_Meals] meals per day? INTERVIEWER: ANSWER CANNOT EXCEED 7 MEALS PER DAY
43
REQUIRED
IF PTCPT = CM, HDM OR NON
J2.
When at home, [do you/does he/does she] usually prepare [your/his/her] own meals, help
someone else cook, or don’t cook at all?
CODE ONE ONLY
PREPARE OWN MEALS ...................................................................................... 1
HELP SOMEONE ELSE COOK ........................................................................... 2
DON’T COOK ........................................................................................................ 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
J3.
Can [you/he/she] prepare hot meals for [yourself/himself/herself] if [you need/he
needs/she needs] to?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
J4.
[Are you/Is he/Is she] currently on any special diet for health, medication, religious, or
cultural reasons?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO J7
DON’T KNOW ....................................................................................................... d
SKIP TO J7
REFUSED ............................................................................................................. r
SKIP TO J7
44
REQUIRED
IF J4 = 1
J5.
What kind of special diet [are you/is he/is she] on?
CODE ALL THAT APPLY
DIABETIC .............................................................................................................. 1
LOW SODIUM/SALT............................................................................................. 2
LOW CHOLESTEROL .......................................................................................... 3
LOW CALORIE ..................................................................................................... 4
LOW SUGAR ........................................................................................................ 5
LOW FAT .............................................................................................................. 6
LOW FIBER .......................................................................................................... 7
HIGH FIBER .......................................................................................................... 8
GROUND OR PUREED ........................................................................................ 9
VEGETARIAN ....................................................................................................... 10
NON-DAIRY/ LACTOSE-FREE ............................................................................ 11
KOSHER ............................................................................................................... 12
HALAL ................................................................................................................... 13
OTHER (PLEASE SPECIFY) ............................................................................... 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM OR HDM AND J4 = 1
J6.
How often does [NAME OF PROGRAM SITE]’s nutrition program serve foods that help
meet [your/his/her] special dietary needs? Would [you/he/she] say . . .
CODE ONE ONLY
Almost always, .................................................................................................... 1
Often, .................................................................................................................... 2
Sometimes, .......................................................................................................... 3
Seldom, or ............................................................................................................ 4
Never? .................................................................................................................. 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
45
REQUIRED
IF PTCPT = CM, HDM OR NON
J7.
How is [your/his/her] appetite? Would [you/he/she] say it is usually excellent, good, fair, or
poor?
CODE ONE ONLY
EXCELLENT ......................................................................................................... 1
GOOD ................................................................................................................... 2
FAIR ...................................................................................................................... 3
POOR .................................................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
J8.
[Do you/Does he/Does she] eat alone most of the time?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
J9.
[Do you/Does he/Does she] have a refrigerator that works?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
J10.
[Do you/Does he/Does she] have a freezer that works?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
46
REQUIRED
IF PTCPT = CM, HDM OR NON
J11.
[Do you/Does he/Does she] have a stove or toaster oven that works?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
J12.
[Do you/Does he/Does she] have a microwave that works?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
47
K. FOOD SECURITY
PROGRAMMER BOX I1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER
QUESTIONS IN SECTION K.
K_Intro:
These next questions are about the food eaten in [your/his/her] household in the last
30 days and whether [you were/he was/she was] able to afford the food [you need/he
needs/she needs].
REQUIRED
IF PTCPT = CM, HDM OR NON
K1.
I'm going to read you several statements that people have made about their food situation.
For these statements, please tell me whether the statement was OFTEN, SOMETIMES, or
NEVER true for [your/his/her] household in the last 30 days.
The first statement is, “The food that [I/he/she] bought just didn’t last, and [I/he/she] didn't
have money to get more.” Was that often, sometimes, or never true for [your/his/her]
household in the last 30 days?
CODE ONE ONLY
OFTEN TRUE ....................................................................................................... 1
SOMETIMES TRUE .............................................................................................. 2
NEVER TRUE ....................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
K2.
“[I/he/she] couldn't afford to eat balanced meals.” Was that often, sometimes, or never true
for [your/his/her] household in the last 30 days?
CODE ONE ONLY
OFTEN TRUE ....................................................................................................... 1
SOMETIMES TRUE .............................................................................................. 2
NEVER TRUE ....................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
48
REQUIRED
IF PTCPT = CM, HDM OR NON
K3.
In the last 30 days, did anyone in [your/his/her] household ever cut the size of
[your/his/her] meals or skip meals because there wasn't enough money for food?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO K5
DON’T KNOW ....................................................................................................... d
SKIP TO K5
REFUSED ............................................................................................................. r
SKIP TO K5
REQUIRED
IF K3 = 1
K4.
In the last 30 days, how many days did this happen?
|
|
| DAYS (1-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF K4 = 0; In a previous question you answered that in the last 30 days, someone in
your household cut the size of [your/his/her] meals because there wasn’t enough money for food.
However, in K4 you answered that this happened on 0 days. Have I entered something
incorrectly? INTERVIEWER: ANSWER MUST BE GREATER THAN 0 DAYS.
HARD CHECK: IF K4 GT 30; I want to be sure I recorded your answer correctly. Did you say [fill K4]
days? INTERVIEWER: ANSWER CANNOT EXCEED 30 DAYS.
REQUIRED
IF PTCPT = CM, HDM OR NON
K5.
In the last 30 days, did [you/he/she] ever eat less than [you/he/she] felt [you/he/she] should
because there wasn't enough money to buy food?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
49
REQUIRED
IF PTCPT = CM, HDM OR NON
K6.
In the last 30 days, [were you/was he/was she] ever hungry but didn't eat because
[you/he/she] couldn't afford enough food?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
50
L. HEALTH STATUS
PROGRAMMER BOX L1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER
QUESTIONS IN SECTION L.
L_Intro:
The next questions are about [your/his/her] health.
REQUIRED
IF PTCPT = CM, HDM OR NON
L1.
In general, would [you/he/she] say [your/his/her] health is excellent, very good, good, fair,
or poor?
CODE ONE ONLY
EXCELLENT ......................................................................................................... 1
VERY GOOD ........................................................................................................ 2
GOOD ................................................................................................................... 3
FAIR ...................................................................................................................... 4
POOR .................................................................................................................... 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
L2.
During the past year, about how many different times [were you/was he/was she] treated in
an emergency room?
|
|
| TIMES (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF L2 GT 10; I want to be sure I recorded your answer correctly. Did you say [fill L2]
times?
HARD CHECK: IF L2 GT 50; I want to be sure I recorded your answer correctly. Did you say [fill L2]
times? INTERVIEWER: ANSWER CANNOT EXCEED 50 TIMES.
51
REQUIRED
IF PTCPT = CM, HDM OR NON
L3.
During the past year, about how many different times did [you/he/she] spend at least one
night in the hospital?
|
|
| TIMES (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF L3 GT 10; I want to be sure I recorded your answer correctly. Did you say [fill L3]
times?
HARD CHECK: IF L3 GT 50; I want to be sure I recorded your answer correctly. Did you say [fill L3]
times? INTERVIEWER: ANSWER CANNOT EXCEED 50 TIMES.
REQUIRED
IF PTCPT = CM, HDM OR NON
L4.
During the past year, did [you/he/she] stay in a nursing home, convalescent home, or
rehabilitation center?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
L5.
During the past year, was there a particular clinic, health center, medical doctor’s office, or
other place that [you/he/she] usually went to if [you were/he was/she was] sick, needed
advice about your health, or for routine care?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
52
REQUIRED
IF PTCPT = CM, HDM OR NON
L6.
During the past 30 days, about how many times did [you/he/she] see or talk to a medical
doctor or other health care professional? Do not count doctors seen while being an
overnight patient in a hospital or nursing home.
|
|
| TIMES (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF L6 GT 10; I want to be sure I recorded your answer correctly. Did you say [fill L6]
times?
HARD CHECK: IF L6 GT 30; I want to be sure I recorded your answer correctly. Did you say [fill L6]
times? INTERVIEWER: ANSWER CANNOT EXCEED 30 TIMES.
REQUIRED
IF L6 = 0 TIMES
L6a.
During the past year, about how many times did [you/he/she] see or talk to a medical
doctor or other health care professional? Do not count doctors seen while being an
overnight patient in a hospital or nursing home.
|
|
| TIMES (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF L6a GT 10; I want to be sure I recorded your answer correctly. Did you say
[fill L6a] times?
HARD CHECK: IF L6a GT 30; I want to be sure I recorded your answer correctly. Did you say
[fill L6a] times? INTERVIEWER: ANSWER CANNOT EXCEED 30 TIMES.
53
REQUIRED
IF PTCPT = CM, HDM OR NON
L7.
Has a doctor ever told [you/he/she] that [you have/he has/she has]:
YES
NO
DON’T
KNOW
REFUSED
a. Arthritis or rheumatism?
1
0
d
r
b. High blood pressure or hypertension?
1
0
d
r
1
0
d
r
d. High cholesterol?
1
0
d
r
e. Diabetes or high blood sugar?
1
0
d
r
1
0
d
r
g. Cancer or malignant tumor, excluding minor skin cancer?
1
0
d
r
h. A hearing impairment?
1
0
d
r
i.
Stroke?
1
0
d
r
j.
Anemia?
1
0
d
r
k.
Osteoporosis?
1
0
d
r
l.
Kidney disease?
1
0
d
r
1
0
d
r
c.
f.
A heart attack, coronary heart disease, angina, congestive
heart failure, or any other heart problems?
Allergies, asthma, emphysema, chronic bronchitis, or other
breathing and lung problems?
m. Eye or vision conditions such as glaucoma, cataracts,
macular degeneration or other medical conditions of the
eye?
[INTERVIEWER NOTE: THIS DOES NOT INCLUDE JUST
WEARING GLASSES OR CONTACTS.]
REQUIRED
IF PTCPT = CM, HDM OR NON
L8.
[Do you/Does he/Does she] currently wear dentures?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
54
REQUIRED
IF PTCPT = CM, HDM OR NON
L9.
In the past year, did [you/he/she] get a flu shot?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON AND RESPONDENT AGE < 65
L10.
[Have you/Has he/Has she] ever had a vaccination to protect [you/him/her] from
pneumonia?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON AND RESPONDENT AGE > OR = 65
L11.
Since age 65, [have you/has he/has she] had a vaccination to protect [you/him/her] from
pneumonia?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
55
REQUIRED
IF PTCPT = CM, HDM OR NON
L12.
In the past 12 months, how many times have you fallen?
|
|
| TIMES (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF L12 GT 10; I want to be sure I recorded your answer correctly. Did you say
[fill L12] times?
HARD CHECK: IF L12 GT 30; I want to be sure I recorded your answer correctly. Did you say
[fill L12] times? INTERVIEWER: ANSWER CANNOT EXCEED 30 TIMES.
REQUIRED
IF L12 = DK
L13.
In the past 12 months, have you fallen more than two times?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
56
M. SMOKING
PROGRAMMER BOX M1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM, OR NON) ANSWER
QUESTIONS IN SECTION M.
M_Intro:
The next questions are about cigarette smoking.
REQUIRED
IF PTCPT = CM, HDM OR NON
M1.
[Have you/Has he/Has she] smoked at least 100 cigarettes in [your/his/her] entire life?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
GO TO N1
DON’T KNOW ....................................................................................................... d
GO TO N1
REFUSED ............................................................................................................. r
GO TO N1
REQUIRED
IF M1 = 1
M2.
[Do you/Does he/Does she] now smoke cigarettes . . .
CODE ONE ONLY
Every day, ............................................................................................................ 1
Some days, or ...................................................................................................... 2
Not at all? ............................................................................................................. 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
57
N. ALCOHOL CONSUMPTION
PROGRAMMER BOX N1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER
QUESTIONS IN SECTION M.
N_Intro:
The next set of questions are about alcohol consumption.
REQUIRED
IF PTCPT = CM, HDM OR NON
N1.
During the past 30 days, how many days did [you/he/she] have at least one drink of any
alcoholic beverage?
|
|
| DAYS (Range 0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF N1 GT 20; I want to be sure I recorded your answer correctly. Did you say [fill N1]
days?
HARD CHECK: IF N1 GT 30; I want to be sure I recorded your answer correctly. Did you say [fill N1]
days? INTERVIEWER: ANSWER CANNOT EXCEED 30 DAYS.
REQUIRED
IF N1 > 0
N2.
On the days when [you/he/she] drank, about how many drinks did [you/he/she] drink on
average?
|
|
| DRINKS PER DAY (1-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF N2 GT 5; I want to be sure I recorded your answer correctly. Did you say [fill N2]
drinks per day?
HARD CHECK: IF N2 GT 10; I want to be sure I recorded your answer correctly. Did you say [fill N2]
drinks per day? INTERVIEWER: ANSWER CANNOT EXCEED 10 DRINKS .
HARD CHECK: IF N2 = 0; I want to be sure I recorded your answer correctly. Did you say [fill N2]
drinks per day? INTERVIEWER: ANSWER CANNOT BE 0.
58
O. MEDICAL INSURANCE
PROGRAMMER BOX O1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON).
O_Intro:
The next questions are about health insurance and health care coverage.
PROGRAMMER NOTE: IF STATE IS CALIFORNIA, FILL STATE NAME FOR MEDICAID WITH
MEDIC-CAL; IF MASSACHUSETTS, FILL WITH MASS-HEALTH; IF
OREGON, FILL WITH OREGON HEALTH PLAN; IF TENNESSEE, FILL
WITH TENNCARE; IF ARIZONA, FILL WITH AHCCCS/ACCESS; IF MAINE,
FILL WITH MAINECARE.
REQUIRED
IF PTCPT = CM, HDM OR NON
O1.
What kind of health insurance plan or health care coverage [do you/does he/does she]
have right now? Please include those that pay for only one type of service (nursing home
care, accidents, or dental care). Please exclude private plans that only provide extra cash
while hospitalized. If [you have/he has/she has] more than one kind of health insurance,
tell me all plans that [you have/he has/she has].
CAPI INSTRUCTION: DO NOT ALLOW MORE THAN ONE ANSWER WHEN 10
(NO COVERAGE OF ANY TYPE) IS CODED.
CODE ALL THAT APPLY
MEDICARE ........................................................................................................... 1
MEDI-GAP ............................................................................................................ 2
OTHER PRIVATE HEALTH INSURANCE............................................................ 3
MEDICAID ({DISPLAY STATE PLAN NAME}). .................................................... 4
MILITARY HEALTH CARE (TRICARE/VA/CHAMP-VA) ...................................... 5
INDIAN HEALTH SERVICE .................................................................................. 6
STATE-SPONSORED HEALTH PLAN ({DISPLAY STATE PLAN NAME}) ......... 7
OTHER GOVERNMENT PROGRAM ................................................................... 8
SINGLE SERVICE PLAN (E.G., DENTAL, VISION) ............................................ 9
NO COVERAGE OF ANY TYPE .......................................................................... 10
SKIP TO O3
DON’T KNOW ....................................................................................................... d
SKIP TO O3
REFUSED ............................................................................................................. r
SKIP TO O3
59
REQUIRED
IF O1 = 1
O2.
[Are you/Is he/Is she] currently enrolled in Medicare Part D, also known as the Medicare
Prescription Drug Plan?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF O2 IS YES
O3.
[Are you/Is he/Is she] currently getting Extra Help from the government to pay for Medicare
Part D monthly premiums, annual deductibles, and prescription co-payments?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF O1 >= 2 AND <=9
O4.
Do any of [your/his/her] [IF O2=1 add “other”] health insurance plans cover any part of the
cost of [your/his/her] prescriptions?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
60
REQUIRED
IF O4 IS YES
O4.1
Which of [your/his/her] other health insurance plans cover part of the cost of [your/his/her]
prescriptions?
CODE ALL THAT APPLY
A STATE PRESCRIPTION ASSISTANCE PROGRAM (FILL STATE
PROGRAM NAME). .............................................................................................. 1
A DRUG MANUFACTURER PRESCRIPTION ASSISTANCE PROGRAM ......... 2
A COPAYMENT PROGRAM (FOUNDATION, NONPROFIT).............................. 3
SAVINGS CARD ................................................................................................... 4
OTHER (PLEASE SPECIFY) ............................................................................... 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
O5.
[Do you/Does he/Does she] have a Medicare Savings Program to pay for Medicare Part A
or Part B insurance premiums?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF O4.1 DOES NOT INCLUDE 1
O6.
During the past 30 days, did [you/he/she] receive assistance from [STATE NAME
PRESCRIPTION PROGRAM] to help with prescription drug expenses?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
61
P. MOBILITY
PROGRAMMER BOX P1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER
QUESTIONS IN SECTION P.
P_Intro:
The next set of questions are about [your/his/her] physical and mental health.
REQUIRED
IF PTCPT = CM, HDM OR NON
P1.
(ASK IF NOT APPARENT) Is [respondent/he/she] . . .
CODE ONE ONLY
Able to walk, ........................................................................................................ 1
SKIP TO P4
Bed bound, .......................................................................................................... 2
SKIP TO P2
Chair bound or in a wheelchair? ....................................................................... 3
SKIP TO P3
REQUIRED
IF P1 = 2
P2.
How long [have you/has he/has she] been confined to a bed?
|
|
| (0-999)
DAYS (Range 1-99) .............................................................................................. 1
SKIP TO P6
WEEKS (Range 1-30) ........................................................................................... 2
SKIP TO P6
MONTHS (Range 1-13) ........................................................................................ 3
SKIP TO P6
YEARS (Range 1-10) ............................................................................................ 4
SKIP TO P6
DON’T KNOW ....................................................................................................... d
SKIP TO P6
REFUSED ............................................................................................................. r
SKIP TO P6
HARD CHECK: IF P2 GT 99; I want to be sure I recorded your answer correctly. Did you say
[fill P2]? INTERVIEWER: ANSWER CANNOT EXCEED 99.
HARD CHECK: IF WEEKS GT 30; I want to be sure I recorded your answer correctly. Did you say
[fill P2] weeks? INTERVIEWER: ANSWER CANNOT EXCEED 30 WEEKS.
HARD CHECK: IF MONTHS GT 13; I want to be sure I recorded your answer correctly. Did you say
[fill P2] months? INTERVIEWER: ANSWER CANNOT EXCEED 13 MONTHS.
HARD CHECK: IF YEARS GT 10; I want to be sure I recorded your answer correctly. Did you say
[fill P2] years? INTERVIEWER: ANSWER CANNOT EXCEED 10 YEARS.
HARD CHECK: IF P2 = 0; I want to be sure I recorded your answer correctly. Did you say [fill P2]?
INTERVIEWER: ANSWER CANNOT BE 0.
62
REQUIRED
IF P1 = 3
P3.
How long [have you/has he/has she] been confined to a chair or a wheelchair?
|
|
| (0-999)
DAYS (Range 1-99) .............................................................................................. 1
SKIP TO P6
WEEKS (Range 1-30) ........................................................................................... 2
SKIP TO P6
MONTHS (Range 1-13) ........................................................................................ 3
SKIP TO P6
YEARS (Range 1-10) ............................................................................................ 4
SKIP TO P6
DON’T KNOW ....................................................................................................... d
SKIP TO P6
REFUSED ............................................................................................................. r
SKIP TO P6
HARD CHECK: IF P3 GT 99; I want to be sure I recorded your answer correctly. Did you say
[fill P3]? INTERVIEWER: ANSWER CANNOT EXCEED 99.
HARD CHECK: IF WEEKS GT 30; I want to be sure I recorded your answer correctly. Did you say
[fill P3] weeks? INTERVIEWER: ANSWER CANNOT EXCEED 30 WEEKS.
HARD CHECK: IF MONTHS GT 13; I want to be sure I recorded your answer correctly. Did you say
[fill P3] months? INTERVIEWER: ANSWER CANNOT EXCEED 13 MONTHS.
HARD CHECK: IF YEARS GT 10; I want to be sure I recorded your answer correctly. Did you say
[fill P3] years? INTERVIEWER: ANSWER CANNOT EXCEED 10 YEARS.
HARD CHECK: IF P3 = 0; I want to be sure I recorded your answer correctly. Did you say [fill P3]?
INTERVIEWER: ANSWER CANNOT BE 0.
REQUIRED
IF P1 = 1
P4.
[Do you/Does he/Does she] currently use a cane or walker?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF P1 = 1
P5.
[Do you/Does he/Does she] have serious difficulty walking or climbing stairs?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
63
REQUIRED
IF PTCPT = CM, HDM OR NON
P6.
Because of a physical, mental, or emotional condition, [do you/does he/does she] have
serious difficulty concentrating, remembering, or making decisions?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
P7.
The next questions ask about difficulties [you/he/she] may have doing certain activities.
[Do you/Does he/Does she] have difficulty . . .
YES
NO
NOT
APPLICABLE
DON’T
KNOW
REFUSED
a. shopping for personal items, such as toilet items
or medicine?
1
0
99
d
r
b. getting to a grocery store?
1
0
99
d
r
c.
shopping for groceries?
1
0
99
d
r
d. carrying a bag of groceries?
1
0
99
d
r
e. using the telephone?
1
0
99
d
r
f.
1
0
99
d
r
g. preparing meals?
1
0
99
d
r
h. using public transportation or riding in a private
automobile?
1
0
99
d
r
i.
taking medications?
1
0
99
d
r
j.
managing money or balancing a checkbook?
1
0
99
d
r
k.
taking a bath or shower?
1
0
99
d
r
l.
dressing?
1
0
99
d
r
m. getting in or out of a bed or chair?
1
0
99
d
r
n. eating?
1
0
99
d
r
o. using the toilet?
1
0
99
d
r
p. chewing or swallowing?
1
0
99
d
r
doing light housework?
[ASK ONLY IF P1=1]
64
Q. PHYSICAL ACTIVITY
PROGRAMMER BOX Q1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM, OR NOM) ANSWER
QUESTIONS IN SECTION Q.
Q_Intro:
The next questions are about physical activity.
REQUIRED
IF PTCPT = CM, HDM OR NON
Q1.
During the past 30 days, [have you/has he/has she] done any exercise, sports, or physical
activities?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO R1
DON’T KNOW ....................................................................................................... d
SKIP TO R1
REFUSED ............................................................................................................. r
SKIP TO R1
REQUIRED
IF Q1 = 1
Q2.
How many times per week did [you/he/she] do those kinds of activities?
|
|
| TIMES PER WEEK (1-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF Q2 GT 10; I want to be sure I recorded your answer correctly. Did you say [fill Q2]
times per week?
HARD CHECK: IF Q2 GT 30; I want to be sure I recorded your answer correctly. Did you say
[fill Q2] times per week? INTERVIEWER: ANSWER CANNOT EXCEED 30 TIMES PER WEEK.
HARD CHECK: IF Q2 = 0; I want to be sure I recorded your answer correctly. Did you say [fill Q2]
times per week? INTERVIEWER: ANSWER CANNOT BE 0.
65
R. HEIGHT AND WEIGHT
PROGRAMMER BOX R1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER
QUESTIONS IN SECTION R.
R_Intro:
The next questions are about [your/his/her] height and weight.
REQUIRED
IF PTCPT = CM, HDM OR NON
R1.
How tall [are you/is he/is she] without shoes?
|
| FEET (0-99)
|
|
| INCHES (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF FEET LT 4; I want to be sure I recorded your answer correctly. Did you say
[fill R1] feet? INTERVIEWER: ANSWER CANNOT BE LESS THAN 4 FEET.
HARD CHECK: IF FEET GT 7; I want to be sure I recorded your answer correctly. Did you say
[fill R1] feet? INTERVIEWER: ANSWER CANNOT EXCEED 7 FEET.
HARD CHECK: IF INCHES GT 11; I want to be sure I recorded your answer correctly. Did you say
[fill R1] inches? INTERVIEWER: ANSWER CANNOT EXCEED 11 INCHES.
REQUIRED
IF PTCPT = CM, HDM OR NON
R2.
How much [do you/does he/does she] weigh without clothes or shoes?
|
|
|
| POUNDS (0-999)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF POUNDS GT 300; I want to be sure I recorded your answer correctly. Did you say
[fill R2] pounds?
HARD CHECK: IF POUNDS LT 50 I want to be sure I recorded your answer correctly. Did you say
[fill R2] pounds? INTERVIEWER: ANSWER CANNOT BE LESS THAN 50 POUNDS.
HARD CHECK: IF POUNDS GT 500; I want to be sure I recorded your answer correctly. Did you say
[fillR2] pounds? INTERVIEWER: ANSWER CANNOT EXCEED 500 POUNDS.
66
REQUIRED
IF PTCPT = CM, HDM OR NON
R3.
Without trying to, [have you/has he/has she] gained or lost ten pounds in the last six
months?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
67
S. PRESCRIPTIONS
PROGRAMMER BOX S1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM, OR NON) ANSWER
QUESTIONS IN SECTION S.
S_Intro:
The next set of questions are about prescription medications.
REQUIRED
IF PTCPT = CM, HDM OR NON
S1.
How many different prescription medications [do you/does he/does she] take every day?
|
|
| NUMBER (0-99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF S1 GT 10; I want to be sure I recorded your answer correctly. Did you say [fill S1]
prescriptions?
HARD CHECK: IF S1 GT 30; I want to be sure I recorded your answer correctly. Did you say [fill S1]
prescriptions? INTERVIEWER: ANSWER CANNOT EXCEED 30.
68
T. VITAMIN AND MINERAL SUPPLEMENTS
PROGRAMMER BOX T1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER
QUESTIONS IN SECTION T.
T_Intro:
The following questions are about vitamin and mineral supplements.
REQUIRED
IF PTCPT = CM, HDM OR NON
T1.
[Do you/Does he/Does she] take any of the following on a regular basis . . .
YES
NO
DON’T
KNOW
REFUSED
a. Multivitamin without minerals?
1
0
d
r
b. Multivitamin plus minerals?
1
0
d
r
c.
1
0
d
r
1
0
d
r
Individual vitamin and mineral supplements?
d. Herbal supplements?
REQUIRED
IF PTCPT = CM, HDM OR NON
T2.
[Do you/Does he/Does she] currently use any diet or nutritional supplements, such as
Boost or Ensure?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
SKIP TO U1
DON’T KNOW ....................................................................................................... d
SKIP TO U1
REFUSED ............................................................................................................. r
SKIP TO U1
69
REQUIRED
IF T2 = 1
T3.
How often [do you/does he/does she] use diet or nutritional supplements?
|
|
| TIMES (0-999)
PER DAY (Range 1-10) ........................................................................................ 1
PER WEEK (Range 1-21) ..................................................................................... 2
PER MONTH (Range 1-50) .................................................................................. 3
PER YEAR (Range 1-90) ...................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF T3 GT 90; I want to be sure I recorded your answer correctly. Did you say
[fill T3]? INTERVIEWER: ANSWER CANNOT EXCEED 90.
HARD CHECK: IF PER DAY GT 10; I want to be sure I recorded your answer correctly. Did you say
[fill T3] times per day? INTERVIEWER: ANSWER CANNOT EXCEED 10 TIMES PER DAY.
HARD CHECK: IF PER WEEK GT 21; I want to be sure I recorded your answer correctly. Did you
say [fill T3] times per week? INTERVIEWER: ANSWER CANNOT EXCEED 21 TIMES PER WEEK.
HARD CHECK: IF PER MONTH GT 50; I want to be sure I recorded your answer correctly. Did you
say [fill T3] times per month? INTERVIEWER: ANSWER CANNOT EXCEED 50 TIMES PER MONTH.
HARD CHECK: IF T3 = 0; I want to be sure I recorded your answer correctly. Did you say [fill T3]
times? INTERVIEWER: ANSWER CANNOT BE 0.
70
U. DEPRESSION, LONELINESS, SOCIAL ISOLATION
PROGRAMMER BOX U1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER
QUESTION IN SECTION U.
U_Intro:
The next set of questions are about [your/his/her] social life.
REQUIRED
IF PTCPT = CM, HDM OR NON
U1.
Overall, how satisfied [are you/is he/is she] with the opportunities [you have/he has/she
has] to spend time with other people? Would [you/he/she] say [you are/he is/she is] . . .
CODE ONE ONLY
Very satisfied, ...................................................................................................... 1
Somewhat satisfied,............................................................................................ 2
Not too satisfied, or ............................................................................................ 3
Not at all satisfied? ............................................................................................. 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
U2.
[Do you/Does he/Does she] belong to any religious or social groups, book clubs, special
interest groups, or other organizations?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
71
REQUIRED
IF PTCPT = CM, HDM OR NON
U3.
How often [do you/does he/does she] feel that you lack companionship?
CODE ONE ONLY
Hardly ever, .......................................................................................................... 1
Some of the time, or............................................................................................ 2
Often? ................................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
U4.
How often [do you/does he/does she] feel left out?
CODE ONE ONLY
Hardly ever, .......................................................................................................... 1
Some of the time, or............................................................................................ 2
Often? ................................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
U5.
How often [do you/does he/does she] feel isolated from others?
CODE ONE ONLY
Hardly ever, .......................................................................................................... 1
Some of the time, or............................................................................................ 2
Often? ................................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
72
For the next three questions, please think about the past two weeks.
REQUIRED
IF PTCPT = CM, HDM OR NON
U6.
[During the past two weeks], how often [have you/has he/has she] been bothered by any of
the following problems? Little interest or pleasure in doing things. Would [you/he/she]
say . . .
CODE ONE ONLY
Not at all, .............................................................................................................. 1
Several days, ....................................................................................................... 2
More than half of the days, or ............................................................................ 3
Nearly every day? ............................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
U7.
[During the past two weeks], how often [have you/has he/has she] felt down, depressed or
hopeless. Would [you/he/she] say . . .
CODE ONE ONLY
Not at all, .............................................................................................................. 1
Several days, ....................................................................................................... 2
More than half of the days, or ............................................................................ 3
Nearly every day? ............................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
73
REQUIRED
IF PTCPT = CM, HDM OR NON
U8.
[During the past two weeks], how often was it difficult to get in touch with others when
[you/he/she] wanted to. Would [you/he/she] say . . .
CODE ONE ONLY
Almost always, .................................................................................................... 1
Most of the time,.................................................................................................. 2
About half the time,............................................................................................. 3
Occasionally, or .................................................................................................. 4
Not at all? ............................................................................................................. 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
74
V. DEMOGRAPHICS
PROGRAMMER BOX V1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM, OR NON) ANSWER
QUESTIONS IN SECTION V.
V_Intro:
The following questions are about [your/his/her] background and education.
REQUIRED
IF PTCPT = CM, HDM OR NON
V1.
INTERVIEWER:
ASK IF NOT OBVIOUS: WHAT IS [YOUR/HIS/HER] GENDER?
MALE..................................................................................................................... 1
FEMALE ................................................................................................................ 2
REQUIRED
IF PTCPT = CM, HDM OR NON
V2.
In what year [were you/was he/was she] born?
|
|
|
|
| YEAR (Range 1800-2012)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF V2 LT 1900; I want to be sure I recorded your answer correctly. Did you say you
were born in [fill V2]? INTERVIEWER: YEAR OF BIRTH MUST BE GREATER THAN 1900.
HARD CHECK: IF V2 GT 1965; I want to be sure I recorded your answer correctly. Did you say you
were born in [fill V2]? INTERVIEWER: YEAR OF BIRTH MUST BE PRIOR TO 1965.
REQUIRED
IF PTCPT = CM, HDM OR NON
V3.
Are you a veteran of the U.S. Armed Forces?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
75
REQUIRED
IF PTCPT = CM, HDM OR NON
V4.
What is the highest grade or level of school [you have/he has/she has] completed or the
highest degree [you have/he has/she has] received?
CODE ONE ONLY
NEVER ATTENDED/KINDERGARTEN ONLY ..................................................... 0
1ST GRADE .......................................................................................................... 1
2ND GRADE ......................................................................................................... 2
3RD GRADE ......................................................................................................... 3
4TH GRADE .......................................................................................................... 4
5TH GRADE .......................................................................................................... 5
6TH GRADE .......................................................................................................... 6
7TH GRADE .......................................................................................................... 7
8TH GRADE .......................................................................................................... 8
9TH GRADE .......................................................................................................... 9
10TH GRADE ........................................................................................................ 10
11TH GRADE ........................................................................................................ 11
12TH GRADE, NO DIPLOMA ............................................................................... 12
HIGH SCHOOL GRADUATE ................................................................................ 13
GED OR EQUIVALENT ........................................................................................ 14
SOME COLLEGE, NO DEGREE .......................................................................... 15
ASSOCIATE DEGREE; OCCUPATIONAL, TECHNICAL, OR VOCATIONAL
PROGRAM ............................................................................................................ 16
ASSOCIATE DEGREE: ACADEMIC PROGRAM ................................................ 17
BACHELOR’S DEGREE(EXAMPLE: BA, AB, BS, BBA)...................................... 18
MASTER’S DEGREE (EXAMPLE: MA, MS, MEng, MEd, MBA).......................... 19
PROFESSIONAL SCHOOL DEGREE (EXAMPLE: MD, DDS, DVM, JD) ........... 20
DOCTORAL DEGREE (EXAMPLE: PhD, EdD) ................................................... 21
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
76
REQUIRED
IF PTCPT = CM, HDM OR NON
V5.
[Are you/Is he/Is she] of Hispanic or Latino origin?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
V6.
I am going to read a list of five race categories. Please choose one or more races that [you
consider yourself/he considers himself/she considers herself] to be. American Indian or
Alaska Native; Asian; Black or African American; Native Hawaiian or other Pacific Islander
or White.
CODE ALL THAT APPLY
AMERICAN INDIAN OR ALASKA NATIVE .......................................................... 1
ASIAN.................................................................................................................... 2
AFRICAN AMERICAN OR BLACK ....................................................................... 3
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER ........................................ 4
WHITE ................................................................................................................... 5
OTHER (PLEASE SPECIFY) ................................................................................ 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
77
REQUIRED
IF PTCPT = CM, HDM OR NON
V7.
[Are you/Is he/Is she] now married, widowed, divorced, separated, never married or living
with a partner?
CODE ONE ONLY
MARRIED .............................................................................................................. 1
WIDOWED ............................................................................................................ 2
DIVORCED ........................................................................................................... 3
SEPARATED ........................................................................................................ 4
NEVER MARRIED ................................................................................................ 5
LIVING WITH A PARTNER................................................................................... 6
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
V8.
What is [your/his/her] home zip code?
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF NUMBER OF DIGITS ENTER GT 5; I want to be sure I entered your answer
correctly. Did you say zip code [fill V8]? INTERVIEWER: ZIP CODE MUST HAVE 5 DIGITS.
HARD CHECK: IF NUMBER OF DIGITS ENTER LT 5; I want to be sure I entered your answer
correctly. Did you say zip code [fill V8]? INTERVIEWER: ZIP CODE MUST HAVE 5 DIGITS.
78
REQUIRED
IF PTCPT = CM, HDM OR NON
V9.
Including [yourself/himself/herself], how many people live in [your/his/her] household? By
“live in [your/his/her] household” I mean all people who usually stay in the household.
Please do include people who are away, such as students, people on vacation, or traveling
for business, or people who are in the hospital for a brief stay. Do not include people in
institutions, in the military, or people who are temporary visitors.
|
|
| NUMBER OF PEOPLE IN HOUSEHOLD (0 – 99)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF V9 GT 10; I want to be sure I recorded your answer correctly. Did you say [fill V9]
people live in your household?
HARD CHECK: IF V9 = 0; I want to be sure I recorded your answer correctly. Did you say [fill V9]
people live in your household? INTERVIEWER: NUMBER OF PEOPLE IN HOUSEHOLD CANNOT
BE 0.
HARD CHECK: IF V9 GT 20; I want to be sure I recorded your answer correctly. Did you say [fill V9]
people live in your household? INTERVIEWER: NUMBER OF PEOPLE IN HOUSEHOLD CANNOT
EXCEED 20.
REQUIRED
IF V9 = 1, GO TO V11
IF V9 NE 1
V10.
Who are all the people who live in [your/his/her] household?
CODE ALL THAT APPLY
HUSBAND/WIFE/PARTNER ................................................................................ 1
CHILD OR CHILDREN.......................................................................................... 2
BROTHER(S) OR SISTER(S) .............................................................................. 3
GRANDCHILD OR GRANDCHILDREN ............................................................... 4
SON-IN-LAW OR DAUGHTER-IN-LAW ............................................................... 5
OTHER RELATIVE (PLEASE SPECIFY) ............................................................. 6
___________________________________________________ (STRING (30))
NON RELATIVE OR FRIEND ............................................................................... 7
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
79
REQUIRED
IF PTCPT = CM, HDM OR NON
V11.
Now I’d like to ask you some questions about income and financial assistance
[you/he/she] [IF V9 NE 1 fill (or others) in [your/his/her] household] may be receiving.
During the past 30 days, did [you/he/she] (or anyone in [your/his/her] household) receive
money from any of the following . . .
YES
NO
DON’T
KNOW
REFUSED
a. Full- or part-time work?
1
0
d
r
b. Social Security?
1
0
d
r
c.
1
0
d
r
d. Disability (SSDI) or Worker’s Compensation?
1
0
d
r
e. Supplemental Security Income or SSI?
1
0
d
r
f.
1
0
d
r
g. General Assistance?
1
0
d
r
h. Money from relatives? or
1
0
d
r
i.
1
0
d
r
Unemployment Compensation?
Pension or retirement fund?
Other sources? (PLEASE SPECIFY)
(STRING (30))
REQUIRED
IF PTCPT = CM, HDM OR NON
V12.
What was ([your/his/her] household’s) total income last month before taxes? Please
include all types of income received by all household members last month, including all
earnings, pensions, Social Security, cash welfare benefits and SSI. Do not include the
value of SNAP benefits or food stamps, Medicaid, or public housing.
$|
|
|, |
|
|
| (0-99,999)
NO INCOME ......................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF V12 GT 5,000; I want to be sure I recorded your answer correctly. Did you say
[your/his/her] household’s) total income last month before taxes was $[fill V12]?
HARD CHECK: IF V12 GT 15,000; I want to be sure I recorded your answer correctly. Did you say
[your/his/her] household’s) total income last month before taxes was $[fill V12]? INTERVIEWER:
ANSWER CANNOT EXCEED $15,000.
80
REQUIRED
IF V12 = d, r
V13.
Please stop me when I reach [your/his/her] household’s total income for last month.
Was It . . .
CODE ONE ONLY
Less than $900, ................................................................................................... 1
$901 - $1,200, ....................................................................................................... 2
$1,201 - $1,500, .................................................................................................... 3
$1,501 - $1,800, .................................................................................................... 4
$1,801 - $2,100, .................................................................................................... 5
$2,101 - $2,400, .................................................................................................... 6
$2,401 or more? ................................................................................................... 7
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
V14.
What was ([your /his/her] household’s) total income before taxes last year from all
sources, including Social Security and other government programs but excluding the
value of SNAP benefits or food stamps, Medicaid, or public housing. Your best estimate is
fine.
$|
|
|
|, |
|
|
| (0-999,999)
NO INCOME ......................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
SOFT CHECK: IF V14 LT 1,000; I want to be sure I recorded your answer correctly. Did you say
[your/his/her] household’s) total income last year before taxes was$[fill V14]?
SOFT CHECK: IF V14 GT 100,000; I want to be sure I recorded your answer correctly. Did you say
[your/his/her] household’s) total income last year before taxes was $[fill V14]?
HARD CHECK: IF V14 GT 250,000; I want to be sure I recorded your answer correctly. Did you say
[your/his/her] household’s) total income last year before taxes was $[fill V14]? INTERVIEWER:
ANSWER CANNOT EXCEED $250,000.
81
REQUIRED
IF V14 = d, r
V15.
Please stop me when I reach [your/his/her] household’s total income for last year.
Was It . . .
CODE ONE ONLY
Less than $10,000, .............................................................................................. 1
$10,001 - $14,000, ................................................................................................ 2
$14,001 - $18,000, ................................................................................................ 3
$18,001 - $22,000, ................................................................................................ 4
$22,001 - $26,000, ................................................................................................ 5
$26,001 - $30,000, ................................................................................................ 6
$30,001 or more?................................................................................................. 7
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
82
W. ADEQUACY OF MONEY
PROGRAMMER BOX W1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER
QUESTIONS IN SECTION W.
REQUIRED
IF PTCPT = CM, HDM OR NON
W1.
How well does the amount of money [you have/he has/she has] take care of [your/his/her]
needs? Would you say very well, fairly well, or poorly?
CODE ONE ONLY
VERY WELL .......................................................................................................... 1
FAIRLY WELL ....................................................................................................... 2
POORLY ............................................................................................................... 3
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
W2.
In the past month, did [you/he/she] ever have to choose between buying food and buying
medications?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
W3.
In the past month, did [you/he/she] ever have to choose between buying food and paying
[your/his/her] utility bills?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
83
REQUIRED
IF PTCPT = CM, HDM OR NON
W4.
In the past month, did [you/he/she] ever have to choose between buying food and paying
[your/his/her] rent?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
84
X. PROGRAM PARTICIPATION
PROGRAMMER BOX X1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER
QUESTIONS IN SECTION X.
X_Intro:
The next questions are about [your/his/her] participation in different types of programs.
REQUIRED
IF PTCPT = CM, HDM OR NON
X1.
Are [you/he/she] or anyone else in [your/his/her] household currently receiving SNAP
benefits or food stamps?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
X2.
During the past 30 days, did [you/he/she] or anyone else in [your/his/her] household get
food from a food pantry or food bank?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = CM, HDM OR NON
X3.
During the past 30 days, did [you/he/she] receive any meals provided by churches or
meals at a soup kitchen or emergency kitchen?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
85
REQUIRED
IF PTCPT = CM, HDM OR NON
X4.
During the past 30 days, did [you/he/she] receive assistance to help with heating and
cooling your home, such as LIHEAP?
INTERVIEWER:
LIHEAP IS PRONOUNCED [LI-HEEP] AND STANDS FOR LOW INCOME
HOME ENERGY ASSISTANCE PROGRAM.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = NON AND MATCH = CM
X5.
[Are you/Is he/Is she] aware that the Administration on Aging’s Elderly Nutrition Program
provides for meals and related nutrition services for individuals aged 60 years and older in
group settings such as senior centers, faith-based settings, and schools? [You/He/She]
may know of this as a congregate nutrition program.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = NON AND MATCH = HDM
X5.1
Are you aware that the Administration on Aging’s Elderly Nutrition Program provides for
meals and related nutrition services for individuals aged 60 years and older who are
homebound due to illness, disability, or geographic isolation? You may know of this as a
home-delivered nutrition program.
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
86
REQUIRED
IF PTCPT = NON AND MATCH = CM
X6.
[Have you/Has he/Has she] ever been contacted about going to a congregate nutrition
program?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = NON AND MATCH = HDM
X6.1
[Have you/Has he/Has she] ever been contacted about getting meals from a homedelivered nutrition program?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
87
REQUIRED
IF PTCPT = NON AND MATCH = CM
X7.
What are the reasons that [you do/he does/she does] not participate in a congregate
nutrition program?
CODE ONE ONLY
DON’T KNOW ABOUT THE PROGRAM/DON’T KNOW WHERE MEAL
SITES ARE LOCATED ......................................................................................... 1
DON’T NEED THIS PROGRAM/NOT OLD ENOUGH/TOO HEALTHY ............... 2
TRANSPORTATION PROBLEMS/BARRIERS .................................................... 3
DO NOT NEED/WANT ASSISTANCE FROM THE GOVERNMENT ................... 4
HEALTH IS TOO POOR/PHYSICAL IMPAIRMENT/MEAL SITE IS NOT
ACCESSIBLE BASED ON PHYSICAL HEALTH .................................................. 5
MEALS OFFERED DO NOT MEET NEEDS/TASTES/ETHNIC
VALUES/NOT ENOUGH VARIETY IN MEALS .................................................... 6
LANGUAGE BARRIER/DO NOT SPEAK ENGLISH WELL ................................. 7
MEAL SITE IS NOT IN A SAFE LOCATION/ DON’T FEEL SAFE AT MEAL
SITE/DON’T FEEL SAFE LEAVING HOME TO GO TO MEAL SITE .................. 8
HOURS THAT MEALS ARE OFFERED ARE TOO LIMITED .............................. 9
WANTED TO PARTICIPATE BUT WAS PLACED ON WAITING LIST ............... 10
COST OF MEAL IS TOO HIGH ............................................................................ 11
OTHER (PLEASE SPECIFY) ................................................................................ 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
88
REQUIRED
IF PTCPT = NON AND MATCH = HDM
X7.1
What are the reasons that [you do/he does/she does] not participate in a home-delivered
nutrition program?
CODE ONE ONLY
DON’T KNOW ABOUT THE PROGRAM.............................................................. 1
DON’T NEED THIS PROGRAM/NOT OLD ENOUGH/TOO HEALTHY ............... 2
DO NOT NEED/WANT ASSISTANCE FROM THE GOVERNMENT ................... 3
MEALS OFFERED DO NOT MEET NEEDS/ TASTES/ETHNIC
VALUES/NOT ENOUGH VARIETY IN MEALS .................................................... 4
LANGUAGE BARRIER/DO NOT SPEAK ENGLISH WELL ................................. 5
COST OF MEAL IS TOO HIGH ............................................................................ 6
WANTED TO PARTICIPATE BUT WAS PLACED ON WAITING LIST ............... 7
APPLIED BUT WAS NOT ELIGIBLE TO RECEIVE MEALS................................ 8
DO NOT LIKE OTHER PEOPLE COMING INTO HOME ..................................... 9
OTHER (PLEASE SPECIFY) ............................................................................... 99
___________________________________________________ (STRING (30))
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = NON AND MATCH = CM
X8.
[Do you/Does he/Does she] think [you/he/she] will be interested in going to a congregate
nutrition program in the future?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
REQUIRED
IF PTCPT = NON AND MATCH = HDM
X8.1
[Do you/Does he/Does she] think [you/he/she] will be interested in getting meals from a
home-delivered nutrition program in the future?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
89
Y. RELEASE OF SOCIAL SECURITY NUMBER
PROGRAMMER BOX Y1
CATI: ALL RESPONDENTS (PTCPT = CM, HDM OR NON) ANSWER
QUESTIONS IN SECTION Y.
REQUIRED
IF PTCPT = CM, HDM OR NON
Y1.
Mathematica Policy Research will conduct statistical research by combining your survey
data with health and other related records. To obtain these records, we need your social
security number. We will not release it to anyone, including any government agency, for
any other reason. Providing this information is voluntary. There will be no effect on your
benefits if you do not provide it.
|
|
|
|-|
|
|-|
|
|
|
| ENTER SOCIAL SECURITY NUMBER
DON’T KNOW/DOES NOT HAVE SOCIAL SECURITY NUMBER ..................... d
SKIP TO SECTION Z
REFUSED ............................................................................................................. r
SKIP TO SECTION Z
INTERVIEWER:
IF RESPONDENT CANNOT RECALL FROM MEMORY ASK {HIM/HER} TO
GET CARD AT THIS TIME.
IF SOCIAL SECURITY NUMBER IS ENTERED AT Y1, A NEW SCREEN
SHOULD APPEAR FOR THE INTERVIEWER TO VERIFY THE NUMBER
THAT WAS ENTERED:
INTERVIEWER:
READ THE NUMBER BACK TO THE RESPONDENT TO MAKE SURE IT
WAS RECORDED CORRECTLY.
IF RESPONDENT REFUSES, DISPLAY THESE INTERVIEWER NOTES:
IF RESPONDENT IS RELUCTANT TO GIVE NUMBER OR IF RESPONDENTS ASK IF THEY
MUST GIVE NUMBER: It is extremely useful to have this information to be able to link to
health records such as Medicare records. Many years in the future, the information you
gave me can be used to see how health habits and diet at one point in your life influence
how healthy you are in the future. If you prefer, you can give us only the last four digits of
your social security number, and we can use this number to access your records.
IF RESPONDENT CITES PRIVACY CONCERNS: I understand your concern. Mathematica
has never had a breach of confidentiality in the more than 40 years we have been
conducting research studies. I do not have access to this information after I type it. Once I
complete the interview all the information is sent to a secure facility. Only one or two
people have access to the file to use it for our health research. If you prefer, you can give
us only the last four digits of your social security number, and we can use this number to
access your records.
90
REQUIRED
IF Y1 = d
Y1_DK. INTERVIEWER:
CODE PREVIOUS RESPONSE.
DOES NOT HAVE SOCIAL SECURITY NUMBER .............................................. 1
DON’T KNOW ....................................................................................................... 2
REQUIRED
IF Y1 NE d, r
Y2.
INTERVIEWER:
SELECT CATEGORY FOR REPORTING OF SOCIAL SECURITY
NUMBER.
SELF REPORTED FROM MEMORY ................................................................... 1
SELF REPORTED FROM RECORDS ................................................................. 2
91
Z. 24 HOUR DIETARY RECALL
In the next part of the survey, I will ask you questions about what you ate and drank over the last
24 hours . . .
92
AA. RESPONDENT PAYMENT
Confirm1.
Thank you very much for your time. You have really helped us with this study. I’d like
to make sure the contact information we have on file for you is correct so that we can
send you a $50 gift card within the next few weeks. According to our records we
have . . .
[FILL NAME, ADDRESS, CITY, STATE, ZIP, PHONE NUMBER]
YES ....................................................................................................................... 1
NO ......................................................................................................................... 2
FIX THIS NAME/ADDRESS ................................................................................. 3
NEW NAME/ADDRESS ........................................................................................ 4
___________________________________________________ (STRING (30))
FIRST NAME
___________________________________________________ (STRING (30))
MIDDLE INITIAL/NAME
___________________________________________________ (STRING (30))
LAST NAME
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
STREET 3
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
AA1_PhonNum1.
|
|
|
(RANGE)
According to our records your phone number is . . .
|-|
|
|
|-|
(RANGE)
|
|
|
|
(RANGE)
93
AA2.
In about 6 months, we will be contacting you again to see how you are doing. The
interview will take no more than 5 minutes to complete. You will get a $10 gift card for
participating in that interview. In case we can’t reach you at the phone number we just
discussed, is there another number we should try?
|
AA3.
| | |-| | | |-|
(RANGE)
(RANGE)
| | | |
(RANGE)
DON’T KNOW ....................................................................................................... d
GO TO THANK YOU
REFUSED ............................................................................................................. r
GO TO THANK YOU
In case we have trouble reaching you in 6 months, please give me the name and telephone
number of a relative or friend who would know where you could be reached. Please give
me the name of someone not currently living in your household.
___________________________________________________ (STRING (30))
FIRST NAME
___________________________________________________ (STRING (30))
MIDDLE INITIAL/NAME
___________________________________________________ (STRING (30))
LAST NAME
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
STREET 3
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
|
| | |-| | | |-|
(RANGE)
(RANGE)
| | | |
(RANGE)
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
94
GO TO THANK YOU
GO TO THANK YOU
AA4.
How is this person related to you?
HUSBAND/WIFE/PARTNER ................................................................................ 1
CHILD.................................................................................................................... 2
BROTHER OR SISTER ........................................................................................ 3
GRANDCHILD ...................................................................................................... 4
SON-IN-LAW OR DAUGHTER-IN-LAW ............................................................... 5
OTHER RELATIVE ............................................................................................... 6
NON RELATIVE OR FRIEND ............................................................................... 7
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
THANK YOU. Thank you very much for your help with this important study. We look forward to
speaking with you again in about 6 months.
95
Mathematica Reference No.: 06669.202
National Evaluation of Title III-C
Services
Nonparticipant Screener
CATI Questionnaire
May 10, 2012
INTRODUCTION
Hello.
Hello, my name is [NAME] from Mathematica Policy Research in Princeton,
New Jersey. May I please speak to [SAMPLE MEMBER NAME]?
SPEAKING TO [SAMPLE MEMBER NAME] ........................................................ 1
SampMemb
[SAMPLE MEMBER NAME] COMES TO THE PHONE ....................................... 2
SampMemb
PERSON ASKS WHAT CALL IS ABOUT ............................................................. 3
WhatAbout
NEED TO CALL BACK ......................................................................................... 4
CALLBACK
SAMPLE MEMBER HAS A HEALTH PROBLEM/ IS DECEASED....................... 5
HealthProb
SAMPLE MEMBER IS IN AN INSTITUTION ........................................................ 6
Institution
SAMPLE MEMBER HAS MOVED ........................................................................ 7
KnowWhere
SAMPLE MEMBER DOES NOT SPEAK ENGLISH ............................................. 8
Lang
NEVER HEARD OF SAMPLE MEMBER/WRONG NUMBER.............................. 9
Thanks
HUNG UP DURING INTRODUCTION.................................................................. 10
Thanks
REFUSED ............................................................................................................. r
Thanks
SampMemb. [Hello, my name is [NAME] from Mathematica Policy Research in Princeton,
New Jersey.] Recently, the U.S. Department of Health and Human Services,
Administration on Aging and Mathematica Policy Research sent you a letter
describing a study we are conducting to improve nutrition services for older adults.
First I need to determine whether you are eligible to participate in this study. All of
your answers will be kept strictly confidential and your participation is voluntary.
May I ask you a few questions now?
BEGIN INTERVIEW .............................................................................................. 1
A1
DID NOT RECEIVE OR DOES NOT RECALL LETTER ...................................... 2
NoLetter
WANTS MORE INFORMATION ........................................................................... 3
MoreInfo
NOT A GOOD TIME.............................................................................................. 4
CallBack
HUNG UP DURING INTRODUCTION.................................................................. 5
Thanks
SUPERVISOR REVIEW ....................................................................................... 6
Thanks
REFUSED ............................................................................................................. r
RefusalReason
1
WhatAbout. Recently, the U.S. Department of Health and Human Services, Administration on
Aging and Mathematica Policy Research sent [SAMPLE MEMBER NAME] a letter
describing a study we are conducting to improve nutrition services for older adults.
May I speak with [SAMPLE MEMBER NAME]?
SAMPLE MEMBER COMES TO THE PHONE .................................................... 1
SampleMemb (2)
NEED TO CALL BACK ......................................................................................... 2
CallBack
SAMPLE MEMBER HAS A HEALTH PROBLEM/IS DECEASED........................ 3
HealthProb
SAMPLE MEMBER IS IN AN INSTITUTION ........................................................ 4
Institution
SAMPLE MEMBER MOVED ................................................................................ 5
KnowWhere
SAMPLE MEMBER DOES NOT SPEAK ENGLISH ............................................. 6
Lang
SAMPLE MEMBER DIDN’T RECEIVE LETTER .................................................. 7
NoLetter
HUNG UP DURING INTRODUCTION.................................................................. 8
Thanks
SUPERVISOR REVIEW ....................................................................................... 9
Thanks
REFUSED ............................................................................................................. r
Thanks
CALLBACK. When would be a good time to call back?
___________________________________________________ (SPECIFY)
MoreInfo.
The Centers for Medicare & Medicaid Services (CMS), which administers the
Medicare program, is cooperating with the U.S. Department of Health and Human
Services’ Administration on Aging on a study to learn more about how well citizens
are served by certain government programs. Mathematica Policy Research
(Mathematica), an independent research company, is conducting the study.
Today we will ask you a short series of questions about your health and use of
nutrition services. If you are selected based on your responses, one of our
interviewers will call you to schedule a time to meet with you and interview you
about your health and well-being, and what you eat and drink.
Shall we begin?
BEGIN INTERVIEW .............................................................................................. 1
A1
WANTS ANOTHER LETTER ................................................................................ 2
ReadLetter
NOT A GOOD TIME.............................................................................................. 3
Callback
HUNG UP DURING INTRODUCTION.................................................................. 4
Thanks
2
KnowWhere. Recently, the U.S. Department of Health and Human Services, Administration on
Aging and Mathematica Policy Research sent [SAMPLE MEMBER NAME] a letter
describing a study we are conducting to improve nutrition services for older adults.
Do you or anyone there know how we can reach [SAMPLE MEMBER]?
YES ....................................................................................................................... 1
NewPhone
NO ......................................................................................................................... 0
Thanks
NewPhone.
May I please have [his/her] telephone number?
ENTER 1 TO CONTINUE ..................................................................................... 1
| | | |-| | | |-| | | |
(RANGE)
(RANGE)
(RANGE)
PhoneNumber
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF AREA CODE LT 200; Area code must be greater than 200
HARD CHECK: IF PHONE NUMBER NE 10 DIGITS Phone number should be 10 numeric digits, no
spaces, dashes, parentheses, or other punctuation (or empty)
NewAddress. May I please have [his/her] address?
ENTER 1 TO CONTINUE ..................................................................................... 1
AddrCheck
AddrCheck. The address we have is [SAMPLE MEMBER ADDRESS]. Is that correct?
YES ....................................................................................................................... 1
Thanks
NO ......................................................................................................................... 0
Address1
REFUSED ............................................................................................................. r
Thanks
DON’T KNOW ....................................................................................................... d
Thanks
3
Address1.
What is the address?
___________________________________________________ (STRING (NUM))
FIRST NAME
___________________________________________________ (STRING (NUM))
MIDDLE INITIAL/NAME
___________________________________________________ (STRING (NUM))
LAST NAME
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
STREET 3
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
Thanks
REFUSED ............................................................................................................. r
Thanks
HARD CHECK: IF ZIP CODE NE 5 OR 9 DIGITS; The zip code must be 5 or 9 digits, please re-enter
Lang.
CODE LANGUAGE NEEDED TO COMPLETE INTERVIEW IF KNOWN:
SPANISH .............................................................................................................. 1
Thanks
FRENCH ............................................................................................................... 2
NeedProxy
CHINESE .............................................................................................................. 3
NeedProxy
RUSSIAN .............................................................................................................. 4
NeedProxy
GERMAN .............................................................................................................. 5
NeedProxy
OTHER LANGUAGE............................................................................................. 6
OtherLang
(Skips to NeedProxy)
4
NoLetter.
The letter described the study and explained that your name was randomly selected
from a list of Medicare beneficiaries in your area. The letter also explained that we
would be calling to interview you. May I ask you a few questions now to determine if
you are eligible to participate in this study?
BEGIN INTERVIEW .............................................................................................. 1
A1
WANTS ANOTHER LETTER ................................................................................ 2
ReadLetter
WANTS MORE INFORMATION ........................................................................... 3
MoreInfo
NOT A GOOD TIME.............................................................................................. 4
CALLBACK
HUNG UP DURING INTRODUCTION.................................................................. 5
Thanks
REFUSED ............................................................................................................. r
RefusalReason
ReadLetter.
May I read the letter to you and then we can begin?
YES, READ THE LETTER FROM THE HARD COPY ......................................... 1
SKIP TO A1
NO, WANTS ANOTHER LETTER FIRST ............................................................. 2
SendLetter
HUNG UP DURING INTRODUCTION.................................................................. 3
Thanks
REFUSED ............................................................................................................. r
RefusalReason
SendLetter.
Okay, I’ll mail another letter and call back in a few days.
ENTER 1 TO CONTINUE ..................................................................................... 1
AddrCheck
Health Prob. ENTER TYPE OF HEALTH PROBLEM
HEARING PROBLEM ........................................................................................... 1
AmpTTY
SPEECH PROBLEM ............................................................................................. 2
AmpTTY
PHYSICAL PROBLEM .......................................................................................... 3
CallLater
COGNITIVE PROBLEM ........................................................................................ 4
NeedProxy
TOO OLD / FRAIL ................................................................................................. 5
CallLater
IN A COMA ........................................................................................................... 6
NeedProxy
DECEASED .......................................................................................................... 7
Deceased
AMPTTY.
I can get on a phone that will amplify my voice or [SAMPLE MEMBER]’s voice, or we
could use a TTY service. Would either of these enable [him/her] to complete the
interview?
YES, USE AMPLIFIER PHONE ............................................................................ 1
RespAvail
YES, USE TTY CAPABILITY ................................................................................ 2
RespAvail
NO ......................................................................................................................... 3
NeedProxy
5
CallLater.
Will [SAMPLE MEMBER NAME] be able to talk on the telephone if I call back next
week?
YES/MAYBE, CALL BACK ................................................................................... 1
CALLBACK
NO ......................................................................................................................... 2
NeedProxy
DON’T KNOW ....................................................................................................... d
Callback
REFUSED ............................................................................................................. r
RefusalReason
Institution.
ENTER TYPE OF INSTITUTION
HOSPITAL/REHABILITATION CENTER .............................................................. 1
HomeSoon
HOSPICE .............................................................................................................. 2
NURSING HOME .................................................................................................. 3
Capable
ASSISTED LIVING FACILITY ............................................................................... 4
Capable
GROUP HOME ..................................................................................................... 5
Capable
JAIL OR PRISON .................................................................................................. 6
Thanks
HomeSoon. Do you expect [SAMPLE MEMBER NAME] to come home from the hospital within a
week or two?
YES, ARRANGE CALLBACK ............................................................................... 1
CallBack
NO ......................................................................................................................... 2
Capable
SM UNABLE TO RESPOND OVER THE TELEPHONE ...................................... 3
NeedProxy
Deceased.
I am very sorry to hear that [he/she] passed away. I am calling on behalf of
Mathematica Policy Research regarding the U.S. Department of Health and Human
Services, Administration on Aging. A letter explaining why we are calling was
recently sent to [SAMPLE MEMBER NAME].
Please accept my condolences. Good-bye.
Capable.
Recently, the U.S. Department of Health and Human Services, Administration on
Aging and Mathematica Policy Research sent [SAMPLE MEMBER NAME] a letter
describing a study we are conducting for older adults. Would [he/she] be able to
answer questions [himself/herself] or would someone need to answer the questions
for [SAMPLE MEMBER NAME]?
RESPONDENT IS ABLE TO RESPOND.............................................................. 1
Facility
RESPONDENT IS UNABLE TO RESPOND ........................................................ 2
NeedProxy
Facility.
What is the name of the hospital/group home/assisted living facility?
6
Contact.
Do you have the name of the administrator or a contact person there?
ENTER 1 TO CONTINUE ..................................................................................... 1
FirstName
___________________________________________________
FIRST NAME
___________________________________________________
MIDDLE INITIAL
___________________________________________________
LAST NAME
___________________________________________________
CONFIRM
FacAddr.
What is the address of the hospital/group home/assisted living facility?
___________________________________________________
ADDRESS 1
___________________________________________________
ADDRESS 2
___________________________________________________
ADDRESS 3
___________________________________________________
ADDRESS 4
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
___________________________________________________
CONFIRM
DON’T KNOW ....................................................................................................... d
Thanks
REFUSED ............................................................................................................. r
Thanks
FacPhone.
May I please have the telephone number of the hospital/group home/assisted living
facility?
ENTER 1 TO CONTINUE ..................................................................................... 1
| | | |-| | | |-| | | |
(RANGE)
(RANGE)
(RANGE)
PhoneNumber
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF AREA CODE LT 200; Area code must be greater than 200
HARD CHECK: IF PHONE NUMBER NE 10 DIGITS Phone number should be 10 numeric digits, no
spaces, dashes, parentheses, or other punctuation (or empty)
7
NeedProxy. Is there someone who could answer the questions for [SAMPLE MEMBER]?
YES, SPEAKING TO FAMILY MEMBER OR FRIENDS WHO WILL ACT AS
PROXY .................................................................................................................. 1
ProxyName
YES, BUT NOT A GOOD TIME/PROXY NOT AVAILABLE ................................. 2
ProxyName2
PROXY LIVES ELSEWHERE ............................................................................... 3
ProxyName2
NO PROXY AVAILABLE ....................................................................................... 4
Thanks
SUPERVISOR REVIEW ....................................................................................... 5
Thanks
ProxyName. Before we begin, can you please tell me your name?
ENTER 1 TO CONTINUE ..................................................................................... 1
___________________________________________________
FIRST NAME
___________________________________________________
MIDDLE INITIAL
___________________________________________________
LAST NAME
Confirm.
[NAME] ProxyRel
ProxyName2. May I please have [his/her] name?
ENTER 1 TO CONTINUE .................................................................................................. 1
___________________________________________________
FIRST NAME
___________________________________________________
MIDDLE INITIAL
___________________________________________________
LAST NAME
Confirm.
[NAME] ProxyPhone
8
ProxyPhone. May I please have [his/her] telephone number?
ENTER 1 TO CONTINUE .................................................................................................. 1
| | | |-| | | |-| | | |
(RANGE)
(RANGE)
(RANGE)
PhoneNumber
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF AREA CODE LT 200; Area code must be greater than 200
HARD CHECK: IF PHONE NUMBER NE 10 DIGITS Phone number should be 10 numeric digits, no
spaces, dashes, parentheses, or other punctuation (or empty)
ProxyAddr.
And [his/her] address?
ENTER 1 TO CONTINUE .................................................................................................. 1
Addr
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
STREET 3
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
___________________________________________________
CONFIRM
ProxyRel.
ProxyRel2
And how are you related to [SAMPLE MEMBER NAME]?
SPOUSE ............................................................................................................... 1
A1
CHILD.................................................................................................................... 2
A1
SIBLING ................................................................................................................ 3
A1
PARENT ................................................................................................................ 4
A1
NIECE/NEPHEW .................................................................................................. 5
A1
FRIEND/NEIGHBOR/OTHER RELATIVE ............................................................ 6
A1
GROUP/FOSTER HOME/ASSISTED LIVING FACILITY
ADMINISTRATOR/CARER ................................................................................... 7
A1
OTHER .................................................................................................................. 8
OtherRel
9
ProxyRel2.
And how is [he/she] related to [SAMPLE MEMBER NAME]?
SPOUSE ............................................................................................................... 1
Callback
CHILD.................................................................................................................... 2
Callback
SIBLING ................................................................................................................ 3
Callback
PARENT ................................................................................................................ 4
Callback
NIECE/NEPHEW .................................................................................................. 5
Callback
FRIEND/NEIGHBOR/OTHER RELATIVE ............................................................ 6
Callback
GROUP/FOSTER HOME/ASSISTED LIVING FACILITY
ADMINISTRATOR/CARER ................................................................................... 7
Callback
OTHER .................................................................................................................. 8
OtherRel
CallInInfo.
You should call toll-free XXX-XXX-XXXX and ask for XXXXXXXXXXXXXXX. We look
forward to hearing from you.
ENTER 1 TO CONTINUE ..................................................................................... 1
Callback Screener - When calling back to complete screener after reaching A1 or if given a new
number for a proxy.
Callback-Hello. Hello, my name is [NAME] from Mathematica Policy Research in Princeton,
New Jersey. May I please speak to [RESPONDENT NAME]?
SPEAKING TO [RESPONDENT NAME] .............................................................. 1
SampMemb1 or
New Proxy1
[RESPONDENT NAME] COMES TO THE PHONE ............................................. 2
SampMemb2 or
New Proxy2
PERSON ASKS WHAT CALL IS ABOUT ............................................................. 3
WhatAbout
NEED TO CALL BACK ......................................................................................... 4
CALLBACK
NEVER HEARD OF RESPONDENT/WRONG NUMBER .................................... 5
PhoneCheck
10
SampMemb (1). I am calling to complete the interview we are conducting about [your/SAMPLE
MEMBER’s NAME] health and use of nutrition services. Is now a good time?
CONTINUE THE INTERVIEW .............................................................................. 1
Last question answered
NOT A GOOD TIME.............................................................................................. 3
Callback
SUPERVISOR REVIEW ....................................................................................... 3
Thanks
SampMemb (2). Hello, my name is [INTERVIEWER NAME] from Mathematica Policy Research in
Princeton, New Jersey. I am calling to complete the interview we are conducting
about [your/SAMPLE MEMBER’s NAME] health and use of nutrition services. Is
now a good time?
CONTINUE THE INTERVIEW .............................................................................. 1
A1
NOT A GOOD TIME.............................................................................................. 2
CallBack
SUPERVISOR REVIEW ....................................................................................... 3
Thanks
NewProxy(1):
PROGRAMMING NOTE: WHEN THERE IS A PROXY, USE THIS SCREEN IF ON
THE FIRST CALL WE WERE GIVEN THE NAME OF THE PROXY BUT THAT
PROXY WAS NOT AVAILABLE.
Recently , the U.S. Department of Health and Human Services, Administration on
Aging and Mathematica Policy Research sent [SAMPLE MEMBER’s NAME] a
letter describing a study we are conducting to improve nutrition services for
older adults. We wanted to interview [SAMPLE MEMBER’s FIRST NAME], but I
understand that [he/she] is unable to be interviewed and your name was given as
someone who could answer on [his/her] behalf. Is now a good time?
CONTINUE THE INTERVIEW .............................................................................. 1
A1
NOT A GOOD TIME.............................................................................................. 2
CallBack
WANTS MORE INFORMATION ........................................................................... 3
MoreInfo
SUPERVISOR REVIEW ....................................................................................... 4
Thanks
NewProxy(2):
PROGRAMMING NOTE: WHEN THERE IS A PROXY, USE THIS SCREEN IF ON
THE FIRST CALL WE WERE GIVEN THE NAME OF THE PROXY BUT THAT
PROXY WAS NOT AVAILABLE.
Hello, my name is [INTERVIEWER NAME] from Mathematica Policy Research in
Princeton, New Jersey. Recently, the U.S. Department of Health and Human
Services, Administration on Aging and Mathematica Policy Research sent
[SAMPLE MEMBER NAME] a letter describing a study we are conducting to
improve nutrition services for older adults. We wanted to interview [SAMPLE
MEMBER’s FIRST NAME], but I understand that [he/she] is unable to be
interviewed and your name was given as someone who could answer on [his/her]
behalf. Is now a good time?
CONTINUE THE INTERVIEW .............................................................................. 1
A1
NOT A GOOD TIME.............................................................................................. 2
CallBack
WANTS MORE INFORMATION ........................................................................... 3
MoreInfo
SUPERVISOR REVIEW ....................................................................................... 4
Thanks
11
MoreInfo.
The Centers for Medicare & Medicaid Services (CMS), which administers the
Medicare program, is cooperating with the U.S. Department of Health and Human
Services, Administration on Aging on a study to learn more about how well citizens
are served by certain government programs. Mathematica Policy Research
(Mathematica), an independent research company, is conducting the study.
Today
We will ask you a short series of questions about [SAMPLE MEMBER’s NAME]
health and use of nutrition services. If [he/she] is selected based on your responses,
one of our interviewers will call you to schedule a time to meet with you and
interview you about [his/her] health and well-being, and what [he/she] eats and
drinks.
Shall we begin?
BEGIN INTERVIEW .............................................................................................. 1
A1
WANTS ANOTHER LETTER ................................................................................ 2
ReadLetter
NOT A GOOD TIME.............................................................................................. 3
Callback
HUNG UP DURING INTRODUCTION.................................................................. 4
Thanks
WhatAbout. I am calling to complete the interview we are conducting with [RESPONDENT
NAME]. When is a good time to reach [RESPONDENT]?
[RESPONDENT] COMES TO THE PHONE ......................................................... 1
A1
NEED TO CALL BACK ......................................................................................... 2
NoLetter
SUPERVISOR REVIEW ....................................................................................... 3
MoreInfo
PhoneCheck. I’m sorry, I must have misdialed, I thought I dialed [PHONE NUMBER]. Can you tell
me what number I’ve reached to see what kind of mistake I made?
RIGHT NUMBER, NO SUCH PERSON ............................................................... 1
WrongNumber
WRONG CONNECTION/MISDIAL ....................................................................... 2
Thanks
SUPERVISOR REVIEW ....................................................................................... 3
Thanks
REFUSED TO CONFIRM NUMBER .................................................................... 3
Thanks
12
A. NONPARTICIPATION SCREENING
PROGRAMMING NOTE: For questions A1-A15, if there is a proxy (Respondent is not the sample
member), text should fill with [Does he/does she, has he/has she, etc.] depending on the Sample
Member.
If there is no proxy (Respondent is the Sample Member), text should fill with [do you, have you, etc.].
A1.
[Do you/Does he/Does she] currently eat at a senior community meal program, for
example, at a place like a senior center or community center or somewhere else where
older adults get meals on a regular basis, other than a restaurant?
YES ....................................................................................................................... 1
THANK YOU(1)
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
A2.
During the past year, [have you/has he/has she] eaten at a senior community meal
program?
YES ....................................................................................................................... 1
THANK YOU(1)
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PROGRAMMER BOX (NUM)
CATI: IF BOTH A1 AND A2 ARE DON’T KNOW OR REFUSED,
SKIP TO THANK YOU(1).
A3.
[Are you/Is he/Is she] currently in a home-delivered meals or meals-on-wheels program
where meals are delivered to [your/his/her] home?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
13
THANK YOU(1)
A4.
During the past year, [have you/has he/has she] received home-delivered meals or mealson-wheels?
YES ....................................................................................................................... 1
THANK YOU(1)
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PROGRAMMER BOX (NUM)
CATI: IF BOTH A3 AND A4 ARE DON’T KNOW OR REFUSED, GO TO
THANK YOU.
A5.
[Do you/Does he/Does she] currently live in a nursing home?
YES ....................................................................................................................... 1
THANK YOU(1)
NO ......................................................................................................................... 0
A6.
DON’T KNOW ....................................................................................................... d
THANK YOU(1)
REFUSED ............................................................................................................. r
THANK YOU(1)
[Do you/Does he/Does she] currently live in a rehabilitation facility?
YES ....................................................................................................................... 1
A7.
NO ......................................................................................................................... 0
A8
DON’T KNOW ....................................................................................................... d
A8
REFUSED ............................................................................................................. r
A8
Will [you/he/she] be living in the rehabilitation facility for more than two more weeks?
YES ....................................................................................................................... 1
THANK YOU(1)
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
THANK YOU(1)
REFUSED ............................................................................................................. r
THANK YOU(1)
14
A8.
Please tell me how difficult it is for [you/him/her] to go out of [your/his/her] house on
[your/his/her] own without the help of another person.
[Do you/Does he/Does she] have no difficulty, some difficulty, much difficulty, or [are
you/is he/is she] unable to leave the house on [your/his/her] own without the help of
another person?
CODE ONE ONLY
NO DIFFICULTY ................................................................................................... 1
GO TO A13
SOME DIFFICULTY .............................................................................................. 2
MUCH DIFFICULTY.............................................................................................. 3
UNABLE TO DO ................................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
A9.
Is the difficulty because of a medical problem, a physical condition, an emotional or
psychological problem, or a lack of transportation?
CODE ALL THAT APPLY
MEDICAL PROBLEM............................................................................................ 1
PHYSICAL CONDITION ....................................................................................... 2
EMOTIONAL OR PSYCHOLOGICAL PROBLEM ................................................ 3
LACK OF TRANSPORTATION ............................................................................ 4
NONE OF THE ABOVE ........................................................................................ 5
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
PROGRAMMER BOX A10
CATI: IF A8 = 3 OR 4 AND A9 = 1, 2, OR 3, ASK A10; ELSE GO TO A13
A10.
Please tell me how difficult it is for [you/him/her] to walk from one room to another on the
same level by [yourself/himself/herself].
[Do you/Does he/Does she] have no difficulty, some difficulty, much difficulty, or [are
you/is he/is she] unable to go from room to room by [yourself/himself/herself] without the
help of another person?
CODE ONE ONLY
NO DIFFICULTY ................................................................................................... 1
SOME DIFFICULTY .............................................................................................. 2
MUCH DIFFICULTY.............................................................................................. 3
UNABLE TO DO ................................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
15
A11.
Please tell me how difficult it is for [you/him/her] to stand up from an armless chair by
[yourself/himself/herself].
[Do you/Does he/Does she] have no difficulty, some difficulty, much difficulty, or [are
you/is he/is she] unable to get up from an armless chair by [yourself/himself/herself]
without the help of another person?
CODE ONE ONLY
NO DIFFICULTY ................................................................................................... 1
SOME DIFFICULTY .............................................................................................. 2
MUCH DIFFICULTY.............................................................................................. 3
UNABLE TO DO ................................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
A12.
Please tell me how difficult it is for [you/him/her] to get in or out of bed by
[yourself/himself/herself].
[Do you/Does he/Does she] have no difficulty, some difficulty, much difficulty, or
[are you/is he/is she] unable to get in or out of bed by [yourself/himself/herself]
without the help of another person?
CODE ONE ONLY
NO DIFFICULTY ................................................................................................... 1
SOME DIFFICULTY .............................................................................................. 2
MUCH DIFFICULTY.............................................................................................. 3
UNABLE TO DO ................................................................................................... 4
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
A13.
[Are you/Is he/Is she] able to prepare hot meals [yourself/himself/herself]?
YES ....................................................................................................................... 1
Confirm1
NO ......................................................................................................................... 0
A14.
DON’T KNOW ....................................................................................................... d
Confirm1
REFUSED ............................................................................................................. r
Confirm1
Is there someone living in [your/his/her] household who can prepare hot meals for
[you/him/her]?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
16
Confirm1
(IF SAMPLE MEMBER) I would like your help with a survey to find out how the
U.S. Department of Health and Human Services, Administration on Aging can help meet
the needs of older Americans. The survey has two parts. The first part is about your
general health and dietary habits. The second part is about what you ate and drank over a
24 hour period. Your participation is voluntary but we would really like your help. This
survey is for research purposes only and will help to improve services for older adults in
the future. All of your answers will be kept strictly confidential. Your eligibility for services
for this and other programs will not be affected by your decision to participate. The survey
takes about 55 minutes to complete. We’ll mail you a $50 gift card within a few weeks of
completing the survey.
(IF PROXY) I would like your help with a survey to find out how the U.S. Department of
Health and Human Services, Administration on Aging can help meet the needs of older
Americans. The survey has two parts. The first part is about [SAMPLE MEMBER’s FIRST
NAME] general health and dietary habits. The second part is about what [he/she] ate and
drank over a 24 hour period. Your participation is voluntary but we would really like your
help. This survey is for research purposes only and will help to improve services for older
adults in the future. All of your answers will be kept strictly confidential. [SAMPLE
MEMBER’s FIRST NAME] eligibility for services for this and other programs will not be
affected by your decision to participate. The survey takes about 55 minutes to complete.
We’ll mail you a $50 gift card within a few weeks of completing the survey.
(IF SAMPLE MEMBER OR PROXY) One of our trained interviewers will be calling you
shortly to set up an appointment to complete the interview at your convienence. May I
please confirm some information…
___________________________________________________ (STRING (NUM))
FIRST NAME
___________________________________________________ (STRING (NUM))
MIDDLE INITIAL/NAME
___________________________________________________ (STRING (NUM))
LAST NAME
___________________________________________________
STREET 1
___________________________________________________
STREET 2
___________________________________________________
STREET 3
___________________________________________________
CITY
___________________________________________________
STATE
___________________________________________________
ZIP
DON’T KNOW ....................................................................................................... d
GO TO END
REFUSED ............................................................................................................. r
GO TO END
HARD CHECK: IF ZIP CODE NE 5 OR 9 DIGITS; The zip code must be 5 or 9 digits, please re-enter
17
Is that correct?
YES ....................................................................................................................... 1
NO ......................................................................................................................... 0
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
ConfPhoneNumb The phone number we have on record for you is XXX-XXX-XXXX. Is that the
best number where we can reach you?
YES ....................................................................................................................... 1
ThankYou(2)
NO ......................................................................................................................... 0
PhoneNumber
PhoneNumber
Please give me the telephone number, area code first.
| | | |-| | | |-| | | |
(RANGE)
(RANGE)
(RANGE)
|
DON’T KNOW ....................................................................................................... d
REFUSED ............................................................................................................. r
HARD CHECK: IF AREA CODE LT 200; Area code must be greater than 200
HARD CHECK: IF PHONE NUMBER NE 10 DIGITS Phone number should be 10 numeric digits, no
spaces, dashes, parentheses, or other punctuation (or empty)
ThankYou(1).
Thank you for your time.
ThankYou(2).
Thank you for your time. We look forward to your participation in our study.
18
2011 National Evaluation of Title III-C Nutrition Services
[FILL SUA NAME] Data Verification
The information in Column 1 about [FILL SUA NAME] comes from the State Program Report and the NASUA State of
Aging report. Please review the information about your SUA in Column 1. If the information is correct, check the box in
Column 2 and continue to the next row. If the information is incorrect, please make corrections in Column 3.
COLUMN 1
COLUMN 2
COLUMN 3
Organizational Structure
1. The SUA is…
□
Correct
□
an independent agency within state
government
part of an umbrella agency
part of a board or commission
2. (ANSWER 2 ONLY IF SUA IS PART OF
UMBRELLA AGENCY) The umbrella agency of
the SUA is best described as…
Incorrect. The SUA is…
□
□
□
□
Human service
Health
Medicaid
Welfare
Health and Social/Human/ Family services
Governor/Lt. Governor’s Office
Community/Cultural Affairs
None of the above
National Evaluation of Title III-C SUA Fax Back (3-7-12)
Correct
□
an independent agency within state
government
part of an umbrella agency
part of a board or commission
Incorrect. The umbrella agency of the SUA is
best described as…
□
□
□
□
□
□
□
□
Human service
Health
Medicaid
Welfare
Health and Social/Human/ Family
services
Governor/Lt. Governor’s Office
Community/Cultural Affairs
None of the above
1
COLUMN 1
3. The SUA administers the following non-Older
Americans Act (OAA) programs:
COLUMN 2
□
Correct
COLUMN 3
□
Medicaid institutional care
Medicaid Waiver(s)
Energy assistance (LIHEAP)
State health insurance counseling and
assistance program (SHIP)
Pre-admission screening and resident review
screening for mental illness (PASRR)
State funded HCBS
SNAP (Food Stamps)
CACFP
Emergency Food Assistance (TEFAP)
Incorrect. The SUA administers the following
non-Older Americans Act (OAA) programs:
CHECK ALL THAT APPLY
□
□
□
□
□
□
□
□
□
□
Commodity Supplemental Food Program
(CSFP)
Senior Farmers Market (SFMP)
None of the above
□
□
4. There are [FILL NUMBER] tribal organizations
with Title VI grants in this state.
□
Correct
□
Medicaid institutional care
Medicaid Waiver(s)
Energy assistance (LIHEAP)
State health insurance counseling and
assistance program (SHIP)
Pre-admission screening and resident
review screening for mental illness
(PASRR)
State funded HCBS
SNAP (Food Stamps)
CACFP
Emergency Food Assistance (TEFAP)
Commodity Supplemental Food Program
(CSFP)
Senior Farmers Market (SFMP)
None of the above
Incorrect. The state has…
|
|
| TRIBAL ORGANIZATIONS
Staff and Volunteers
5. This SUA has [FILL # FTEs] full-time
equivalent employees, including yourself.
□
6. Of the total number of full-time equivalent
employees, [FILL # FTEs] work on the Elderly
Nutrition Program and are funded in whole or in
part by the Older Americans Act.
□
Correct
□
Incorrect. The SUA has…
|
Correct
□
|
|
| FULL-TIME EQUIVALENT
EMPLOYEES INCLUDING
YOURSELF
Incorrect. The number of employees who
work on the Elderly Nutrition Program is…
|
|
|
| FULL-TIME EQUIVALENT
EMPLOYEES INCLUDING
YOURSELF
Aging and Disability Resource Centers (ADRCs)
7. An Aging and Disability Resource Center
[exists/does not exist] in your state.
□
Correct
□
8. (ANSWER QUESTION 2 ONLY IF ADRC
EXISTS) The Aging and Disability Resource
Center [provides/does not provide] statewide
coverage.
□
Correct
□
National Evaluation of Title III-C SUA Fax Back (3-7-12)
Incorrect. An Aging and Disability Resource
Center [exists/does not exist] in your state.
Incorrect. An Aging and Disability Resource
Center [exists/does not exist] in your state.
2
COLUMN 1
COLUMN 2
COLUMN 3
Service Population
9. The SUA serves the following populations
through all programs and services:
□
Correct
□
Incorrect. The SUA serves…
CHECK ALL THAT APPLY
□
□
□
Adults 60 years and older
Family caregivers
Adults with physical disabilities regardless of
age
Adults with mental retardation or developmental
disability regardless of age
Children with physical disabilities
Children with mental retardation or
developmental disability
□
□
□
10. Between October 2010 and September 2011,
the SUA served [FILL NUMBER] unduplicated
congregate nutrition clients in the Older
Americans Act (OAA) Title III-C Congregate
Nutrition Program.
□
11. Between October 2010 and September 2011,
the SUA served [FILL NUMBER] unduplicated
home-delivery nutrition clients in the Older
Americans Act (OAA) Title III-C HomeDelivered Nutrition Program.
□
Correct
□
Adults 60 years and older
Family caregivers
Adults with physical disabilities regardless
of age
Adults with mental retardation or
developmental disability regardless of
age
Children with physical disabilities
Children with mental retardation or
developmental disability
Incorrect. In the most recently completed
fiscal year, the SUA served…
|
|
|
|,|
|
|
|
UNDUPLICATED CONGREGATE NUTRITION
PROGRAM CLIENTS
Correct
□
Incorrect. In the most recently completed
fiscal year, the SUA served…
|
|
|
|,|
|
|
|
UNDUPLICATED HOME-DELIVERED
NUTRITION PROGRAM CLIENTS
Transfer of Older Americans Act Funds
*THE INFORMATION IN THIS SECTION APPLIES TO FUNDS TRANSFERRED IN THE MOST RECENTLY COMPLETED FISCAL YEAR
12. The SUA transferred $[FILL AMOUNT] in OAA
funds from Congregate Meal to HomeDelivered Meals.
□
Correct
□
Incorrect. The SUA transferred…
$|
|,|
|
|
|,|
|
|
|
FROM CONGREGATE TO HOME-DELIVERED
MEALS
13. The SUA transferred $[FILL AMOUNT] in OAA
funds from Home-Delivered Meals to
Congregate Meals.
□
Correct
□
Incorrect. The SUA transferred…
$|
|,|
|
|
|,|
|
|
|
FROM HOME-DELIVERED TO CONGREGATE
MEALS
14. The SUA transferred $[FILL AMOUNT] in OAA
funds from Congregate Meals to Supportive
Services.
□
Correct
□
Incorrect. The SUA transferred…
$|
|,|
|
|
|,|
|
|
|
FROM CONGREGATE MEALS TO
SUPPORTIVE SERVICES
National Evaluation of Title III-C SUA Fax Back (3-7-12)
3
COLUMN 1
15. The SUA transferred $[FILL AMOUNT] in OAA
funds from Home-Delivered Meals to
Supportive Services.
COLUMN 2
□
Correct
COLUMN 3
□
Incorrect. The SUA transferred…
$|
|,|
|
|
|,|
|
|
|
FROM HOME-DELIVERED MEALS TO
SUPPORTIVE SERVICES
16. The SUA transferred $[FILL AMOUNT] in OAA
funds from Supportive Services to Congregate
Meals.
□
Correct
□
Incorrect. The SUA transferred…
$|
|,|
|
|
|,|
|
|
|
FROM SUPPORTIVE SERVICES TO
CONGREGATE MEALS
17. The SUA transferred $[FILL AMOUNT] in OAA
funds from Supportive Services to HomeDelivered Meals
□
Correct
□
Incorrect. The SUA transferred…
$|
|,|
|
|
|,|
|
|
|
FROM SUPPORTIVE SERVICES TO HOMEDELIVERED MEALS
Program Characteristics
18. The SUA [administers/does not administer] a
state funded HCBS program that includes
home-delivered meals.
□
Correct
□
□
Correct
□
Incorrect. The SUA [administers/does not
administer] a state funded HCBS program
that includes home-delivered meals.
Medicaid Waiver
19. The state offers the following nutrition services
in Medicaid HCBS:
Home delivered meals
Nutrition supplements
None of the above
National Evaluation of Title III-C SUA Fax Back (3-7-12)
Incorrect. The state offers the following
nutrition services in Medicaid HCBS:
□
□
□
Home delivered meals
Nutrition supplements
None of the above
4
2011 National Evaluation of the Title III-C
Elderly Nutrition Services
State Unit on Aging (SUA) Survey
INTRODUCTION
Thank you for helping us with the National Evaluation of the Title III-C Elderly Nutrition Services. The
study will involve a census of all State Units on Aging as well as a large number of Area Agencies on
Aging, Local Service Providers, program participants and eligible non-participants. This survey will collect
information that is not available either in the State Program Report or the NASUA State of Aging report.
•
The survey should be completed by the person in the SUA who is most familiar with the Elderly
Nutrition Program.
•
When completing the survey, please use a black or blue pen and write in the spaces provided.
•
Unless questions specifically indicate that more than one answer may be given, please mark only
one answer per question.
•
If you have any questions regarding the study or completing the State Unit on Aging Survey,
please contact Rhoda Cohen at 1-800-232-8024 or email: rcohen@mathematica-mpr.com
•
The information you provide will be used only for statistical purposes. In accordance with the
Confidential Information Protection and Statistical Efficiency Act of 2002, your responses will not
be disclosed in identifiable form without your consent.
•
Participation is completely voluntary. We thank you for your cooperation and participation in this
very important study.
•
If you do not have exact information available to answer certain questions, your best estimate will
be fine.
A.
ORGANIZATIONAL STRUCTURE, STAFF AND VOLUNTEERS
A1. How many Area Agencies on Aging (AAA) are there currently in your state?
|
|
| AAAs
A2. Of the total number of Area Agencies on Aging currently in your state, please record
the number of AAAs that are characterized by each of the various types of planning
and service area boundaries.
Planning and Service Area Boundaries
Number of AAAs
Don’t Know
a. Single-county ....................................................
|
|
|
d
b. Multi-county ......................................................
|
|
|
d
c.
Single city/metro area .......................................
|
|
|
d
d. Multiple city/metro area ....................................
|
|
|
d
e. Other (Specify) ...................................................
|
|
|
d
□
□
□
□
□
A3. Does the SUA currently employ a Nutrition Program Administrator who plans,
develops, administers, implements and evaluates the Elderly Nutrition Program?
1
0
d
□
□
□
Yes
No
Don’t know
GO TO A6
A4. Is the Nutrition Program Administrator a registered dietitian or state credentialed
nutrition professional?
1
0
d
□
□
□
Yes
No
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
1
A5. What program responsibilities does the Nutrition Program Administrator currently
have other than the Elderly Nutrition Program?
MARK ALL THAT APPLY
1
2
3
□
□
□
Other food and nutrition programs (e.g., SNAP, Senior Farmers’
Market Nutrition Program (SFMNP), etc.)
Non-food and nutrition programs (e.g., transportation services,
senior centers, etc.) (Specify)
No other program responsibilities
A6. How many employees who are registered dietitians and/or state credentialed nutrition
professionals currently work at least part of their time on the Elderly Nutrition
Program?
|
B.
| EMPLOYEES
AGING AND DISABILITY RESOURCE CENTERS (ADRCS)
B1. Has the Elderly Nutrition Program staff been involved in developing or reviewing the
current intake process or assessment tools for nutrition services for the Aging and
Disability Resource Center site(s) in your state?
1
0
2
d
□
□
□
□
Yes
No
ADRC is not operational
GO TO C1
Don’t know
B2. Do Aging and Disability Resource Center sites in your state currently assess clients
for nutrition service needs as part of the client intake and assessment?
1
2
0
d
□
□
□
□
Yes, all sites
Yes, some sites
No
Don’t know
B3. Do the Aging and Disability Resource Center sites currently use client intake and
assessments for nutrition services that are consistent across the state?
1
0
2
d
□
□
□
□
Yes
No
Only one site in state
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
2
C.
CONSUMER DIRECTION
The next questions are about self-directed care. Self-directed care is defined as programs
and services, in which clients can choose to select, manage and dismiss their workers.
This may also be referred to as “consumer-directed” care.
C1. Does the SUA currently have policies that permit self-directed home and communitybased services for older adults?
1
0
d
□
□
□
Yes
No
Don’t know
GO TO D1
C2. Do the self-directed home and community-based service programs for older adults
include nutrition services as allowable services?
1
2
0
d
□
□
□
□
Yes, all self-directed programs allow nutrition services
Yes, some self-directed programs allow nutrition services
No
Don’t know
GO TO D1
C3. What options are currently allowed for delivery of self-directed nutrition services?
MARK ALL THAT APPLY
1
2
3
4
5
6
□
□
□
□
□
□
Payments to friends or family
Restaurant vouchers
Congregate nutrition services
Home-delivered nutrition services
No policy exists about allowable service delivery
Other (Specify)
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
3
D.
FOOD SAFETY
D1. Does the SUA currently have any formal policies, guidance or regulations for
managing food borne illnesses in the Elderly Nutrition Program?
1
0
d
□
□
□
Yes
No
GO TO D3
Don’t know
D2. Which of the following entities were involved in the development of the SUA’s current
food borne illness policy for the Elderly Nutrition Program?
1
2
3
4
5
d
□
□
□
□
□
□
AAAs
Local service providers
State or local health department
State department of agriculture
None of the above
Don’t know
D3. Does the SUA currently have formal policies, guidance or regulations for managing
food recalls?
1
0
d
□
□
□
Yes
No
Don’t know
GO TO D5
D4. Which of the following entities were involved in the development of the SUA’s current
food recall policy?
1
2
3
4
5
d
□
□
□
□
□
□
AAAs
Local service providers
State or local health department
State department of agriculture
None of the above
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
4
D5. Are local service providers currently required by the SUA to report incidents of
food borne illness that occur in the Elderly Nutrition Program (congregate or
home-delivered nutrition programs) to each of the following entities?
Yes
No
a. AAA...................................................................
1
0
b. SUA ..................................................................
1
c.
1
State or local health department ......................
□
□
□
0
0
□
□
□
Don’t
Know
d
d
d
□
□
□
D6. During the past 3 years, how many different times was the food served in the
congregate nutrition program associated with an outbreak of food-borne illness?
|
0
d
□
□
|
| TIMES
Zero
Don’t know
GO TO D8
D7. In total, how many clients got sick during the past 3 years?
|
d
|
□
|
|
| CONGREGATE NUTRITION PROGRAM CLIENTS
Don’t know
D8. During the past 3 years, how many different times was food served in the homedelivered nutrition program associated with an outbreak of food-borne illness?
|
0
d
□
□
|
| TIMES
Zero
Don’t know
GO TO E1
D9. In total, how many clients got sick in the past 3 years?
|
d
|
□
|
|
| HOME-DELIVERED NUTRITION PROGRAM CLIENTS
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
5
E.
NUTRITION PROGRAM QUALITY/MONITORING/SITE VISITS
E1. Please indicate how the DRIs (dietary reference intakes) and Dietary Guidelines for
Americans (2005) had been implemented throughout the Elderly Nutrition Program in
your state as of December 2010?
Dietary Reference
Intakes (DRIs)
Implementation Status
a. Full implementation throughout the state .......................
1
b. Full implementation in portions of the state ..................
2
c.
Partial implementation throughout the state ...................
3
d. Very little implementation throughout the state ..............
4
e. Don’t Know .....................................................................
d
□
□
□
□
□
Dietary Guidelines
for Americans
1
2
3
4
d
□
□
□
□
□
E2. Has the SUA established a formal policy for the Elderly Nutrition Program regarding
the implementation of the DRI or the Dietary Guidelines for Americans?
1
2
3
0
□
□
□
□
Yes, DRI only
Yes, Dietary Guidelines for Americans only
Yes, both DRI and the Dietary Guidelines
No, neither DRI or the Dietary Guidelines
GO TO E4
E3. When were the SUA’s formal policies regarding the DRI or Dietary Guidelines last
updated?
|
d
|
□
|
|
| YEAR
Don’t know
E4. How frequently are SUA policies on the implementation of the DRIs or Dietary
Guidelines in the Elderly Nutrition Program updated?
1
2
3
4
5
6
d
□
□
□
□
□
□
□
Yearly
After every reauthorization of the Older Americans Act (OAA)
After changes are made to the DRI, Dietary Guidelines for Americans or food service
codes
Every 1-5 years
Other (Specify)
No schedule is used
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
6
E5. Has the SUA established a formal policy for the Elderly Nutrition Program regarding
the implementation of state and local food service codes?
1
0
d
□
□
□
Yes
No
Don’t know
E6. Does the SUA currently include assessments in any of the following areas to monitor
the AAAs’ implementation of the Elderly Nutrition Program?
MARK ALL THAT APPLY
1
2
3
4
5
6
7
8
9
d
□
□
□
□
□
□
□
□
□
□
Nutrient quality
Client satisfaction
Food service quality
Targeting of service
Outreach activities
Access to service
Reporting of data
Fiscal management
None of the above
Don’t know
E7. Which of the following does the SUA currently use to contribute to the nutrient quality
of the meals in the Elderly Nutrition Program?
MARK ALL THAT APPLY
1
2
3
4
5
6
7
8
9
0
d
□
□
□
□
□
□
□
□
□
□
□
Statewide catering contract
State approved menus to AAAs
Credentialed nutrition professional to approve AAA submitted menus
Computer assisted menu analysis
Site visits
Training of AAAs and local service providers
Technical assistance
Monitoring of AAAs
AAA assurance of nutrient quality
None of the above
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
7
F.
DATA AND PERFORMANCE
F1. How do AAAs currently report Elderly Nutrition Program data to the SUA?
MARK ALL THAT APPLY
1
2
3
4
5
d
□
□
□
□
□
□
Software/computer system
Email
Phone
Mail
GO TO F3
Other (Specify)
Don’t know
F2. Are all AAAs in your state currently required to use the same software for reporting
Elderly Nutrition Program data?
1
0
d
□
□
□
Yes
No
Don’t know
F3. Does the SUA currently require AAAs to report Elderly Nutrition Program data beyond
that required in the AoA State Program Report?
1
0
d
□
□
□
Yes
No
Don’t know
GO TO F5
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
8
F4. What specific data are currently collected beyond what is required for the State
Program Report?
MARK ALL THAT APPLY
1
2
3
4
d
□
□
□
□
□
Nutrition program service reports/program performance data
Quality assurance findings
Fiscal management reports
None of the above
Don’t know
F5. Has the SUA or AAA established Elderly Nutrition Program performance measures at
the AAA level?
1
0
d
□
□
□
Yes
No
Don’t know
F6. Does the SUA currently share Elderly Nutrition Program performance data with the
public?
1
0
d
□
□
□
Yes
No
Don’t know
F7. How frequently are AAAs required to report Elderly Nutrition Program data to the
SUA?
1
2
3
4
5
6
d
□
□
□
□
□
□
□
Continuously
Monthly
Quarterly
Semi-annually
Annually
Other (Specify)
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
9
F8. Does the SUA currently use Elderly Nutrition Program performance data for any of the
following purposes?
MARK ALL THAT APPLY
1
2
3
4
5
6
7
8
9
d
G.
□
□
□
□
□
□
□
□
□
□
To monitor AAAs’ Elderly Nutrition Program performance
To provide the basis for technical assistance
To provide information to other state agencies
To provide information to the state legislature
To justify or prepare state budget requests
To develop new programs
To improve existing programs
To inform program planning
None of the above
Don’t know
NUTRITION NEEDS ASSESSMENT (COMMUNITY/INDIVIDUAL)
G1. During the previous 5 years, have community needs assessments for elderly nutrition
services been conducted?
1
2
3
d
□
□
□
□
Yes, a state-wide community needs assessment that
includes nutrition has been done
GO TO G3
Yes, one or more local level (PSA-level) community
needs assessments that include nutrition have been done
No assessment has been done
GO TO G4
Don’t know
G2. Did the local level community needs assessment(s) follow a consistent protocol that
included nutrition?
1
0
d
□
□
□
Yes
No
Don’t know
G3. Were results from the community needs assessment(s) pertaining to nutrition utilized
or incorporated into the state plan?
1
0
d
□
□
□
Yes
No
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
10
G4. Does the SUA currently issue formal policies or guidance to the AAAs or local service
providers on the conduct of individual nutrition needs assessment in the Elderly
Nutrition Program?
1
0
d
□
□
□
Yes
No
GO TO H1
Don’t know
G5. Is a consistent individual nutrition needs assessment currently required at the local level
(AAA or local service provider) for the Elderly Nutrition Program? Please exclude the
NSI/DETERMINE Checklist from your response.
1
0
d
H.
□
□
□
Yes
No
Don’t know
STATE AND AREA PLANS
H1. Does the OAA required State Plan on Aging currently include a nutrition services
component?
1
0
d
□
□
□
Yes
No
Don’t know
H2. How was the Elderly Nutrition Program staff involved in developing the current OAA
required State Plan on Aging?
MARK ALL THAT APPLY
1
2
3
4
5
d
□
□
□
□
□
□
Consulted during development
Participated in writing nutrition related components
Reviewed or commented on drafts of the state plan
None of the above
ENP staff were not involved in the development of the current OAA required State Plan
on Aging
Don’t know
H3. Does the Area Plan for Aging format currently include a nutrition services
component?
1
0
d
□
□
□
Yes
No
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
11
I.
EMERGENCY NUTRITION SERVICE
I1.
Does the SUA currently have an Emergency Preparedness Plan that includes nutrition
services?
MARK ALL THAT APPLY
1
2
0
d
I2.
Yes, for short-term emergencies
Yes, for long-term emergencies
No
Don’t know
GO TO I4
Does the SUA currently have policies that require AAA contracts or grants to local
service providers to include how nutrition services are to be provided during local
emergencies?
1
0
d
I3.
□
□
□
□
□
□
□
Yes
No
Don’t know
Which of the following components are included in the current SUA Emergency
Preparedness Plan for nutrition services?
MARK ALL THAT APPLY
1
2
3
4
d
I4.
□
□
□
□
□
Plan for communications between organizations as well as with clients
Plan for the provision of food and water
Plan for identifying and addressing the health and wellness needs of nutrition clients
None of the above
Don’t know
With which of the following entities does the SUA currently have a relationship to help
meet the needs of Elderly Nutrition Program clients during emergencies?
MARK ALL THAT APPLY
1
2
3
4
5
6
d
□
□
□
□
□
□
□
County/local organizations
Red Cross
FEMA citizens’ corps
National Voluntary Organizations Active in Disasters (VOAD) or their members
(e.g., Feeding America, Catholic Charities, The Jewish Federations)
Private sector entities involved in disasters
None of the above
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
12
J.
TRAINING AND TECHNICAL ASSISTANCE
J1. During the past 2 years, which of the following has the SUA done to provide training
and technical assistance for the Elderly Nutrition Program?
MARK ALL THAT APPLY
1
2
3
4
d
□
□
□
□
□
Held specific trainings that focus on the Elderly Nutrition Program and related topics
Held general trainings that cover a range of programs and services, including the
Elderly Nutrition Program and related topics
Held trainings on the Elderly Nutrition Program and related topics in conjunction with
other state or local agencies or organizations (e.g., state health department)
None of the above
Don’t know
J2. During the past 2 years, on which of the following topics has the SUA provided
training to AAAs or local service providers?
MARK ALL THAT APPLY
1
2
3
4
5
6
7
d
□
□
□
□
□
□
□
□
Nutrition quality
Food safety
Food service
Nutrition education
Nutrition counseling
Program evaluation or outcome measurement
None of the above
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
13
K.
TARGETING
The next question is about targeting. Targeting is defined as modifying or adapting
services and outreach to attract and meet the needs of identified groups who may be
under-represented or are considered in special need of services. Target populations are
defined by the Older Americans Act as… “older individuals with greatest economic need
and older individuals with greatest social need (with particular attention to low-income
older individuals, including low-income minority older individuals, older individuals with
limited English proficiency, and older individuals residing in rural areas).”
K1. What mechanisms does the SUA use to insure targeting of Elderly Nutrition Program
services?
1
2
3
4
5
6
7
d
L.
□
□
□
□
□
□
□
□
Formal policies
Guidance
Regulations
Contract language
Area plan review and approval
Monitoring of AAAs
None of the above
Don’t know
PRIORITIZATION OF SERVICES
The next 3 questions are about prioritization. Prioritization is defined as establishing
criteria to be used as a basis for making decisions to serve some individuals before
others when resources are limited.
L1. Which of the following best describes how the SUA’s current prioritization policy was
set for the Elderly Nutrition Program?
1
2
3
4
5
6
d
□
□
□
□
□
□
□
Prioritization policy is set by the SUA
Prioritization policy is set by the SUA with input from AAAs
Prioritization policy is set by the AAAs with input from SUA
Prioritization policy is set by the AAAs
Prioritization policy is set by the local service providers
No prioritization policy exists
Don’t know
L2. Are prioritization criteria statewide or do they vary by AAA?
1
2
3
d
□
□
□
□
Prioritization criteria are statewide
Prioritization criteria are AAA specific
Prioritization criteria are local service provider specific
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
14
L3. Which of the following criteria are used to determine Elderly Nutrition Program
service priority according to SUA policy?
MARK ALL THAT APPLY
Criteria
Congregate meal
prioritization
a. ADL and/or IADL impairment minimum
(e.g., 3+ ADL impairments)..............................
1
b. Lack of informal/family support ........................
1
c.
Geographic isolation (e.g., rural) .....................
1
d. Social isolation (e.g., lives alone) ....................
1
e. Chronic health condition (e.g., diabetes) .........
1
f.
Poor housing or lack of kitchen access ...........
1
g. Homebound .....................................................
1
h. Racial/ethnic minority ......................................
1
i.
Advanced age (e.g., 75+, 85+) ........................
1
j.
Low income (e.g., % of federal poverty level) .
1
k.
Limited English proficiency ..............................
1
l.
Dementia or cognitive impairment ...................
1
m. Food insecurity/hunger ....................................
1
n. Nutrition risk assessment ................................
1
o. Adult day care participation .............................
1
p. Long-term care need for service......................
1
q. Short-term care need for service .....................
1
r.
Other (Specify) ..................................................
1
s.
No prioritization criteria ....................................
1
t.
Criteria are not set by the SUA ........................
1
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
15
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Home-delivered meal
prioritization
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
M
WAITING LISTS
M1. Does the SUA currently have policies, guidance or regulations pertaining to the
creation and management of waiting lists for Elderly Nutrition Program services?
MARK ALL THAT APPLY
1
2
0
d
□
□
□
□
Yes, for the home-delivered nutrition service
Yes, for the congregate nutrition service
No
Don’t know
M2. Does the SUA currently maintain or have access to information on waiting lists for
any of the following services?
MARK ALL THAT APPLY
1
2
3
0
d
N.
□
□
□
□
□
Yes, for home-delivered nutrition service
Yes, for congregate nutrition service
Yes, for other OAA services
No
Don’t know
ACCESSING SERVICES/ELIGIBILITY
The following two questions ask about eligibility criteria. Eligibility criteria refer to criteria
used to determine who may receive services regardless of program resource limitations.
N1. Does the SUA have specific policies, guidance or regulations on the eligibility criteria
for the Home-Delivered Nutrition Program?
1
0
d
□
□
□
Yes
No
GO TO N3
Don’t know
N2. Which of the following best describes how eligibility criteria are set for the homedelivered nutrition program?
MARK ONE
1
2
3
4
d
□
□
□
□
□
Eligibility is set by the SUA
Eligibility is set at the AAA level but must be consistent with SUA policy
Eligibility is set at the AAA level
Eligibility is set at the local service provider level
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
16
N3. Does the SUA currently have policies, guidance or regulations regarding the location
of congregate nutrition sites?
1
0
d
□
□
□
Yes
No
Don’t know
N4. Does the SUA currently have policies, guidance or regulations regarding the
accessibility of congregate nutrition sites, that is, sites are compliant with the
Americans with Disabilities Act?
1
0
d
□
□
□
Yes
No
Don’t know
N5. What percent of congregate sites in your state are accessible as defined by the
Americans with Disabilities Act?
|
d
O.
|
□
|
| %
Don’t know
NUTRITION EDUCATION
O1. Currently, how often does the SUA require the AAA or local service provider to offer
nutrition education?
MARK ONE
1
2
3
4
5
6
7
d
□
□
□
□
□
□
□
□
Monthly
Quarterly
Semi-annually
Annually
No policy exists at the SUA level on frequency of nutrition education
Nutrition education only provided by the SUA and not by AAA or local service provider
Other (Specify)
Don’t know
O2. Currently, does the SUA have formal policies, guidance or regulations on the
qualifications of staff that provide nutrition education at the AAA or local service
provider level?
1
0
d
□
□
□
Yes
No
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
17
O3. Currently, does the SUA require that AAAs or local service providers develop a
nutrition education plan?
1
0
d
□
□
□
Yes
No
GO TO P1
Don’t know
O4. What is the SUA’s role with regard to the AAA/local service provider nutrition
education plan?
MARK ALL THAT APPLY
1
2
3
4
5
d
P.
□
□
□
□
□
□
The SUA must approve the plan
The SUA provides guidance on developing the plan
The SUA sets minimum components of the plan
The SUA monitors the plan
Other (Specify)
Don’t know
NUTRITION COUNSELING
P1. Currently, does the SUA require that nutrition counseling be available in each PSA
(provided by the AAA or their service providers)?
1
0
d
□
□
□
Yes
No
Don’t know
P2. Currently, does the SUA have policies, guidance or regulations related to nutrition
counseling on any of the following topics?
MARK ALL THAT APPLY
1
2
3
4
d
□
□
□
□
□
Criteria for authorizing nutrition counseling
Qualifications of the nutrition counseling staff
Content of the nutrition counseling
None of the above
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
18
Q.
BUDGET AND FISCAL
Q1. Which of the following budget related activities involve the participation of Elderly
Nutrition Program staff?
MARK ALL THAT APPLY
1
2
3
4
5
d
□
□
□
□
□
□
Providing research or analysis on the implications of budget options
Preparing or reviewing budget justification materials
Determining budget request amounts
Determining budget allocation
None of the above
Don’t know
Q2. Which of the following does the Elderly Nutrition Program staff currently monitor at
the SUA or AAA level?
MARK ALL THAT APPLY
1
2
3
4
5
6
d
□
□
□
□
□
□
□
Expenditures per meal
Expenditures per client
Contract costs
Program income
Funding sources
None of the above
Don’t know
Q3. Does the SUA have policy, guidance, or regulations related to AAA and local service
provider offering private pay/fee-for-service nutrition services?
1
0
d
□
□
□
Yes
No
Don’t know
Q4. Please indicate how much your SUA encourages or discourages AAAs or service
providers to operate private pay/fee-for-service nutrition programs for older adults?
1
2
3
4
5
d
□
□
□
□
□
□
Strongly encourages
Encourages
Allows private pay but neither encourages nor discourages the activity
Discourages
Prohibits
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
19
Q5. Is there a statewide unit rate for the following nutrition services programs and were
nutrition program staff involved in setting the unit rate?
Statewide Unit Rate
Nutrition Program
Yes
a. Congregate nutrition program............
1
b. Home-delivered nutrition program .....
1
c.
1
R.
Medicaid waiver nutrition services .....
□
□
□
No
0
0
0
□
□
□
Don’t
know
d
d
d
□
□
□
Program staff involved in
setting unit rate
Yes
1
1
1
Don’t
know
No
□
0
□
0
□
0
□
d
□
d
□
d
□
□
□
PROGRAM CONTRIBUTIONS
The next questions ask about the SUA policy regarding participant contributions for the
Elderly Nutrition Program.
R1. Does the SUA currently have a policy regarding the…
Yes
a. Collection and/or management of participant
contributions for the Elderly Nutrition Program?..............
b. Distribution of participant contributions for the Elderly
Nutrition Program?...........................................................
c.
Spending of participant contributions for the Elderly
Nutrition Program?...........................................................
1
1
1
□
□
□
No
0
0
0
□
□
□
Don’t know
d
d
d
□
□
□
R2. Does the SUA currently have specific policies on the non-coercion of participants
with regard to participant contributions?
1
0
d
□
□
□
Yes
No
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
20
R3. How does the SUA determine if participant contributions to the Elderly Nutrition
Program are used to expand services?
MARK ALL THAT APPLY
1
2
3
4
d
S.
□
□
□
□
□
AAAs and local service providers are required to spend participant contributions first and
then other funds
AAAs and local service providers are required to report data on services delivered using
participant contributions
The SUA monitors program data (e.g., service units, people served) in relation to
participant contributions reported.
Other (Specify)
Don’t know
FACILITIES AND EQUIPMENT
S1. Currently, does the SUA provide equipment, either directly or through designated
funding, for use by the Elderly Nutrition Program (home-delivered nutrition or
congregate nutrition programs)?
1
0
d
□
□
□
Yes
No
Don’t know
S2. Currently, does the SUA provide any facilities, either directly or through designated
funding for use by the Elderly Nutrition Program (home-delivered nutrition or
congregate nutrition programs)?
1
0
d
□
□
□
Yes
No
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
21
T.
INTEGRATION WITH OTHER FOOD AND NUTRITION PROGRAMS
T1. Currently, to what extent does the Elderly Nutrition Program staff collaborate with
each of the following food and nutrition partners to improve access or service
delivery to older adults (e.g., through modification/streamlining of application
process, review or development of policies, etc.)?
Extent of Collaboration
Very
much
a. Supplemental Nutrition Assistance
Program (SNAP) .................................
1
b. Senior Farmers’ Market Nutrition
Program (SFMNP) ..............................
1
c.
Commodity Supplemental Food
Program (CSFP) .................................
1
d. Child and Adult Care Food Program
(CACFP) .............................................
1
e. The Emergency Food Assistance
Program (TEFAP) ...............................
1
Somewhat
□
2
□
2
□
2
□
2
□
2
Not at
all
A little
□
3
□
3
□
3
□
3
□
3
□
4
□
4
□
4
□
4
□
4
Not
applicable
□
n
□
n
□
n
□
n
□
n
□
□
□
□
□
T2. Have the Elderly Nutrition Program staff collaborated with the following food and
nutrition programs in any of the following ways?
MARK ALL THAT APPLY
Type of Collaboration
SNAP
a. Participate in review or development of policies
or procedures.........................................................
1
b. Promote older adult access to the program ..........
1
c.
Participate in training and technical assistance.....
1
d. Participate in committees and workshops .............
1
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
22
□
□
□
□
SFMNP
2
2
2
2
□
□
□
□
CSFP
3
3
3
3
□
□
□
□
CACFP
4
4
4
4
□
□
□
□
TEFAP
5
5
5
5
□
□
□
□
U.
INTEGRATION WITH NON-FOOD AND NUTRITION PROGRAMS
U1. Have the Elderly Nutrition Program staff been involved with case management,
information and referral/assistance or ADRC services in any of the following ways?
MARK ALL THAT APPLY
1
2
3
4
5
6
7
8
n
□
□
□
□
□
□
□
□
□
Review or development of policies, guidance or regulations regarding the inclusion of
nutrition services
Development or review of screening protocols
Implementation of screening protocols
Development or review of assessment tools
Development or review of referral/assistance process
Implementation of referral/assistance process
Provision of training
Receipt of training from non-food nutrition program
Not applicable, no consistent state level intake, assessment or referral process
U2. Have the Elderly Nutrition Program staff been involved with evidence-based health
promotion and disease prevention programs (e.g., chronic disease self-management
program) in any of the following way?
1
2
3
4
5
n
V.
□
□
□
□
□
□
Management of evidence-based health promotion and disease prevention grants
Promotion of inclusion of nutrition program clients as participants
Participation in outreach activities
Coordination with state health department evidence-based grantees
None of the above
Not applicable, no evidence-based health promotion and disease prevention grants
MEDICAID WAIVER
V1. Currently, does the SUA administer a Medicaid waiver program for the elderly?
1
0
2
d
□
□
□
□
Yes
No
GO TO V3
State does not have a Medicaid
waiver program for the elderly
GO TO W1
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
23
V2. Which of the following services are provided under the current state Medicaid waiver
program for the elderly?
MARK ALL THAT APPLY
1
2
3
4
5
6
7
8
d
□
□
□
□
□
□
□
□
□
Nutrition assessment
Nutrition counseling
Nutrition risk reduction
Home-delivered meals
Medical nutrition therapy
Dietitian services
Nutritional supplements
None of the above
Don’t know
V3. Was the SUA Elderly Nutrition Program staff involved with the current state Medicaid
waivers for the elderly by…
Yes
a. Reviewing policies related to nutrition services? .............
1
b. Providing input regarding the use of nutritional
supplements in the waiver programs? .............................
1
□
□
No
0
0
□
□
Don’t know
d
d
□
□
V4. Are the following consistent across Medicaid waiver and the Elderly Nutrition Programs?
Yes
a. Are nutrition standards consistent? .................................
1
b. Are food safety standards consistent? ............................
1
c.
Are nutrition counseling services consistent? .................
1
d. Are cost or rates for nutrition services consistent?..........
1
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
24
□
□
□
□
No
0
0
0
0
□
□
□
□
Don’t know
d
d
d
d
□
□
□
□
W.
COORDINATION/COLLABORATION/PARTNERSHIPS
W1. Please mark your five most important partners or collaborators specifically for the
Elderly Nutrition Program.
MARK ONLY FIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
d
□ Hospital or nursing facility state associations
□ State transportation department or agency
□ State Medicaid agency/unit
□ State Medicaid waiver agency/unit
□ Veterans Affairs (state or federal)
□ State public housing department or agency
□ Supplemental Nutrition Assistance Program (SNAP)
□ Supplemental Nutrition Assistance Program – Education (SNAP-Ed)
□ Food Distribution Program on Indian Reservations (FDPIR)
□ Commodity Supplemental Nutrition Program (CSNP)
□ The Emergency Food Assistance Program (TFAP)
□ Child and Adult Care Food Program (CACFP)
□ Senior Farmers Market Nutrition Program (SFMNP)
□ OAA Title VI (Native American, Alaska Native and Native Hawaiian Elders) program
□ Other Older Americans Act (OAA) programs
□ Aging and Disability Resource Center program
□ Non OAA funded Home delivered nutrition programs (e.g. Meals on Wheels)
□ State public health departments or agencies
□ Other state human services agencies or programs
□ Elder abuse prevention programs or Adult Protective Services (APS)
□ Legal services for older adults
□ Energy assistance (LIHEAP)
□ State association of area agencies on aging
□ Other stakeholder organizations
□ Professional Organizations
□ Foundations
□ Churches, synagogues, mosques, faith-based organizations
□ College or university
□ Volunteer bureaus/organizations
□ Private Industry
□ Other (Specify)
□ None of the above
□ Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
GO TO W3
25
W2. For each partner/collaborator that you marked in Question W1, please record the
partner/collaborator number from Question W1 and indicate which activities
you jointly engage in for the Elderly Nutrition Program.
First
Partner
Number
Second
Partner
Number
Third
Partner
Number
Fourth
Partner
Number
Fifth
Partner
Number
|
|
|
|
|
|
a. TA or training about fundraising ........
1
b. Shared resources ..............................
1
c.
Advocacy ...........................................
1
d. Strategic planning ..............................
1
e. Public education ................................
1
f.
Development of policies, guidance or
regulations .........................................
1
g. Development of procedures ..............
1
h. Service delivery .................................
1
i.
Shared outreach ................................
1
j.
Targeting special populations ............
1
k.
Training/technical assistance ............
1
l.
Development of consumer materials .
1
m. Promotion of older adult nutrition
issues in other agencies/programs ....
1
n. None of the above .............................
1
Don’t know .........................................
d
|
□
|
2
□
2
□
2
□
2
□
2
□
2
□
2
□
2
□
2
□
2
□
2
□
2
□
2
□
2
□
d
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
|
|
3
3
3
3
3
3
3
3
3
3
3
3
3
3
d
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
|
|
4
4
4
4
4
4
4
4
4
4
4
4
4
4
d
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
|
|
5
5
5
5
5
5
5
5
5
5
5
5
5
5
d
|
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
W3. Is there one or more OAA Title VI Nutrition and Supportive Services for Native American,
Alaska Native and Native Hawaiian Program in your state?
1
0
d
□
□
□
Yes
No
GO TO X1
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
26
W4. What are the major areas in which your SUA currently collaborates with Title VI
programs?
MARK ALL THAT APPLY
Areas of Partnership or Collaboration
1
2
3
4
5
6
7
8
9
10
11
12
13
14
d
X.
□ TA or training about fundraising
□ Shared resources
□ Advocacy
□ Strategic planning
□ Public education
□ Development of policies, guidance or regulations
□ Development of procedures
□ Service delivery
□ Shared outreach
□ Targeting special populations
□ Training/technical assistance
□ Development of consumer materials
□ Promotion of older adult nutrition issues in other agencies/programs
□ None of the above
□ Don’t know
FUNDING/RESOURCE ALLOCATION
The next questions are about total expenditures incurred by your SUA during the most
recently completed fiscal year. Total expenditures include service, administrative, and
overhead expenditures.
X1. When did your most recently completed fiscal year end?
|
|
|/|
|
MONTH
|/|
|
DAY
|
|
|
YEAR
X2. During the most recently completed fiscal year, what were the total expenditures for
your SUA, including expenditures for the Elderly Nutrition Program?
$|
d
□
|,|
|
|
|,|
|
|
|,|
|
|
|
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
27
X3. During the most recently completed fiscal year, what were the total expenditures for
the Elderly Nutrition Program? This includes expenditures from funds received from
the OAA plus expenditures from any additional sources of funds for the Elderly
Nutrition Program.
$|
d
□
|
|
|,|
|
|
|,|
|
|
|
Don’t know
X4. During the most recently completed fiscal year, how much did your SUA spend for the
Elderly Nutrition Program from each of the following sources?
Funding Category
a.
Congregate nutrition expenditures
All federal funding sources
1. Older Americans Act funds including
NSIP
2. Other HHS funds (e.g., SSBG)
3. Other non-HHS funds (e.g., USDA,
VA)
4. Multiple federal funds (unidentified)
b.
$|
d
d
2. State lottery funds
3. State targeted tax funds
4. Other state funds (Specify)
Other funding sources, excluding
AAA and local service provider funds
|,|
|
|
|,|
|
|
|
|
|
|,|
|
|
|
|
|
|,|
|
|
|
|
|
|,|
|
|
|
|
|
|,|
|
|
|
|
|,|
|
|
|,|
|
|
|
|,|
|
|,|
|
|,|
□ Don’t know
|
|
|,|
|
|
|
|
|
|,|
|
|
|
|
|
|,|
|
|
|
|
|
|,|
|
|
|,|
|
|
|
|
|,|
|
|
|,|
|
|
|
|
|,|
|
|
|,|
|
|
|
|
|,|
|
|
|,|
|
|
|
|
|,|
|
|
|,|
|
|
|
|
|,|
|
|
|,|
|
|
|
|
|,|
|
|
|,|
|
|
|
|
|,|
|
|
|,|
|
|
|
□ Don’t know
$|
d
|
□ Don’t know
$|
d
|
□ Don’t know
$|
d
|,|
□ Don’t know
$|
d
|
□ Don’t know
$|
d
|
□ Don’t know
$|
d
|,|
□ Don’t know
$|
d
|
□ Don’t know
$|
d
|,|
|
$|
d
|
□ Don’t know
$|
d
|
□ Don’t know
$|
d
|,|
□ Don’t know
$|
d
|
□ Don’t know
$|
d
|,|
□ Don’t know
$|
d
|
□ Don’t know
$|
d
|,|
□ Don’t know
$|
d
|
□ Don’t know
$|
All state funding sources
1. General state funds
c.
Home-delivered nutrition expenditures
□ Don’t know
X5. Which of the following statements best describes how decisions are currently made
on transferring funds among congregate nutrition, home-delivered nutrition, and
supportive services programs?
1
2
3
4
d
□
□
□
□
□
SUA alone determines amounts
SUA determines amounts with consultation with AAAs or local providers
SUA and AAAs make a joint decision
SUA determines the amounts based solely on the amounts requested by AAAs
Don’t know
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
28
Y.
CONTACT INFORMATION
Y1. Please provide contact information for the person who completed this questionnaire.
Contact Name:
Title or Role in SUA:
Email Address:
Telephone Number: |
|
|
|-|
|
|
|-|
|
|
|
|
Area Code
THANK YOU FOR COMPLETING THIS SURVEY. WE VALUE YOUR PARTICIPATION.
Please Return to:
Rhoda Cohen, Survey Director
Mathematica Policy Research
P.O. Box 2393
Princeton, NJ 08543-2393
If you have any questions, please call Ms. Cohen at 1-800-232-8024.
National Evaluation of Title III-C SUA Survey Draft (3-9-12)
29
2011 National Evaluation of Title III-C Nutrition Services
Area Agency on Aging (AAA) Survey
Fax Back Form
A.
ORGANIZATIONAL STRUCTURE
1.
What was the end date of your most recently completed fiscal year? Note: You may use your organization’s
fiscal year or another entity’s fiscal year (e.g. federal, state). Please use the same fiscal year as the reference
for all questions that follow.
|
2.
|
| |
Year
|
During your most recently completed fiscal year, what was the total, unduplicated number of people who
received any registered service, supported in whole or in part by Older Americans Act (OAA) Title III?
Registered services include personal care, homemaker, chore, home-delivered meals, adult day care/health,
case management, assisted transportation, congregate meals, and nutrition counseling.
|
d
3.
| |/| | |/|
Month
Day
□
|
|,|
|
|
| PEOPLE RECEIVED ANY REGISTERED OAA SERVICE
Don’t know
During your most recently completed fiscal year, what was the total, unduplicated number of people who
received the following?
a. Congregate nutrition services for older adults?
d
□
□
|
|,|
|
|
|
|
|
|,|
|
|
|
Don’t know
b. Home-delivered nutrition services for older adults?
d
|
Don’t know
B.
STAFF AND VOLUNTEERS
1.
During your most recently completed fiscal year, including yourself, how many full-time equivalent
employees did your AAA have?
|
d
2.
d
□
|
| NUMBER OF FULL-TIME EQUIVALENT EMPLOYEES
Don’t know
|
|
| NUMBER OF FULL-TIME EQUIVALENT EMPLOYEES
Don’t know
During your most recently completed fiscal year, how many individual volunteers worked on the nutrition
program (congregate and home delivered nutrition) at your AAA?
|
4.
|
During your most recently completed fiscal year, including yourself, how many full-time equivalent
employees worked on the nutrition program (congregate and home-delivered) funded in whole or in
part by the OAA?
|
3.
□
|,|
|
|,|
|
|
| NUMBER OF VOLUNTEERS
During your most recently completed fiscal year, in total, how many volunteer hours did the nutrition
program at your AAA directly receive?
|
d
□
|,|
|
|
|,|
|
|
| NUMBER OF VOLUNTEER HOURS
Don’t know
Prepared by Mathematica Policy Research
1
C.
TARGETING
1.
In the table below, please record the number of AAA program participants that fell into each of the following
racial or ethnic categories for both congregate and home-delivered nutrition programs during your most
recently completed fiscal year. Also indicate whether each category is a target population for your AAA.
2.
Racial or Ethnic Category
Number in
Congregate
Nutrition Program
a. American Indian or Alaska Native
(alone) ...........................................
|
|
|,|
|
|
|
d
b. Asian (alone) .................................
|
|
|,|
|
|
|
d
c. Black or African American (alone) .
|
|
|,|
|
|
|
d
d. Native Hawaiian or other Pacific
Islander (alone)..............................
|
|
|,|
|
|
|
d
e. White (alone) .................................
|
|
|,|
|
|
|
d
f. Person reporting 2 or more races..
|
|
|,|
|
|
|
d
g. Other (Specify) ..............................
|
|
|,|
|
|
|
d
h. Hispanic (Total) .............................
|
|
|,|
|
|
|
d
Number in HomeDelivered Nutrition
Program
Don’t
know
Is this a target
population?
Don’t
know
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
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d
□
|
|
|,|
|
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d
□
|
|
|,|
|
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d
□
|
|
|,|
|
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d
□
|
|
|,|
|
|
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d
□
|
|
|,|
|
|
|
d
□
□
□
□
□
□
□
□
Yes
1
1
1
1
1
1
1
1
□
□
□
□
□
□
□
□
No
0
0
0
0
0
0
0
0
□
□
□
□
□
□
□
□
Don’t
know
d
d
d
d
d
d
d
d
□
□
□
□
□
□
□
□
In the table below, please record the number of your AAA’s program participants that fell into each of the
categories listed below for both congregate and home-delivered nutrition programs during your most
recently completed fiscal year. Also indicate whether each category is a target population for your AAA.
Category
Number in
Congregate
Nutrition Program
Don’t
know
Number in HomeDelivered Nutrition
Program
Is this a target
population?
Don’t
know
a. Impairments in 3 or more
Activities of Daily Living ..............
|
|
|,|
|
|
|
d
b. Impairments in 1-2 Activities of
Daily Living .................................
|
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|,|
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d
□
|
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d
□
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d
□
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d
□
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d
□
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d
□
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|,|
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d
□
|
|
|,|
|
|
|
d
c. Living alone ................................
|
|
|,|
|
|
|
d
d. Rural residents ...........................
|
|
|,|
|
|
|
d
e. Living below the federal poverty
level ............................................
|
|
|,|
|
|
|
d
f. Female........................................
|
|
|,|
|
|
|
d
g. 60-74 years old ...........................
|
|
|,|
|
|
|
d
h. 75-84 years old ...........................
|
|
|,|
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|
|
d
i. 85+ years old ..............................
|
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|,|
|
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|
d
Prepared by Mathematica Policy Research
2
□
□
□
□
□
□
□
□
□
Yes
1
1
1
1
1
1
1
1
1
□
□
□
□
□
□
□
□
□
No
0
0
0
0
0
0
0
0
0
□
□
□
□
□
□
□
□
□
Don’t
know
d
d
d
d
d
d
d
d
d
□
□
□
□
□
□
□
□
□
D.
PROGRAM RESOURCES
The next questions concern the total expenditures incurred by your AAA during your most recently completed
fiscal year. Total expenditures include service, administrative, and overhead expenditures. Unless specified,
expenditures do not include the estimated value of donated goods and services (e.g., volunteers).
During your most recently completed fiscal year, ...
1.
...what were the total expenditures for your AAA?
$|
d
2.
□
d
□
d
□
|
|
|,|
|
|
|
Don’t know
|
|
|,|
|
|
|,|
|
|
|
Don’t know
|
|
|,|
|
|
|,|
|
|
|
Don’t know
...what were the total expenditures for the home-delivered nutrition program?
$|
d
5.
|,|
...what were the total expenditures for the congregate nutrition program?
$|
4.
|
...what were the total expenditures for the Elderly Nutrition Program? This includes expenditures from funds
received from the OAA plus expenditures from any additional sources of funds for the elderly nutrition
program.
$|
3.
|
□
|
|
|,|
|
|
|,|
|
|
|
Don’t know
During your most recently completed fiscal year, what was the estimated annual value of donated facilities,
equipment, goods and services for the Elderly Nutrition Program?
a. Congregate nutrition program
$|
|
|
|,|
|
|
|
b. Home-delivered nutrition program
$|
|
|
|,|
|
|
|
Prepared by Mathematica Policy Research
3
6.
For each of the following funding sources, please indicate how much your AAA spent for congregate
nutrition expenditures and home-delivered nutrition expenditures during your most recently completed
fiscal year.
Congregate
Home-Delivered
Nutrition
Don’t
Nutrition
Don’t
Funding Sources
Expenditures
know
Expenditures
know
Direct Federal Sources
a. Older Americans Act funds including NSIP .........................
$____________
b. Other HHS (e.g., SSBG) ......................................................
$____________
c.
Other non-HHS (e.g., USDA, VA) ........................................
$____________
d. Multiple federal funds (unidentified) .....................................
$____________
e. Other state sources .............................................................
$____________
□
d□
d□
d□
d□
□
d□
d□
d□
d□
$____________
d
d
$____________
$____________
$____________
$____________
Other Local Sources
f.
County Government.............................................................
$____________
g. City Government ..................................................................
$____________
h. Other local funding...............................................................
$____________
i.
$____________
Multiple local funds (unidentified) ........................................
□
d□
d□
d□
□
d□
d□
d□
$____________
d
d
$____________
$____________
$____________
Private Sources
j.
Non-profit org (e.g., United Way, 501 3-c)...........................
$____________
k.
Private for-profit (e.g., food industry) ...................................
$____________
l.
Participant contributions ......................................................
$____________
m. Program income other than participant contributions ..........
$____________
n. Other private funds ..............................................................
$____________
o. Other (Specify) .....................................................................
$____________
7.
□
d□
d□
d□
d□
d□
□
d□
d□
d□
d□
d□
$____________
d
d
$____________
$____________
$____________
$____________
$____________
The Older Americans Act permits the transfer of funds between the congregate nutrition, home-delivered
nutrition, and supportive services programs. During your most recently completed fiscal year, what were the
total amounts of funds transferred from...
Funds transferred from…
Don’t
know
Amount Transferred
a. Congregate Nutrition to Home-Delivered Nutrition? ...................
$|
|
|
|,|
|
|
|
b. Home-Delivered Nutrition to Congregate Nutrition? ...................
$|
|
|
|,|
|
|
|
c.
Congregate Nutrition to Supportive Services? ...........................
$|
|
|
|,|
|
|
|
d. Home-Delivered Nutrition to Supportive Services? ....................
$|
|
|
|,|
|
|
|
e. Supportive Services to Congregate Nutrition? ...........................
$|
|
|
|,|
|
|
|
f.
$|
|
|
|,|
|
|
|
Supportive Services to Home-Delivered Nutrition? ....................
Prepared by Mathematica Policy Research
4
d
d
d
d
d
d
□
□
□
□
□
□
OMB: xxxx-xxxx
Expiration Date: xx/xx/xxxx
2011 National Evaluation of Title III-C
Nutrition Services
Area Agency on Aging (AAA) Survey
INTRODUCTION
Thank you for helping us with the National Evaluation of Title III-C Elderly Nutrition Services.
This study will examine how effectively and efficiently the Elderly Nutrition Program helps to
keep older Americans healthy and active in their homes and communities. Results of the study
will be used to support program planning and guide program practices at various levels of the
aging network.
This survey contains questions about your AAA’s characteristics and objectives, staffing, use of
technology, program decision processes, and measures used to coordinate with internal staff
and other organizations. The questionnaire takes approximately 60 minutes to complete.
•
If you have any questions regarding the study or completing the Area Agency on
Aging survey, please contact Rhoda Cohen at 1-800-232-8024 or email:
rcohen@mathematica-mpr.com
•
The information you provide will be used only for statistical purposes. In accordance with
the Confidential Information Protection and Statistical Efficiency Act of 2002, your
responses will not be disclosed in identifiable form without your consent.
•
Participation is completely voluntary. We thank you for your cooperation and
participation in this very important study.
•
If you do not have exact information available to answer certain questions, your best
estimate will be fine.
•
After hitting the submit button, it may take a few seconds for the next page of the survey
to load. Please be patient and your responses will be accepted.
•
Please be aware that after using the “Review my answers” link to go back to a previous
question of the survey, you will need to continue through the survey again from that point
forward.
5/24/12
SECTION A. ORGANIZATIONAL STRUCTURE
REQUIRED
ALL
A1.
Is your AAA currently a standalone organization or is it part of another organization?
Standalone organization ....................................................................................... 1
Part of another organization ................................................................................. 2
Don’t know ............................................................................................................ d
REQUIRED
ALL
A2.
Which of the following best describes the current management structure of your AAA?
A not for profit private agency (non-governmental) .............................................. 1
For profit ............................................................................................................... 2
A division of city or county government ................................................................ 3
Part of a council of governments or regional planning and development
agency .................................................................................................................. 4
A Tribal Government entity ................................................................................... 5
Educational institution ........................................................................................... 6
Other (SPECIFY) .................................................................................................. 7
Don’t know ............................................................................................................ d
NOTE: Responses to all questions regarding Older Americans Act programs and
services should be based on all funding sources and not restricted to the federal
share of the program or service unless otherwise specified. [FOOTER TO APPEAR
ON THE BOTTOM OF EVERY PAGE ON THE WEB SURVEY]
REQUIRED
ALL
A3.
Does a Title VI (Native American) program currently operate within your Planning and Service
Area (PSA) or in an adjacent PSA?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
1
REQUIRED
ALL
A4.
Which of the following populations does the AAA currently serve through all its programs and
services?
Select all that apply
Adults 60 years and older ..................................................................................... 1
Adults with physical disabilities regardless of age................................................ 2
Adults with mental retardation or developmental disability regardless of age ..... 3
Children with physical disabilities ......................................................................... 4
Children with mental retardation or developmental disability ............................... 5
Family caregivers ................................................................................................. 6
Don’t know ............................................................................................................ d
HARD CHECK: IF A4 = DON’T KNOW and any other answer category is selected. Don’t know cannot
be selected along with other response options.
REQUIRED
ALL
A5.
Please describe the areas included in your PSA.
Select all that apply
Urban area ............................................................................................................ 1
Suburban area ...................................................................................................... 2
Rural area ............................................................................................................. 3
Frontier area ......................................................................................................... 4
Don’t know ............................................................................................................ d
HARD CHECK: If A5 = DON’T KNOW and any other category is selected. Don’t know cannot be
selected along with other response options.
2
REQUIRED
ALL
A6.
Which of the following best describes the current boundaries of your PSA?
Single county ........................................................................................................ 1
Multi-county .......................................................................................................... 2
Single city/Metro area ........................................................................................... 3
Multiple city/Metro area ........................................................................................ 4
Other (SPECIFY) .................................................................................................. 5
Don’t know ............................................................................................................ d
REQUIRED
ALL
A7.
Currently, is there an Aging and Disability Resource Center (ADRC) in your PSA? In your state,
the ADRC is known as [FILL ADRC NAME (to the public)].
Yes ........................................................................................................................ 1
Under development/in progress ........................................................................... 2
No ......................................................................................................................... 0
SKIP TO B1
Don’t know ............................................................................................................ d
SKIP TO B1
REQUIRED
A7=Yes OR Under development/in progress
A8.
Which of the following best describes the relationship of the AAA to the Aging and Disability
Resource Center (ADRC)?
AAA is lead agency of the ADRC ......................................................................... 1
AAA partners with the ADRC................................................................................ 2
AAA has a different relationship to the ADRC (SPECIFY) ................................... 3
AAA has no relationship with the ADRC .............................................................. 4
Don’t know ............................................................................................................ d
3
REQUIRED
A7=Yes OR Under development/in progress
A9.
Was your nutrition program staff involved in developing the Aging and Disability Resource
Center (ADRC)?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
REQUIRED
A7=Yes OR Under development/in progress
A9a.
Is your nutrition staff currently, or was your nutrition staff ever, involved in operating the
ADRC?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
4
SECTION B. TITLE III-C ELDERLY NUTRITION PROGRAM CHARACTERISTICS
REQUIRED
ALL
B1.
Are the following services currently available in your PSA?
YES
NO
DON’T
KNOW
a. Nutrition education (a program to promote better health by providing
nutrition, physical fitness, and nutrition-related health information and
instruction in a group or individual setting)
1
0
d
b. Nutrition counseling (individualized guidance provided one-on-one to
address options and methods for improving nutritional status)
1
0
d
c.
1
0
d
Nutrition screening
5
REQUIRED
ALL
B1.1.
How are the following services currently provided in your PSA?
Note: Local service providers, at a minimum, have the following responsibilities for the meal
portion of the OAA Elderly Nutrition Program: (1) are responsible for the delivery of the
meal (not necessarily the production or responsible for the production – i.e., AAA could
enter into a PSA wide catering contract through which all providers receive meals);
(2) are responsible for providing an opportunity for and the collection of voluntary
contributions; (3) are responsible for documenting and reporting meals served; and
(4) are responsible for food safety and sanitation during meal delivery. In the case of a
restaurant/voucher based-program, the provider is the entity that has entered into an
agreement with the restaurant or other meal producer for the provision of meals that meet
the OAA dietary requirements and is responsible for issuing the voucher for service. A
caterer with no responsibility beyond production of the meal is not considered a local
service provider for the OAA Elderly Nutrition Program.
Note: Nutrition counseling services and nutrition education services may also be provided
through an agreement (e.g., contract, grant, MOU) with a local provider organization other
than the Area Agency on Aging.
Select all that apply for each row
DIRECTLY
BY THE
AAA
THROUGH A
CONTRACT
BETWEEN THE AAA
AND ANOTHER
ORGANIZATION
THROUGH A GRANT
PROVIDED BY THE
AAA TO ANOTHER
ORGANIZATION
THROUGH SOME
OTHER
ARRANGEMENT
DON’T
KNOW
a.
Congregate meal
1
2
3
0
d
b.
Home-delivered meal
1
2
3
0
d
1
2
3
0
d
1
2
3
0
d
1
2
3
0
d
B1a = Yes
c.
Nutrition education (a program to promote
better health by providing nutrition,
physical fitness, and nutrition-related
health information and instruction in a
group or individual setting)
B1b = Yes
d.
Nutrition counseling (individualized
guidance provided one-on-one to address
options and methods for improving
nutritional status)
B1c = Yes
e.
Nutrition screening
PROGRAMMER SKIP BOX B1.1
IF ANY B1.1a-e = “Through a contract between the AAA and another
organization,” CONTINUE TO B2. ELSE, SKIP TO B4
HARD CHECK: If B1.1 = DON’T KNOW and any other category is selected within a row. Don’t know
cannot be selected along with other response options.
6
REQUIRED
ANY B1.1 a-e = THROUGH A CONTRACT BETWEEN THE AAA AND ANOTHER ORGANIZATION
B2.
What type of contracts does the AAA currently enter into with Elderly Nutrition Program service
providers?
Select all that apply
Unit rate ................................................................................................................ 1
Performance based .............................................................................................. 2
Cost reimbursement ............................................................................................. 3
Other (SPECIFY) .................................................................................................. 4
Specify
Don’t know ............................................................................................................ d
HARD CHECK: If B2 = DON’T KNOW and any other category is selected. Don’t know cannot be
selected along with other response options.
REQUIRED
ANY B1.1 a-e = THROUGH A CONTRACT BETWEEN THE AAA AND ANOTHER ORGANIZATION
B3.
Which of the following are included in your AAA’s current contracts or grants with Elderly
Nutrition Program service providers?
Select all that apply
Quality assurance component (e.g., HACCP (Hazard Analysis Critical
Control Points), food safety, program participant satisfaction) ............................. 1
Targets or goals .................................................................................................... 2
None of the above ................................................................................................ 0
Don’t know ............................................................................................................ d
HARD CHECK: If B3 = NONE OF THE ABOVE and any other category is selected. None of the above
cannot be selected along with other response options.
HARD CHECK: If B3 = DON’T KNOW and any other category is selected. Don’t know cannot be
selected along with other response options.
7
REQUIRED
IF B1.1a INCLUDES THROUGH A CONTRACT BETWEEN THE AAA AND ANOTHER ORGANIZATION,
THROUGH A GRANT PROVIDED BY THE AAA TO ANOTHER ORGANIZATION, OR THROUGH SOME
OTHER ARRANGEMENT
B4.
Currently, how many nutrition service providers does your AAA have either through contract,
grant, or other formal mechanism? These are nutrition providers funded by your AAA to provide
nutrition services. Please do not include caterers or vendors that only prepare meals and
perform no other program operation.
Providers of congregate and home-delivered nutrition (0-999)
Providers of congregate nutrition only (0-999)
Providers of home-delivered nutrition only (0-999)
Don’t know ............................................................................................................ d
SOFT CHECK: IF LT1; You have indicated that your AAA has 0 nutrition service providers of
[congregate and home delivered nutrition/congregate nutrition only/home-delivered nutrition
only]. Is this correct?
SOFT CHECK: IF GT 50; You have indicated that your AAA has more than 50 nutrition service
providers of [congregate and home delivered nutrition/congregate nutrition only/home-delivered
nutrition only]. Is this correct?
HARD CHECK: IF GT 200; The number of nutrition service providers cannot be greater than 200.
HARD CHECK: If B4 = DK AND number is entered. Don’t know cannot be selected if a number is
entered.
REQUIRED
ALL
B5.
How many different congregate nutrition locations currently exist in your PSA? A congregate
nutrition location is any group dining setting such as, but not limited to, senior centers, adult
day care centers, community centers, faith-based locations, and restaurants.
Number of congregate nutrition locations (0-999)
Don’t know ............................................................................................................ d
SOFT CHECK: IF LT 1; You have indicated that your PSA has 0 congregate nutrition locations. Is
this correct?
SOFT CHECK: IF GT 100; You have indicated that your PSA has more than 100 congregate
nutrition locations. Is this correct?
HARD CHECK: IF GT 500; The number of nutrition service providers cannot be greater than 500.
HARD CHECK: If B5 = DK AND number is entered. Don’t know cannot be selected if a number is
entered.
8
REQUIRED
ALL
B6.
What is the current availability of congregate nutrition services in your PSA?
Number of Days Congregate Locations are Open in Your PSA
1 Day Per Week
2-4 Days Per Week
5 or More Days Per
Week
Number of locations
Don’t know ............................................................................................................ d
HARD CHECK: IF GT 500 in any column The number of nutrition service locations cannot be greater
than 500.
HARD CHECK: If B6 = DK AND number is entered. Don’t know cannot be selected if any numbers
are entered.
HARD CHECK: IF B6 GT NUMBER OF CONGREGATE NUTRITION LOCATIONS IN B5, Please enter a
number that does not exceed the total number of congregate nutrition locations in the PSA.
REQUIRED
ALL
B7.
Which areas of your PSA currently do not have home-delivered nutrition services?
Select all that apply
Some urban areas ................................................................................................ 1
Some suburban areas .......................................................................................... 2
Some rural areas .................................................................................................. 3
Some frontier areas .............................................................................................. 4
Some mixed areas ................................................................................................ 5
All areas of the PSA have home-delivered nutrition services .............................. 6
Don’t know ............................................................................................................ d
HARD CHECK: If B7 = ALL AREAS OF THE PSA HAVE HOME-DELIVERED NUTRITION SERVICES
and any other category selected. All areas of the PSA have home-delivered nutrition services cannot
be selected along with other response options.
HARD CHECK: If B7 = DON’T KNOW and any other category is selected, Don’t know cannot be
selected along with other response options.
9
REQUIRED
ALL
B8.
In what ways does your AAA and/or service providers respond to increased service costs such
as labor, fuel, or food costs for the Elderly Nutrition Program?
Select all that apply
Group purchasing ................................................................................................. 1
Shared resources ................................................................................................. 2
Changes in catering or service provider contract requirements/specifics to
reduce costs ......................................................................................................... 3
Modification of menu (increased use of prepared food/use less expensive
food)...................................................................................................................... 4
Additional restrictions in program eligibility criteria............................................... 5
Reduced or eliminated compensation to volunteers (e.g., mileage to
drivers) .................................................................................................................. 6
Reductions in staff or staff hours .......................................................................... 7
Reductions in the number of congregate nutrition locations ................................ 8
Reductions in the number of days of service per week at congregate
nutrition locations .................................................................................................. 9
Reductions in the number of people served at congregate nutrition
locations ................................................................................................................ 10
Reductions in home-delivered nutrition service area ........................................... 11
Reductions in the frequency of home-delivered nutrition deliveries ..................... 12
Reductions in the number of home-delivered meals provided per
participant ............................................................................................................. 13
Reductions in the number of home-delivered nutrition participants served ......... 14
Increased use of frozen meals in the home-delivered nutrition program ............. 15
Other response to increased costs (SPECIFY) .................................................... 16
No changes in response to increased costs......................................................... 0
Don’t know ............................................................................................................ d
HARD CHECK: If B8 = NO CHANGES IN RESPONSE TO INCREASED COSTS and any other category
is selected. No changes in response to increased costs cannot be selected along with other
response options.
HARD CHECK: If B8 = DON’T KNOW and any other category is selected. Don’t know cannot be
selected along with other response options.
10
SECTION C. STAFF
REQUIRED
ALL
C1.
Does your AAA currently have a paid staff member who is a registered dietician or statecredentialed nutrition professional working on the Elderly Nutrition Program?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
11
SECTION D. TECHNOLOGY AND DATA
REQUIRED
ALL
D1.
Which of the following systems does your AAA currently use?
Select all that apply
Computer-assisted menu planning and analysis.................................................. 1
Software to track inventory or order food ............................................................. 2
Delivery systems for home-delivered nutrition (e.g., route mapping
software) ............................................................................................................... 3
Program participant tracking or referral systems.................................................. 4
Electronic client ID card ........................................................................................ 5
Electronic system for recording service (e.g., the meal) was received ................ 6
Financial systems for billing and/or making payments for services ..................... 7
Cost-centered accounting system ........................................................................ 8
Geographic Information Systems (GIS) ............................................................... 9
Other automated system ...................................................................................... 10
No automated systems ......................................................................................... 0
Don’t know ............................................................................................................ d
HARD CHECK: If D1 = NO AUTOMATED SYSTEMS and any other category is selected. No automated
systems cannot be selected along with other response options.
HARD CHECK: If D1 = DON’T KNOW and any other category is selected, Don’t know cannot be
selected along with other response options.
12
REQUIRED
ALL
D2.
Which of the following types of program performance data does your AAA currently collect
either directly or through your individual services providers?
Select all that apply
Nutrition program service reports/program performance data ............................. 1
Quality assurance findings ................................................................................... 2
Fiscal management reports .................................................................................. 3
Client assessments of service .............................................................................. 4
Client outcomes .................................................................................................... 5
None of the above ................................................................................................ 0
Don’t know ............................................................................................................ d
HARD CHECK: If D2 = NONE OF THE ABOVE, no other category should be selected. None of the
above cannot be selected along with other response options.
HARD CHECK: If D2 = DON’T KNOW and any other category is selected, Don’t know cannot be
selected along with other response options.
REQUIRED
ALL
D3.
How does your AAA currently use Elderly Nutrition Program performance data?
Select all that apply
To justify funding requests .................................................................................... 1
To manage the Elderly Nutrition Program ............................................................ 2
To administer vendor contracts ............................................................................ 3
To provide information to stakeholders (governing board, advocacy
organizations, local government, etc.) .................................................................. 4
For program planning ........................................................................................... 5
Do not use performance data ............................................................................... 0
Don’t know ............................................................................................................ d
HARD CHECK: If D3 = DO NOT USE PERFORMANCE DATA, and any other category is selected, Do
not use performance data cannot be selected along with other response options.
HARD CHECK: If D3 = DON’T KNOW and any other category is be selected, Don’t know cannot be
selected along with other response options.
13
SECTION E. SELF-DIRECTED CARE & PRIVATE PAY/FEE-FOR-SERVICE
The next question is about self-directed care. Self-directed care is defined as programs and
services in which clients can choose to select, manage and dismiss their workers. Self-directed
care may also be referred to as “consumer-directed care.”
REQUIRED
ALL
E1.
Does your AAA currently include nutrition services as part of any self-directed care programs
for older adults?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
AAA does not offer self-directed care programs .................................................. 2
Don’t know ............................................................................................................ d
REQUIRED
ALL
E2.
Currently, does your AAA have policies that permit, encourage, or prohibit the operations of
private pay/fee-for-service nutrition programs for older adults offered by your service providers
(or for your organization if you provide direct service)?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
REQUIRED
ALL
E3.
On a scale from 1 to 5, how much does your AAA currently encourage or discourage service
providers to operate private pay/fee-for-service nutrition programs for older adults?
Strongly encourage .............................................................................................. 1
Encourage ............................................................................................................ 2
Neither encourage nor discourage ....................................................................... 3
Discourage............................................................................................................ 4
Prohibit.................................................................................................................. 5
Don’t know ............................................................................................................ d
14
SECTION F. ACCESS TO SERVICES
REQUIRED
ALL
F1a.
Is your AAA responsible for prioritizing clients (i.e., using characteristics to base decisions for
serving some individuals before others when resources are limited) for the elderly nutrition
service programs you provide?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
REQUIRED
ALL
F1b.
Does your AAA have specific prioritization criteria (i.e., characteristics to base decisions on for
serving some individuals before others when resources are limited) for the elderly nutrition
service programs you provide or administer through your local service providers?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
REQUIRED
ALL
F1c.
Did your AAA (either directly or through local nutrition providers) have to prioritize who
received congregate or home-delivered nutrition services during the past year?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
15
REQUIRED
IF F1b OR F1c = YES
F2.
Which of the following criteria (do you/did you) use for prioritization?
Select all that apply for each column
Characteristic
Congregate Nutrition
Prioritization Criteria
Home-Delivered Nutrition
Prioritization Criteria
a. ADL cut-off
1
2
b. IADL cut-off
1
2
c.
1
2
d. Food insecure/hungry
1
2
e. Nutrition Risk Assessment
1
2
f.
1
2
g. Low income
1
2
h. Lack of informal/family support
1
2
i.
Racial/ethnic minority
1
2
j.
Geographic isolation
1
2
k.
Social isolation
1
2
l.
Chronic health condition
1
2
m. Advanced age
1
2
n. Dementia/cognitive impairment
1
2
o. Limited English proficiency
1
2
p. Adult day care participation
1
2
q. Long-term need for service
1
2
r.
Other
1
2
s.
Do not prioritize for this type of service
1
2
Homebound
Poor housing/lack kitchen access
HARD CHECK: If F2 = DO NOT PRIORITIZE FOR THIS TYPE OF SERVICE and any other category is
be selected, Do not prioritize for this type of service cannot be selected along with other response
options.
16
REQUIRED
IF F1b OR F1c = YES
F2.1
Who established the prioritization criteria?
My organization, the AAA ..................................................................................... 1
SUA ...................................................................................................................... 2
Other (SPECIFY) .................................................................................................. 3
Don’t know ............................................................................................................ d
REQUIRED
IF F1b OR F1c = YES
F2.2
How much influence did the AAA have on the prioritization criteria?
A lot ....................................................................................................................... 1
Some .................................................................................................................... 2
A little .................................................................................................................... 3
None ..................................................................................................................... 0
Don’t know ............................................................................................................ d
REQUIRED
ALL
F3.
Who authorizes home-delivered nutrition services for a new client?
AAA ....................................................................................................................... 1
Local service provider ........................................................................................... 2
Either AAA or local service provider ..................................................................... 3
Both AAA and local service provider .................................................................... 4
Other authorizing system (SPECIFY) ................................................................... 5
Don’t know ............................................................................................................ d
17
REQUIRED
ALL
F4.
How is the current number of meals per week for a home-delivered nutrition program participant
determined?
Select all that apply
Program participant/family request ....................................................................... 1
Nutrition needs assessment ................................................................................. 2
Prioritization criteria other than nutrition needs .................................................... 3
All program participants receive the same number of meals per week................ 4
Other (SPECIFY) .................................................................................................. 5
Don’t know ............................................................................................................ d
HARD CHECK: If F4 = DON’T KNOW and any other category is selected, Don’t know cannot be
selected along with other response options.
IF F4 = All program participants receive the same number of meals per week, and any other category is
selected, All program participants receive the same number of meals per week cannot be selected
along with other response options.
REQUIRED
ALL
F6.
Does your AAA currently have criteria for the termination of home-delivered nutrition services?
Yes ........................................................................................................................ 1
No, we don’t have criteria ..................................................................................... 0
Not applicable, neither the AAA nor local service provider initiates
termination ............................................................................................................ n
Don’t know ............................................................................................................ d
18
REQUIRED
F6 = Yes
F7.
What criteria are currently used by the AAA/local service provider to initiate termination of
home-delivered nutrition service?
Select all that apply
Service is time limited ........................................................................................... 1
AAA or local service provider determines the program participant is no
longer in need ....................................................................................................... 2
The program participant becomes eligible for services through another
nutrition program .................................................................................................. 3
The program participant does not adhere to rights/responsibilities
(uncooperative, inappropriate behavior, not home, etc.) ...................................... 4
Other (SPECIFY) .................................................................................................. 5
Don’t know ............................................................................................................ d
HARD CHECK: If F7 = DON’T KNOW and any other category is selected, Don’t know cannot be
selected along with other response options.
REQUIRED
ALL
F8.
Does your AAA track reasons for home-delivered nutrition service termination, regardless of
whether or not it is initiated by the AAA or local service provider?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
19
REQUIRED
F8 = Yes
F9.
Which of the following reasons for home-delivered nutrition service termination is currently
tracked by your AAA?
YES
NO
DON’T
KNOW
F7 = Service is time limited
a. Time limit on service is reached
1
0
d
b. Nursing home placement
1
0
d
c.
Death
1
0
d
d. Relocation
1
0
d
e. No longer in need of service (participant or AAA/local service
provider determined)
1
0
d
f.
1
0
d
1
0
d
Participant’s dissatisfaction
g. Other (SPECIFY)
20
SECTION G. NUTRITION SERVICE OPERATION AND QUALITY ASSURANCE
REQUIRED
ALL
G1.
Currently, which entity has primary responsibility for the following activities for the congregate
nutrition program?
Select one per row
Role/Responsibility
STATE
UNIT
ON
AGING
AAA
LOCAL
SERVICE
PROVIDER
OTHER
ENTITY
NO ENTITY
TAKES PRIMARY
RESPONSIBILITY
ACTIVITY
NOT
PROVIDED
DON’T
KNOW
a. Meal production (either self
produced or through
caterer/vendor contract)
1
2
3
4
5
6
d
b. Menu planning
1
2
3
4
5
6
d
Nutrition program
planning/development
1
2
3
4
5
6
d
d. Nutrition program outreach
1
2
3
4
5
6
d
e. Nutrition community needs
assessment
1
2
3
4
5
6
d
f.
1
2
3
4
5
6
d
g. Congregate site management
1
2
3
4
5
6
d
h. Nutrition screening
1
2
3
4
5
6
d
i.
Nutrition individual assessment
1
2
3
4
5
6
d
j.
Nutrition education
1
2
3
4
5
6
d
k.
Nutrition counseling
1
2
3
4
5
6
d
c.
Nutrition quality assurance
21
REQUIRED
ALL
G2.
Currently, which entity has primary responsibility for the following activities for the homedelivered nutrition program?
Select one per row
Role/Responsibility
STATE
UNIT
ON
AGING
AAA
LOCAL
SERVICE
PROVIDER
OTHER ENTITY
NO ENTITY
TAKES PRIMARY
RESPONSIBILITY
ACTIVITY
NOT
PROVIDED
DON’T
KNOW
a. Meal production (either self
produced or through
caterer/vendor contract)
1
2
3
4
5
6
d
b. Menu planning
1
2
3
4
5
6
d
Nutrition program
planning/development
1
2
3
4
5
6
d
d. Nutrition program outreach
1
2
3
4
5
6
d
e. Nutrition community needs
assessment
1
2
3
4
5
6
d
f.
1
2
3
4
5
6
d
g. Delivery service management
1
2
3
4
5
6
d
h. Nutrition screening
1
2
3
4
5
6
d
i.
Nutrition individual assessment
1
2
3
4
5
6
d
j.
Nutrition education
1
2
3
4
5
6
d
k.
Nutrition counseling
1
2
3
4
5
6
d
c.
Nutrition quality assurance
22
REQUIRED
G1j = AAA OR G2j = AAA
G3.
Which of the following does your AAA currently use to contribute to the quality of nutrition
education?
Select all that apply
Require credentialed nutrition professional to conduct education ........................ 1
Conduct a survey of program participant need .................................................... 2
Use evidence-based education programs ............................................................ 3
Use cooperative extension materials ................................................................... 4
Use curricula from a reliable, science-based organization (academia,
government, American Heart Association, American Diabetic Association) ........ 5
None of the above ................................................................................................ 0
Don’t know ............................................................................................................ d
HARD CHECK: If G3 = NONE OF THE ABOVE No other category should be selected. None of the
above cannot be selected along with other response options.
HARD CHECK: If G3 = DON’T KNOW No other category should be selected. Don’t know cannot be
selected along with other response options.
REQUIRED
G1k = AAA OR G2k = AAA
G4.
Which of the following does your AAA currently use to contribute to the quality of nutrition
counseling?
Select all that apply
Require credentialed nutrition professional to conduct the counseling ................ 1
Require use of protocols approved by a respected source such as the
American Dietetic Association, Patient Education Association, or
Association of Diabetic Educators ........................................................................ 2
Require credentialed non-nutrition professionals (e.g., nurses, diabetes
educators, etc.) to conduct the counseling ........................................................... 3
Require evidence-based method to conduct the counseling ............................... 4
None of the above ................................................................................................ 0
Don’t know ............................................................................................................ d
HARD CHECK: If G4 = NONE OF THE ABOVE and any other category is selected, None of the above
cannot be selected along with other response options.
HARD CHECK: If G4 = DON’T KNOW and any other category is selected. Don’t know cannot be
selected along with other response options.
23
REQUIRED
ALL
G5.
Which of the following does your AAA currently use to contribute to the nutrient quality of
meals?
Select all that apply
Computer-assisted menu analysis ....................................................................... 1
Meal patterns ........................................................................................................ 2
Use of dietician or state credentialed nutrition professional ................................. 3
State Unit on Aging guidance ............................................................................... 4
Older Americans Act guidance ............................................................................. 5
None of the above ................................................................................................ 0
Don’t know ............................................................................................................ d
HARD CHECK: If G5 = NONE OF THE ABOVE and any other category is be selected, None of the
above cannot be selected along with other response options.
HARD CHECK: If G5 = DON’T KNOW and any other category is selected, Don’t know cannot be
selected along with other response options.
24
REQUIRED
ALL
G6.
Which of the following does your AAA currently use to contribute to the overall food service
quality provided by the AAA or service providers, caterers, or vendors?
Select all that apply
Food service license/safety inspections ............................................................... 1
Training of staff ..................................................................................................... 2
Survey of program participants............................................................................. 3
Program participant feedback mechanism (comment box/card, complaint
mechanism, etc.) .................................................................................................. 4
Regularly scheduled site visits either to production location and/or service
location ................................................................................................................. 5
Visits to home of home-delivered nutrition clients ................................................ 6
Program participant advisory or menu committees .............................................. 7
Food quality specifications ................................................................................... 8
Use of dietician or state credentialed nutrition professional ................................. 9
State Unit on Aging guidance ............................................................................... 10
Older Americans Act guidance ............................................................................. 11
None of the above ................................................................................................ 0
Don’t know ............................................................................................................ d
HARD CHECK: If G6 = NONE OF THE ABOVE and any other category is selected, None of the above
cannot be selected along with other response options.
HARD CHECK: If G6 = DON’T KNOW and any other category is selected, Don’t know cannot be
selected along with other response options.
25
SECTION H. EMERGENCY PLANNING
REQUIRED
ALL
H1.
Does the AAA currently have an emergency plan that includes providing nutrition services?
Select all that apply
Yes, for short-term emergencies .......................................................................... 1
Yes, for long-term emergencies ........................................................................... 2
No ......................................................................................................................... 0
HARD CHECK: If H1 = “No,” and any other category is selected, No cannot be selected along with
other response options.
REQUIRED
ALL
H2.
Has your organization experienced a disaster (natural or manmade) in the past 3 years?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
REQUIRED
IF H1 = 1 OR 2 AND H2 = YES
H3.
During the disaster did you organization initiate an emergency plan?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Did not have an emergency plan at the time ........................................................ 2
Don’t know ............................................................................................................ d
REQUIRED
IF H3 = YES
H4.
Please rate the effectiveness of the emergency plan.
Very effective ........................................................................................................ 1
Effective ................................................................................................................ 2
Somewhat effective .............................................................................................. 3
Not very effective .................................................................................................. 4
Not effective .......................................................................................................... 5
Don’t know ............................................................................................................ d
26
SECTION I. PARTNERSHIP DEVELOPMENT
REQUIRED
ALL
I1.
Please select all of your partners for the Elderly Nutrition Program during your most recently
completed fiscal year. Partners are organizations or groups in which you may jointly engage in
some of the following activities: fundraising, shared resources, advocacy, strategic planning,
public education, referrals, senior activities, service delivery, shared outreach, targeting special
populations, training or technical assistance, or volunteer recruitment or retention.
Select all that apply
Hospitals, nursing facilities, including discharge planning and emergency
room care.............................................................................................................. 1
Transportation (public services – county/municipal) ............................................ 2
Medicare ............................................................................................................... 3
Medicaid (Non-waiver) .......................................................................................... 4
Medicaid Waiver ................................................................................................... 5
Veterans Affairs .................................................................................................... 6
Social Security ...................................................................................................... 7
Public housing and related services, including senior housing ............................ 8
Homeless shelters ................................................................................................ 9
SNAP (Food Stamps)/SNAP Ed (Food Stamp Nutrition Education) .................... 10
Senior farmers market .......................................................................................... 11
Other food and nutrition programs (e.g., Emergency food service programs
including food banks and pantries, Commodity Supplemental Nutrition
Program) ............................................................................................................... 12
Title VI (Native American) program ...................................................................... 13
Other Older Americans Act programs .................................................................. 14
Aging and Disability Resource Center .................................................................. 15
Non OAA funded Meals on Wheels ...................................................................... 16
Community health centers .................................................................................... 17
Public health services ........................................................................................... 18
City or county social services agency .................................................................. 19
City or county regional planning office ................................................................. 20
Elder Abuse Prevention programs or Adult Protective Services (APS) ............... 21
Legal services for older adults .............................................................................. 22
Energy assistance (LIHEAP) ................................................................................ 23
Churches, synagogues, mosques, faith-based organizations.............................. 24
College or university ............................................................................................. 25
Volunteer bureaus/organizations .......................................................................... 26
Civic organization ................................................................................................. 27
Local business (SPECIFY THE TYPE) ................................................................ 28
Other (SPECIFY) .................................................................................................. 29
Do not have any partners ..................................................................................... 30
Don’t know ............................................................................................................ d
27
PROGRAMMER DISPLAY BOX I2
IF GT 5 SELECTIONS FOR J1, CONTINUE TO I2. ELSE, GO TO I3.
HARD CHECK: If I1 = DO NOT HAVE ANY PARTNERS and any other
category is selected, Do not have any partners cannot be selected along
with other response options.
HARD CHECK: If I1 = DON’T KNOW and any other category is selected,
Don’t know cannot be selected along with other response options.
REQUIRED
I1 GT 5 SELECTIONS
I2.
Please select the five most important Elderly Nutrition Program partners you had during your
most recently completed fiscal year.
Select only five
PROGRAMMER DISPLAY BOX I2
PROGRAMMER: DISPLAY ALL CHECKED SELECTIONS FROM I1. IF
RESPONDENT CHECKED “Local business” or “Other,” ALSO DISPLAY
TEXT IN “Specify” FIELD.
HARD CHECK: IF RESPONDENT CHECKS FEWER THAN FIVE SELECTIONS FROM LIST, SHOW
VALIDATION MESSAGE, You have selected fewer than five partners. Please select your five most
important partners.
HARD CHECK: IF RESPONDENT CHECKS MORE THAN FIVE SELECTIONS FROM LIST, SHOW
VALIDATION MESSAGE, You have selected more than five partners. Please select your five most
important partners.
28
REQUIRED
ALL
I3.
For each partnership listed, please indicate which activities you jointly engaged in for the
Elderly Nutrition Program during your most recently completed fiscal year.
PROGRAMMER DISPLAY BOX I3
If MORE THAN 5 SELECTIONS FOR I1, FILL PARTNERSHIP NAME
WITH CHECKED SELECTIONS FROM I2. ELSE, FILL PARTNERSHIP
NAMES FROM I1.
Select all that apply for each column
[Partnership 1
Name]
[Partnership 2
Name]
[Partnership 3
Name]
[Partnership 4
Name]
[Partnership 5
Name]
a. Fundraising
1
2
3
4
5
b. Shared resources
1
2
3
4
5
c.
1
2
3
4
5
d. Strategic planning
1
2
3
4
5
e. Public education
1
2
3
4
5
f.
1
2
3
4
5
g. Senior activities
1
2
3
4
5
h. Service delivery
1
2
3
4
5
i.
Shared outreach
1
2
3
4
5
j.
Targeting special populations
1
2
3
4
5
k.
Training/technical assistance
1
2
3
4
5
l.
Volunteer recruitment or retention
1
2
3
4
5
1
2
3
4
5
Advocacy
Referrals
m. None of the above
PROGRAMMER SKIP BOX I3
IF I3 DOES NOT INCLUDE “Title VI (Native American) program” and A3 =
YES, THEN ASK I4. ELSE, SKIP TO SECTION J.
HARD CHECK: IF I3 = NONE OF THE ABOVE, and any other category is selected, None of the above
cannot be selected along with other response options.
29
REQUIRED
I3 NE “Title VI (Native American) program” AND A3 = YES
I4.
What are the major areas in which your AAA collaborated with Title VI programs during your
most recently completed fiscal year?
Select all that apply
Fundraising ........................................................................................................... 1
Shared resources ................................................................................................. 2
Advocacy .............................................................................................................. 3
Strategic planning ................................................................................................. 4
Public education ................................................................................................... 5
Referrals ............................................................................................................... 6
Senior activities .................................................................................................... 7
Service delivery .................................................................................................... 8
Meal production .................................................................................................... 9
Shared outreach ................................................................................................... 10
Targeting special populations ............................................................................... 11
Training/technical assistance ............................................................................... 12
Volunteer recruitment or retention ........................................................................ 13
Other (SPECIFY) .................................................................................................. 14
Don’t collaborate with Title VI programs............................................................... 15
Don’t know ............................................................................................................ d
HARD CHECK: IF I4 = DON’T COLLABORATE WITH TITLE VI PROGRAMS, and any other category is
selected, Don’t collaborate with Title VI programs cannot be selected along with other response
options.
HARD CHECK: IF I4 = DON’T KNOW, and any other category is selected, Don’t know cannot be
selected along with other response options.
30
SECTION J. MEDICAID WAIVER PROGRAMS FOR THE ELDERLY
REQUIRED
ALL
J1.
Does your AAA or your parent organization currently authorize or receive payment for services
from the state’s Medicaid Waiver programs for the elderly?
Yes, AAA authorizes or receives payment for services from the state’s
Medicaid Waiver programs for the elderly ............................................................ 1
Yes, parent organization authorizes or receives payment for services from
the state’s Medicaid Waiver programs for the elderly .......................................... 2
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
31
SECTION K. WAITING LISTS
REQUIRED
ALL
K1.
Does your AAA or another organization currently maintain waiting lists for the congregate
nutrition or home-delivered nutrition programs that are funded in whole or part with OAA funds?
Select one response for each row
MAINTAINS WAITING LIST FOR CONGREGATE
NUTRITION PROGRAM
YES
NO
DON’T KNOW
a. State Unit on Aging
1
0
d
b. Area Agency on Aging
1
0
d
c.
1
0
d
Local Service Provider
Select one response for each row
MAINTAINS WAITING LIST FOR HOME-DELIVERED
NUTRITION PROGRAM
YES
NO
DON’T KNOW
a. State Unit on Aging
1
0
d
b. Area Agency on Aging
1
0
d
c.
1
0
d
Local Service Provider
PROGRAMMER SKIP BOX K1
IF ALL K1 a-c = NO, DK (for congregate and home-delivered), SKIP TO K9
32
REQUIRED
ANY K1a-c = Yes
K2.
What is the current waiting list policy in the PSA for congregate nutrition and home-delivered
nutrition?
Select one per column
Congregate
Nutrition
Home-Delivered
Nutrition
a. The waiting list contains everyone who requested service
without screening for service eligibility or need, ordered by
date of request
1
2
b. The waiting list contains everyone who is screened eligible
for services on a first-come first-served basis
1
2
1
2
d. Policy varies across the PSA
1
2
e. Other (SPECIFY)
1
2
f.
1
2
d
d
c.
The waiting list contains everyone who is screened eligible
and in priority order (by priority criteria)
There is no waiting list policy
g. Don’t know
PROGRAMMER SKIP BOX K2
IF ALL K1a-c = NO OR DON’T KNOW FOR CONGREGATE NUTRITION,
SKIP TO K6
33
REQUIRED
ANY K1a-c = YES FOR CONGREGATE NUTRITION
K3.
How many people are currently on the waiting list in your PSA for the congregate nutrition
program?
People (0-9999)
Don’t know ............................................................................................................ d
SOFT CHECK: IF LT 1 You have indicated that your PSA currently has 0 people on the waiting list.
Is this correct?
SOFT CHECK: IF GT 1000 You have indicated that your PSA currently has more than 1000 people
on the waiting list. Is this correct?
HARD CHECK: IF GT 5000 The number of people on the waiting list cannot be greater than 5000.
HARD CHECK: If K3 = DK AND number is entered. Don’t know cannot be selected if a number is
entered.
PROGRAMMER SKIP BOX K3
IF K3=0 OR DK, THEN SKIP TO K5
34
REQUIRED
ANY K1a-c = YES FOR CONGREGATE NUTRITION
K4.
What is the longest time a person has been on the current congregate nutrition program waiting
list in your PSA?
Days/Weeks/Months/Years [DROP DOWN BOX]
Don’t know ............................................................................................................ d
PROGRAMMER BOX K4
USE LIMIT OF 10 YEARS IN ANY TYPE OF UNIT (DAYS, WEEKS,
MONTHS, YEARS)
SOFT CHECK: IF GT 5 YEARS You have indicated that the longest time a person has been on the
current waiting list is more than 5 years. Is this correct?
HARD CHECK: IF GT 10 YEARS The longest time a person has been on the current waiting list
cannot be greater than 10 years.
HARD CHECK: IF NUMBER FIELD IS FILLED BUT DROP DOWN IS NOT SELECTED, SHOW
VALIDATION MESSAGE Please select days, weeks, months or years from the drop down menu.
HARD CHECK: IF K4 = DK AND number is entered. Don’t know cannot be selected along with other
response options.
REQUIRED
ANY K1a-c = YES FOR CONGREGATE NUTRITION
K5.
On average, how often is the waiting list for the congregate nutrition program checked for
duplicates and those no longer eligible or in need and then updated?
Weekly .................................................................................................................. 1
Monthly ................................................................................................................. 2
Quarterly ............................................................................................................... 3
Semi-annually ....................................................................................................... 4
Yearly.................................................................................................................... 5
Never .................................................................................................................... 0
Other (SPECIFY) .................................................................................................. 6
Don’t know ............................................................................................................ d
35
REQUIRED
ANY K1a-c = YES FOR HOME-DELIVERED NUTRITION
K6.
How many people are currently on the waiting list for the home-delivered nutrition program in
your PSA?
People (0-9999)
Don’t know ............................................................................................................ d
SOFT CHECK: IF LT 1; You have indicated that your PSA currently has 0 people on the waiting list.
Is this correct?
SOFT CHECK: IF GT 1000; You have indicated that your PSA currently has more than 1000 people
on the waiting list. Is this correct?
HARD CHECK: IF GT 5000; The number of people on the waiting list cannot be greater than 5000.
HARD CHECK: IF K6 = DK AND number is entered. Don’t know cannot be selected along with other
response options.
PROGRAMMER SKIP BOX K6
IF K6=0 OR DK, THEN SKIP TO K8
REQUIRED
ANY K1a-c = YES FOR HOME-DELIVERED NUTRITION
K7.
What is the longest time a person has been on the current home-delivered nutrition program
waiting list in your PSA?
Days/Weeks/Months/Years [DROP DOWN BOX]
Don’t know ............................................................................................................ d
PROGRAMMER BOX K7
USE LIMIT OF 10 YEARS IN ANY TYPE OF UNIT (DAYS, WEEKS,
MONTHS, YEARS)
SOFT CHECK: IF GT 5 YEARS You have indicated that the longest time a person has been on the
current waiting list is more than 5 years. Is this correct?
HARD CHECK: IF GT 10 YEARS The longest time a person has been on the current waiting list
cannot be greater than 10 years.
HARD CHECK: HARD CHECK: IF NUMBER FIELD IS FILLED BUT DROP DOWN IS NOT SELECTED,
SHOW VALIDATION MESSAGE Please select days, weeks, months or years from the drop down
menu.
HARD CHECK: IF K7 = DK AND number is entered. Don’t know cannot be selected along with other
response options.
36
REQUIRED
ANY K1a-c = YES FOR HOME-DELIVERED NUTRITION
K8.
On average, how often is the waiting list for the home-delivered nutrition program checked for
duplicates and those no longer eligible or in need and then updated?
Weekly .................................................................................................................. 1
Monthly ................................................................................................................. 2
Quarterly ............................................................................................................... 3
Semiannually ........................................................................................................ 4
Yearly.................................................................................................................... 5
Never .................................................................................................................... 6
Other (SPECIFY) .................................................................................................. 7
Don’t know ............................................................................................................ d
REQUIRED
ALL
K9.
For which of the following OAA services does the AAA or its service providers currently
maintain a waiting list?
Select all that apply
Transportation....................................................................................................... 1
Case management ............................................................................................... 2
Personal care........................................................................................................ 3
Chore services ...................................................................................................... 4
Homemaker assistance ........................................................................................ 5
Legal services ....................................................................................................... 6
Adult day care ....................................................................................................... 7
Evidence-based disease prevention or health promotion program ...................... 8
Family caregiver respite ....................................................................................... 9
Family caregiver counseling ................................................................................. 10
Family caregiver support group ............................................................................ 11
Family caregiver training ...................................................................................... 12
None of the above ................................................................................................ 0
Don’t know ............................................................................................................ d
HARD CHECK: IF K9 = NONE OF THE ABOVE and any other category is selected, None of the above
cannot be selected along with other response options.
HARD CHECK: IF K9 = DON’T KNOW and any other category is selected, Don’t know cannot be
selected along with other response options.
37
REQUIRED
K9 = AT LEAST 2 RESPONSE OPTIONS CHOSEN
K10.
Please select the service that currently has the longest waiting list in the PSA (Planning and
Service Area).
Transportation....................................................................................................... 1
Case management ............................................................................................... 2
Personal care........................................................................................................ 3
Chore services ...................................................................................................... 4
Homemaker assistance ........................................................................................ 5
Legal services ....................................................................................................... 6
Adult day care ....................................................................................................... 7
Evidence-based disease prevention or health promotion program ...................... 8
Family caregiver respite ....................................................................................... 9
Family caregiver counseling ................................................................................. 10
Family caregiver support group ............................................................................ 11
Family caregiver training ...................................................................................... 12
Don’t know ............................................................................................................ d
PROGRAMMER BOX K10
IF K9 = AT LEAST 2 RESPONSE OPTIONS CHOSEN, ASK K10.
REQUIRED
K9 = ANY ANSWER CATEGORY EXCEPT “NONE OF THE ABOVE” AND “DON’T KNOW” OR K10 =
ANY EXCEPT “DON’T KNOW”
K11.
How many people are currently on this waiting list?
People (0-9999)
Don’t know ............................................................................................................ d
SOFT CHECK: IF LT 1 You have indicated that there are currently 0 people on the waiting list. Is
this correct?
SOFT CHECK: IF GT 1000 You have indicated that there are more than 1000 people on the waiting
list. Is this correct?
HARD CHECK: IF GT 5000 The number of people on the waiting list cannot be greater than 5000.
HARD CHECK: IF K11 = DK AND number is entered. Don’t know cannot be selected along with other
response options.
38
REQUIRED
K9 = ANY ANSWER CATEGORY EXCEPT “NONE OF THE ABOVE” AND “DON’T KNOW” OR K10 =
ANY EXCEPT “DON’T KNOW”
K12.
What is the longest a person has been on this current waiting list?
Days/Weeks/Months/Years [DROP DOWN BOX]
Don’t know ............................................................................................................ d
PROGRAMMER BOX K12
USE LIMIT OF 10 YEARS IN ANY TYPE OF UNIT (DAYS, WEEKS,
MONTHS, YEARS)
SOFT CHECK: IF GT 5 YEARS You have indicated that the longest time a person has been on the
current waiting list is more than 5 years. Is this correct?
HARD CHECK: IF NUMBER FIELD IS FILLED BUT DROP DOWN IS NOT SELECTED, SHOW
VALIDATION MESSAGE Please select days, weeks, months or years from the drop down menu.
HARD CHECK: IF K12 = DK AND number is entered. Don’t know cannot be selected if a number is
entered.
39
SECTION L: REFERRALS AND NEEDS ASSESSMENTS
REQUIRED
ALL
L1.
Has a community needs assessment that included a nutrition needs component been conducted
in your PSA in the past 5 years?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
REQUIRED
ALL
L2.1
Does your AAA currently have a formal process (performed by the AAA or through local service
providers) for assessing service needs (both nutrition and non-nutrition) for Elderly Nutrition
Program participants (e.g., transportation, SNAP, housing, etc.)?
Nutrition Needs
YES
NO
DON’T
KNOW
Non-Nutrition Needs
YES
NO
DON’T
KNOW
a. Congregate nutrition
1
0
d
1
0
d
b. Home-delivered nutrition
1
0
d
1
0
d
REQUIRED
IF L2.1 = DON’T KNOW FOR NUTRITION NEEDS AND NON-NUTRITION NEEDS, SKIP TO L3.
L2.2
How often are Elderly Nutrition Program participants re-assessed for service needs (both
nutrition and non-nutrition services)?
Select all that apply for each column
Congregate nutrition program participants
□
2□
1
□
4□
5□
3
d
□
No policy (frequency determined by staff)
At least yearly (1 or more assessments per
year)
Home-delivered nutrition program participants
□
2□
1
Other (SPECIFY)
□
4□
5□
Don’t know
d
Less than once per year
After acute care episode (hospital, ER visit)
3
□
No policy (frequency determined by staff)
At least yearly (1 or more assessments per
year)
Less than once per year
After acute care episode (hospital, ER visit)
Other (SPECIFY)
Don’t know
HARD CHECK: If L2.2 = DON’T KNOW and any other category is be selected, Don’t know cannot be
selected along with other response options.
40
REQUIRED
ALL
L3.
Not including the Nutrition Screening Initiative (NSI) DETERMINE checklist, does your AAA
currently have a formal process (performed by the AAA or through service providers) for
assessing nutrition service needs for non-nutrition program participants?
Yes, participants receive a separate nutrition needs assessment ....................... 1
Yes, participants receive a general needs assessment that includes
nutrition ................................................................................................................. 2
No, participants are not formally assessed for nutrition service needs ................ 0
Don’t know ............................................................................................................ d
41
REQUIRED
ALL
L4.
Currently, which of the following services does your AAA (directly or through nutrition service
providers) actively assist congregate or home-delivered nutrition participants to access? Active
assistance involves more than providing reading materials and brochures.
Select all that apply for each column
Congregate Nutrition
Program
Service
Home-Delivered
Nutrition Program
a. Medicaid Waiver programs
1
2
b. Medicaid (non-waiver)
1
2
c.
1
2
d. Medicare Part D
1
2
e. Housing programs
1
2
f.
1
2
g. Low Income Home Energy Assistance Program
(LIHEAP)
1
2
h. Supplemental Security Income
1
2
i.
Other supportive services (chore, homemaker)
1
2
j.
SNAP (Food Stamps)
1
2
k.
Other food or nutrition services (food pantry)
1
2
l.
Veterans Affairs services
1
2
m. Adult Protective Services
1
2
n. Evidence-based health promotion and disease
prevention programs
1
2
o. Other
1
2
p. Do not provide this type of assistance
1
2
Medicare Parts A or B
Transportation services
HARD CHECK: IF L4p = CONGREGATE AND Any L4a-o = CONGREGATE, Do not provide this type
of assistance cannot be selected along with other response options.
HARD CHECK: IF L4p = HOME DELIVERED AND Any L4a-o = HOME DELIVERED, Do not provide
this type of assistance cannot be selected along with other response options.
42
REQUIRED
ALL
L5.
Please rank the top 5 referral sources for the congregate nutrition and home-delivered nutrition
programs during your most recently completed fiscal year.
Rank top 5 referral sources in each
column
Congregate
Nutrition Referrals
Referral Source
Home-Delivered
Nutrition
Referrals
a. Family/friends
b. Hospital/health care facility/discharge planner
c.
Nursing homes
d. Physician
e. Case management system
f.
Aging and Disability Resource Center
g. Information and Assistance system
h. Medicaid Waiver
i.
Other food or nutrition program
j.
Faith-based organizations
k.
Self
l.
Other
m. Cannot rank referral sources
1
2
PROGRAMMER BOX L5
RANGE FOR L5a-k IS (1-5). EACH NUMBER (1-5) CAN ONLY BE
ENTERED ONCE IN EACH COLUMN.
HARD CHECK: If L5 = CANNOT RANK REFERRAL SOURCES AND number is entered. Cannot rank
referral sources cannot be selected if ranks are entered.
PROGRAMMER SKIP BOX L5
CHECK B1b: IF NUTRITION COUNSELING = NO OR DK, SKIP TO
CHECK BEFORE L9
43
REQUIRED
B1b= YES
L6.
How many congregate nutrition locations in the PSA currently provide nutrition counseling to
eligible program participants? The nutrition counseling may be offered by your AAA or
coordinated with a local service provider.
Locations (0-999)
Don’t know ............................................................................................................ d
SOFT CHECK: IF LT 1; You have indicated that 0 congregate nutrition locations in the PSA
currently provide nutrition counseling. Is this correct?
HARD CHECK: IF GT 500; The number of congregate nutrition locations in the PSA that currently
provide nutrition counseling cannot be greater than 500.
HARD CHECK: If L6 = DK AND number is entered. Don’t know cannot be selected if a number is
entered.
HARD CHECK: IF L6 GT NUMBER OF CONGREGATE NUTRITION LOCATIONS IN B5, Please enter a
number that does not exceed the total number of congregate nutrition locations in the PSA.
REQUIRED
B1b = Yes
L7.
Currently, what is the availability of nutrition counseling for home-delivered nutrition program
participants? The nutrition counseling may be offered by your AAA or coordinated with a local
service provider.
Available throughout the entire PSA .................................................................... 1
Available in a portion of the PSA .......................................................................... 2
Not available in the PSA ....................................................................................... 3
Don’t know ............................................................................................................ d
44
REQUIRED
B1b = Yes
L8.
How is the current need for nutrition counseling determined?
Select all that apply
Nutrition needs assessment ................................................................................. 1
Nutrition Screening Initiative (NSI) score ............................................................. 2
Presence of nutrition related chronic disease ...................................................... 3
Food insecurity assessment ................................................................................. 4
Health care provider orders or recommendation .................................................. 5
Other criteria (SPECIFY) ...................................................................................... 6
Don’t know ............................................................................................................ d
HARD CHECK: IF L8 = DON’T KNOW No other category should be selected. Don’t know cannot be
selected along with other response options.
PROGRAMMER SKIP BOX L8
CHECK B1a: IF NUTRITION EDUCATION = NO OR DK, SKIP TO
SECTION M
REQUIRED
B1a = Yes
L9.
How many congregate nutrition locations in the PSA currently provide nutrition education to
eligible program participants?
Locations (0-999)
Don’t know ............................................................................................................ d
SOFT CHECK: IF LT 1; You have indicated that 0 congregate nutrition locations in the PSA
currently provide nutrition education. Is this correct?
HARD CHECK: IF GT 500; The number of congregate nutrition locations in the PSA that currently
provide nutrition education cannot be greater than 500.
HARD CHECK: IF L9 = DK AND number is entered. Don’t know cannot be selected if a number is
entered.
HARD CHECK: IF L9 GT NUMBER OF CONGREGATE NUTRITION LOCATIONS IN B5, Please enter a
number that does not exceed the total number of congregate nutrition locations in the PSA.
45
REQUIRED
B1a = YES
L10.
Currently, what is the availability of nutrition education for home-delivered nutrition program
participants? The nutrition education may be offered by your AAA or coordinated with a local
service provider.
Available throughout the entire PSA .................................................................... 1
Available in a portion of the PSA .......................................................................... 2
Not available in the PSA ....................................................................................... 3
Don’t know ............................................................................................................ d
REQUIRED
B1a = Yes
L11.
According to your current AAA policy, how often are nutrition education services provided to
program participants in your PSA?
Congregate
Nutrition Program
Participants
Home-Delivered
Nutrition Program
Participants
a. No AAA policy (frequency determined by local service
provider)
1
2
b. Yearly (1 session per year)
1
2
c.
1
2
d. Quarterly (4 sessions per year)
1
2
e. Monthly (12 sessions per year)
1
2
f.
1
2
g. Nutrition education is not available
1
2
h. Other
1
2
i.
d
d
Twice per year (2 sessions per year)
More than monthly (12+ sessions per year)
Don’t know
46
SECTION M. FOOD SAFETY
REQUIRED
ALL
M1.
Does your AAA currently require congregate and home-delivered nutrition production facilities
to have a food service license?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
REQUIRED
ALL
M2.
Are the food service personnel for the Elderly Nutrition Program in your PSA currently required
to have food safety and sanitation training?
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
REQUIRED
ALL
M3.
Does your AAA currently follow policies for reporting food borne illnesses and food recalls?
The policies could have been created by your AAA, the State Unit on Aging, a state or local
health department, or some other entity.
Yes ........................................................................................................................ 1
No ......................................................................................................................... 0
Don’t know ............................................................................................................ d
47
REQUIRED
ALL
M4.
To which of the following entities are individual service providers currently required to report
food borne illness incidents in the Elderly Nutrition Program?
Select all that apply
AAA ....................................................................................................................... 1
State Unit on Aging ............................................................................................... 2
State or local department of health ...................................................................... 3
Other (SPECIFY) .................................................................................................. 4
No requirement to report food borne illness ......................................................... 5
Don’t know ............................................................................................................ d
HARD CHECK: IF M4 = NO REQUIREMENT TO REPORT FOOD BORNE ILLNESS and any other
category is selected, No requirement to report food borne illness cannot be selected along with
other response options.
HARD CHECK: IF M4 = DON’T KNOW and any other category is selected, Don’t know cannot be
selected along with other response options.
REQUIRED
ALL
M5.
In the past 3 years, how many different times was the food served in the congregate nutrition
program associated with an outbreak of food borne illness?
TIMES (0-99)
Don’t know ............................................................................................................ d
SOFT CHECK: IF GT 50; You have indicated that food served in the congregate nutrition program
was associated with an outbreak of food borne illness more than 50 times in the last 3 years. Is
this correct?
HARD CHECK: IF M5 = DK AND number is entered. Don’t know cannot be selected if a number is
entered.
PROGRAMMER SKIP BOX M5
IF M5 = 0 OR DK, SKIP TO M7.
48
REQUIRED
M5 GT 0
M6.
In total, how many congregate nutrition program participants got sick in the past 3 years?
CONGREGATE NUTRITION PROGRAM PARTICIPANTS (0-9999)
Don’t know ............................................................................................................ d
SOFT CHECK: IF GT 1000 You have indicated that more than 1000 congregate nutrition program
participants got sick in the past 3 years. Is this correct?
HARD CHECK: IF M6 = DK AND number is entered. Don’t know cannot be selected if a number is
entered.
REQUIRED
ALL
M7.
In the past 3 years, how many different times was food served in the home-delivered nutrition
program associated with an outbreak of food borne illness?
TIMES (0-99)
Don’t know ............................................................................................................ d
SOFT CHECK: IF GT 50 You have indicated that food served in the home-delivered nutrition
program was associated with an outbreak of food borne illness more than 50 times in the last
3 years. Is this correct?
HARD CHECK: IF M = DK AND number is entered. Don’t know cannot be selected if a number is
entered.
PROGRAMMER SKIP BOX M7
IF M7 = 0 OR DK, SKIP TO SECTION N
REQUIRED
M7 GT 0
M8.
In total, how many home-delivered nutrition program participants got sick in the past 3 years?
HOME-DELIVERED NUTRITION PROGRAM PARTICIPANTS (0-9999)
Don’t know ............................................................................................................ d
SOFT CHECK: IF GT 1000 You have indicated that more than 1000 home-delivered nutrition
program participants got sick in the past 3 years. Is this correct?
HARD CHECK: IF M8 = DK AND number is entered. Don’t know cannot be selected if a number is
entered.
49
SECTION N. CONTACT INFORMATION
REQUIRED
ALL
N1.
Please provide contact information for the person who completed this questionnaire.
Contact First Name
Contact Last Name
Title or Role in AAA
Length of time in current position (years)
Email Address
Telephone Number
HARD CHECK: IF TELEPHONE IS LT OR GT 10 DIGITS, SHOW VALIDATION, Please enter a valid
telephone number.
HARD CHECK: IF EMAIL ADDRESS DOES NOT CONTAIN “@” and “.” SHOW VALIDATION
MESSAGE, Please provide a valid email address in the format of myname@xyz.com.
Please use the space below if you would like to provide any additional information or comments.
THANK YOU FOR COMPLETING THIS SURVEY. WE VALUE YOUR PARTICIPATION.
50
2011 National Evaluation of Title III-C Nutrition Services
Local Service Provider (LSP) Survey
Fax Back Form
A.
ORGANIZATIONAL STRUCTURE
1.
What was the end date of your most recently completed fiscal year?
|
2.
| |/| | |/|
Month
Day
|
During your most recently completed fiscal year, what was the total, unduplicated number of people who
received any service through your organization?
|
d
3.
| | |
Year
□
|
|
|,|
|
|
|
PEOPLE RECEIVED ANY SERVICE
Don’t know
During your most recently completed fiscal year, what was the total, unduplicated number of people who
received the following funded in whole or in part by the Older Americans Act (OAA)?
Older Adults
a. Congregate nutrition services for older adults? .........
|
d
b. Home-delivered nutrition services for older adults? ..
|
d
□
□
|
|,|
|
|
|
|
|
Don’t know
|
|,|
|
Don’t know
B.
SOCIALIZATION ACTIVITIES
1.
During you most recent fiscal year, how many of your congregate nutrition sites offered social activities
(through your organization or another organization) in addition to the meal?
|
d
2.
|
□
|
| NUMBER OF CONGREGATE SITES
Don’t know
In a typical week, about how many hours of social activities are available at all congregate sites combined?
|
d
|
□
|
| NUMBER OF HOURS/WEEK
Don’t know
Prepared by Mathematica Policy Research
1
C.
STAFF AND VOLUNTEERS
1.
During your most recently completed fiscal year, including yourself, how many full-time equivalent
employees did your organization have?
|
d
2.
d
|
|
NUMBER OF FULL-TIME EQUIVALENT EMPLOYEES
Don’t know
□
|
|
| NUMBER OF FULL-TIME EQUIVALENT EMPLOYEES
Don’t know
During your most recently completed fiscal year, how many full-time equivalent employees who worked on
the nutrition program (congregate and home-delivered) funded in whole or in part by the OAA were
dieticians or state credentialed nutrition professionals?
|
d
4.
|
During your most recently completed fiscal year, including yourself, how many full-time equivalent
employees worked on the nutrition program (congregate and home-delivered) funded in whole or in part by
the OAA?
|
3.
□
|,|
□
|
NUMBER OF FULL-TIME EQUIVALENT DIETICIANS OR STATE CREDENTIALED NUTRITION PROFESSIONALS
Don’t know
During your most recently completed fiscal year, how many individual volunteers worked on the nutrition
program (congregate and home-delivered) at your LSP?
Please count each volunteer only once.
Number
a. Number of volunteers who work exclusively for the
congregate nutrition program ....................................
|
b. Number of volunteers who work exclusively for the
home-delivered nutrition program .............................
|
c. Number of volunteers who work for both the
congregate and home-delivered nutrition program ...
|
Prepared by Mathematica Policy Research
2
d
d
d
□
□
□
|
|,|
|
|
|
|
|
|
|
Don’t know
|
|,|
|
Don’t know
|
|,|
|
Don’t know
5.
During your most recently completed fiscal year, in total, how many volunteer hours did the nutrition
program at your LSP directly receive?
a. |
|,|
|
|
|,|
|
|
|
NUMBER OF HOURS FOR THE CONGREGATE NUTRITION PROGRAM
d
□
b. |
Don’t know
|,|
|
|
GO TO QUESTION 5C
|,|
|
|
|
NUMBER OF HOURS FOR THE HOME-DELIVERED NUTRITION PROGRAM
d
□
c. |
Don’t know
|,|
|
|
|,|
|
|
|
NUMBER OF HOURS FOR CONGREGATE AND HOME-DELIVERED NUTRITION PROGRAMS
d
□
Don’t know
D.
TARGETING
1.
In the table below, please record the number of your LSP’s program participants that fell into each of the
following racial or ethnic categories for both congregate and home-delivered nutrition programs during your
most recently completed fiscal year. Also indicate whether each category is a target population for your LSP.
Number in
Congregate
Nutrition
Program
Racial or Ethnic Category
Don’t
know
a. American Indian or Alaska Native
(alone) ...........................................
|
|
|,|
|
|
|
d
b. Asian (alone) .................................
|
|
|,|
|
|
|
d
c. Black or African American (alone) .
|
|
|,|
|
|
|
d
d. Native Hawaiian or other Pacific
Islander (alone)..............................
|
|
|,|
|
|
|
d
e. White (alone) .................................
|
|
|,|
|
|
|
d
f. Person reporting 2 or more races..
|
|
|,|
|
|
|
d
g. Other (Specify) ..............................
|
|
|,|
|
|
|
d
h. Hispanic (Total) ............................
|
|
|,|
|
|
|
d
Prepared by Mathematica Policy Research
Number in
HomeDelivered
Nutrition
Program
3
Is this a target
population?
Don’t
know
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
□
□
□
□
□
□
□
Yes
1
1
1
1
1
1
1
1
□
□
□
□
□
□
□
□
No
0
0
0
0
0
0
0
0
□
□
□
□
□
□
□
□
Don’t
know
d
d
d
d
d
d
d
d
□
□
□
□
□
□
□
□
2.
E.
In the table below, please record the number of your LSP’s program participants that fell into each of the
categories listed below for both congregate and home-delivered nutrition programs during your most
recently completed fiscal year. Also indicate whether each category is a target population for your LSP.
Categories:
Number in
Home-Delivered
Nutrition
Program
a. Impairments in 3 or more
Activities of Daily Living ..............
|
|
|,|
|
|
|
d
b. Impairments in 1-2 Activities of
Daily Living .................................
|
|
|,|
|
|
|
d
c. Living alone ................................
|
|
|,|
|
|
|
d
d. Rural residents ...........................
|
|
|,|
|
|
|
d
e. Living below the federal poverty
level ............................................
|
|
|,|
|
|
|
d
f. Female........................................
|
|
|,|
|
|
|
d
g. 60-74 years old ...........................
|
|
|,|
|
|
|
d
h. 75-84 years old ...........................
|
|
|,|
|
|
|
d
i. 85+ years old ..............................
|
|
|,|
|
|
|
d
Is this a target
population?
Number in
Congregate
Nutrition
Program
Don’t
know
Don’t
know
□
Yes
1
□
1
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
|
|
|,|
|
|
|
d
□
□
□
□
□
□
□
1
1
1
1
1
1
1
□
□
□
□
□
□
□
□
□
No
0
0
0
0
0
0
0
0
0
□
□
□
□
□
□
□
□
□
Don’t
know
d
d
d
d
d
d
d
d
d
□
□
□
□
□
□
□
□
□
PROGRAM RESOURCES
The next questions concern the total expenditures incurred by your LSP during your most recently completed
fiscal year. Total expenditures include service, administrative, and overhead expenditures.
During your most recently completed fiscal year...
1.
...what were the total expenditures for your organization?
$|
d
2.
□
|
|,|
|
|
|,|
|
|
|
Don’t know
...what were the total expenditures for the Elderly Nutrition Program? This includes expenditures from funds
received from the AAA plus expenditures from any additional sources of funds for the elderly nutrition
program.
$|
d
3.
|
□
|
|
|,|
|
|
|,|
|
|
|
Don’t know
...what were the total expenditures for the congregate nutrition program?
$|
d
□
|
|
|,|
|
|
|,|
|
|
|
Don’t know
Prepared by Mathematica Policy Research
4
4.
...what were the total expenditures for the home-delivered nutrition program?
$|
d
5.
□
|
|
|,|
|
|
|,|
|
|
|
Don’t know
For each of the following funding sources, please indicate how much your LSP spent for congregate
nutrition expenditures and home-delivered nutrition expenditures during your most recently completed
fiscal year.
Funding Sources
Congregate
Nutrition
Expenditures
Area Agency on Aging ........................................................
$__________
d
Other direct federal sources (not through AAA or state)
(i.e. grants from USDA, Veterans Affairs, HUD, etc.) .......
$__________
d
Other direct state sources..................................................
$__________
d
Other local sources (Including county, city, and other
local public sources) ..........................................................
$__________
d
a. Non-profit organization (e.g., United Way, 501 3-c) ........
$__________
d
b. Private for-profit (e.g., food industry) ...............................
$__________
d
c. Participant contributions ...................................................
$__________
d
d. Program income other than participant contributions ......
$__________
d
e. Other private sources .......................................................
$__________
d
$__________
d
Don’t
know
Home-Delivered
Nutrition
Expenditures
□
$__________
d
□
$__________
d
□
$__________
d
□
$__________
d
□
$__________
d
□
$__________
d
□
$__________
d
□
$__________
d
□
$__________
d
□
$__________
d
Don’t
know
□
□
□
□
Private Sources
□
□
□
□
□
Other (Specify)
Prepared by Mathematica Policy Research
5
□
OMB:
EXPIRATION DATE:
2011 National Evaluation of Title III-C Nutrition Services
Local Service Provider Survey
INTRODUCTION
Thank you for helping us with the National Evaluation of Title III-C Elderly Nutrition
Services. This study will examine how effectively and efficiently the Elderly Nutrition
Program helps to keep older Americans healthy and active in their homes and
communities. Results of the study will be used to support program planning and guide
program practices at various levels of the aging network.
This survey asks about your organization’s characteristics and objectives, staffing, use
of technology, program decision processes, and measures used to coordinate with
internal staff and other organizations. The survey takes approximately 60 minutes to
complete.
•
If you have any questions regarding the study or completing the local service
provider survey, please contact Rhoda Cohen at 1-800-232-8024 or email:
rcohen@mathematica-mpr.com
•
The information you provide will be used only for statistical purposes. In
accordance with the Confidential Information Protection and Statistical Efficiency
Act of 2002, your responses will not be disclosed in identifiable form without your
consent.
•
Participation is completely voluntary. We thank you for your cooperation and
participation in this very important study.
•
If you do not have exact information available to answer certain questions, your
best estimate will be fine.
•
After hitting the submit button, it may take a few seconds for the next page of the
survey to load. Please be patient and your responses will be accepted.
•
Please be aware that after using the “Review my answers” link to go back to a
previous question of the survey, you will need to continue through the survey
again from that point forward.
Prepared by Mathematica Policy Research
1
(5/24/12)
SECTION A. ORGANIZATIONAL STRUCTURE
REQUIRED
ALL
A1.
Which of the following services does your organization provide to older adults or their
caregivers through a grant or contract with the Area Agency on Aging?
Select all that apply
□
□
□
□
□
□
□
□
□
Congregate nutrition services .................................................................. 1
Home-delivered nutrition service ............................................................. 2
Nutrition screening and assessment ........................................................ 3
Nutrition education ................................................................................... 4
Nutrition counseling.................................................................................. 5
Social activities ......................................................................................... 6
Health promotion and disease prevention activities ................................ 7
Other non-nutrition services ..................................................................... 8
Don’t know ............................................................................................... d
SOFT CHECK: IF A1 DNE CONGREGATE NUTRITION SERVICES, SHOW VALIDATION Your
response indicates that your organization does not provide congregate nutrition services. Is this
correct?
SOFT CHECK: IF A1 DNE HOME-DELIVERED NUTRITION SERVICES, SHOW VALIDATION Your
response indicates that your organization does not provide home-delivered nutrition services. Is
this correct?
HARD CHECK: IF A1 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
HARD CHECK: IF A1 DNE CONGREGATE NUTRITION SERVICES AND A1 DNE HOME-DELIVERED
NUTRITION SERVICES, SHOW VALIDATION Your response must include congregate nutrition
services or home-delivered nutrition services. If you believe you have received this survey in
error, please contact please contact Rhoda Cohen at 1-800-232-8024 or email:
rcohen@mathematica-mpr.com
Prepared by Mathematica Policy Research
2
(5/24/12)
REQUIRED
IF A1 INCLUDES “OTHER NON-NUTRITION SERVICES.” ELSE SKIP TO A3.
A2.
Which other non-nutrition services does your organization provide through a grant or
contract with the Area Agency on Aging?
Select all that apply
□
□
□
□
□
□
□
□
□
Housing .................................................................................................... 1
Chore/housekeeping ................................................................................ 2
Grocery assistance .................................................................................. 3
Personal care ........................................................................................... 4
Home health ............................................................................................. 5
Transportation .......................................................................................... 6
Case management ................................................................................... 7
Other (Please Specify) ............................................................................. 8
Don’t know ............................................................................................... d
HARD CHECK: IF A2 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
REQUIRED
ALL
A3.
Which of the following populations does your organization currently serve through all its
programs and services?
Select all that apply
□
□
□
□
□
□
□
Adults 60 years and older ........................................................................ 1
Adults with physical disabilities regardless of age ................................... 2
Adults with mental retardation or developmental disability regardless of
age ........................................................................................................... 3
Children with physical disabilities ............................................................. 4
Children with mental retardation or developmental disability .................. 5
Family caregivers ..................................................................................... 6
Don’t know ............................................................................................... d
HARD CHECK: IF A3 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
Prepared by Mathematica Policy Research
3
(5/24/12)
REQUIRED
ALL
A4.
Is your organization currently a standalone organization or is it part of another
organization?
Standalone organization .......................................................................... 1
Part of another organization ..................................................................... 2
Don’t know ............................................................................................... d
REQUIRED
ALL
A6.
Which of the following best describes the current management structure of your
organization?
A not-for-profit agency (non-governmental) ............................................. 1
For profit ................................................................................................... 2
A division of city or county government ................................................... 3
Part of a council of governments or regional planning and development
agency ...................................................................................................... 4
A Tribal Government entity ...................................................................... 5
Educational institution .............................................................................. 6
Other (Please Specify) ............................................................................. 7
Don’t know ............................................................................................... d
REQUIRED
IF A6 DNE “A TRIBAL GOVERNMENT ENTITY”
A7.
Is your service area for nutrition near an Older American Act Title VI program for Older
Native Americans?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
REQUIRED
ALL
A8.
Is your organization a faith-based organization?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
4
(5/24/12)
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES. ELSE SKIP TO A11.
A9.
Please describe the areas included in your congregate nutrition service area:
Select all that apply
□
□
□
□
□
Urban area ............................................................................................... 1
Suburban area ......................................................................................... 2
Rural area ................................................................................................ 3
Frontier area ............................................................................................. 4
Don’t know ............................................................................................... d
HARD CHECK: IF A9 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES
A10.
Which of the following best describes the current boundaries of your congregate nutrition
service area?
Single county............................................................................................ 1
Multi-county .............................................................................................. 2
Single city/Metro area .............................................................................. 3
Multiple city/Metro area ............................................................................ 4
Other (Please Specify) ............................................................................. 5
Don’t know ............................................................................................... d
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES. ELSE SKIP TO B1.
A11.
Please describe the areas included in your home-delivered nutrition service area:
Select all that apply
□
□
□
□
Urban area ............................................................................................... 1
Suburban area ......................................................................................... 2
Rural area ................................................................................................ 3
Don’t know ............................................................................................... d
HARD CHECK: IF A11 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
Prepared by Mathematica Policy Research
5
(5/24/12)
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES
A12.
Which of the following best describes the current boundaries of your home-delivered
nutrition service area?
Single county............................................................................................ 1
Multi-county .............................................................................................. 2
Single city/Metro area .............................................................................. 3
Multiple city/Metro area ............................................................................ 4
Other (Please Specify) ............................................................................. 5
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
6
(5/24/12)
SECTION B. AGING AND DISABILITY RESOURCE CENTER (ADRC)
REQUIRED
ALL
B1.
Currently, is there an Aging and Disability Resource Center (ADRC) in your service area?
In your state, the ADRC is known as [FILL ADRC NAME (to the public)].
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
REQUIRED
IF B1 = YES. ELSE SKIP TO C1.
B2.
Does your organization receive referrals for nutrition services from the ADRC?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
REQUIRED
IF B1 = YES
B3.
Does your organization refer nutrition clients to the ADRC for non-nutrition needs?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
7
(5/24/12)
SECTION C. STAFF AND VOLUNTEERS
REQUIRED
ALL
C1.
What kinds of tasks are assigned to volunteers for your elderly nutrition services
program?
Select all that apply
□
□
□
□
□
□
□
□
Meal production (e.g., prepare or cook food) ........................................................... 1
Congregate site meal delivery (e.g., serve meals), [PROGRAMMER: SHOW
ONLY IF A1 INCLUDES CONGREGATE NUTRITION] .......................................... 2
Congregate site work, non-production (e.g., hostess, table setting, clean-up,
re-stock, cashier), [PROGRAMMER: SHOW ONLY IF A1 INCLUDES
CONGREGATE NUTRITION] .................................................................................. 3
Home-delivered meal delivery [PROGRAMMER: SHOW ONLY IF A1
INCLUDES HOME-DELIVERED NUTRITION] ........................................................ 4
Nutrition education or counseling............................................................................. 5
Nutrition program management or administration (fund-raising, accounting,
human resources) .................................................................................................... 6
Other (Please Specify) ............................................................................................. 7
Don’t know ............................................................................................................... d
HARD CHECK: IF C1 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
Prepared by Mathematica Policy Research
8
(5/24/12)
REQUIRED
ALL
C2.
Who are your typical volunteers?
Select all that apply
□
□
□
□
□
□
□
□
□
Older adults ...................................................................................................... 1
Client family members/friends .......................................................................... 2
Students ........................................................................................................... 3
Faith-based organization members ................................................................. 4
Civic organization members ............................................................................. 5
Local business employees ............................................................................... 6
General public .................................................................................................. 7
Other (Please Specify) ..................................................................................... 8
Don’t know ....................................................................................................... d
HARD CHECK: IF C2 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES. ELSE SKIP TO CHECK BEFORE C4
C3.
Would your organization continue to provide congregate nutrition services if you had no
volunteers?
Yes, and at the current level of service provision ............................................ 1
Yes, but at a reduced level of service provision (e.g., close some sites,
reduce the number of days of service, reduced number of people served) .... 2
No ..................................................................................................................... 0
Don’t know ....................................................................................................... d
REQUIRED
IF A1 INCLUDES HOME DELIVERED NUTRITION SERVICES. ELSE SKIP TO D1
C4.
Would your organization continue to provide home-delivered nutrition services if you had
no volunteers?
Yes, and at the current level of service provision ............................................ 1
Yes, but at a reduced level of service provision (e.g., reduce service
area, reduced frequency of delivery, reduce number of meals per person,
reduce number of people served) .................................................................... 2
No ..................................................................................................................... 0
Don’t know ....................................................................................................... d
Prepared by Mathematica Policy Research
9
(5/24/12)
SECTION D. TECHNOLOGY AND DATA
REQUIRED
ALL
D1.
Which of the following electronic systems does your organization currently use?
Select all that apply
□
□
□
□
□
□
□
□
□
□
□
□
Computer-assisted menu planning and analysis ..................................... 1
Software to track inventory or order food ................................................. 2
Delivery systems for home-delivered nutrition (e.g., route mapping
software) .................................................................................................. 3
Program participant tracking or referral systems ..................................... 4
Electronic client ID card ........................................................................... 5
Electronic system for recording service (e.g., the meal) as received ...... 6
Financial systems for billing and/or making payments for services ......... 7
Cost-centered accounting system............................................................ 8
Geographic Information Systems (GIS) ................................................... 9
Other automated system ........................................................................ 10
No automated systems ............................................................................ 0
Don’t know ............................................................................................... d
HARD CHECK: IF D1 = NO AUTOMATED SYSTEMS AND ANY OTHER ANSWER CATEGORY IS
SELECTED, SHOW VALIDATION MESSAGE, No automated systems cannot be selected along with
other response options.
HARD CHECK: IF D1 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
Prepared by Mathematica Policy Research
10
(5/24/12)
SECTION E. PROGRAM RESOURCES
REQUIRED
ALL
E1.
How many of each of the following are rented, owned, or donated for use in your Elderly
Nutrition Program?
Note: Please enter 0 if you do not have any of a particular item.
#
RENTED
RESOURCE
# OWNED
# DONATED
a. Kitchen
Don’t know
d
d
d
d
d
d
d
d
d
d
d
d
d
d
d
b. Off-site storage (food/supplies)
Don’t know
c.
Delivery vehicles
Don’t know
d. Vehicle garage/parking facility
Don’t know
e. Congregate site
Don’t know
PROGRAMMER: RANGE FOR E1a-e IS (0-99)
SOFT CHECK: IF GT 25, You indicated more than 25 [resources] are [rented, owned, donated]. Is
that correct?
HARD CHECK: IF E1a-e = DON’T KNOW AND NUMBER FIELD IS FILLED, SHOW VALIDATION
MESSAGE, Don’t know cannot be selected if a number is entered.
Prepared by Mathematica Policy Research
11
(5/24/12)
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES. ELSE SKIP TO E3.
E2.
Is your organization responsible for at least some utilities (e.g., electricity) at your
congregate nutrition sites?
Yes, all sites ............................................................................................. 1
Yes, some sites ........................................................................................ 2
No ............................................................................................................. 0
Don’t know ............................................................................................... d
REQUIRED
ALL
E3.
Does your organization pay for at least some utilities (e.g., electricity) at your production
sites?
Yes, all sites ............................................................................................. 1
Yes, some sites ........................................................................................ 2
No ............................................................................................................. 0
Not applicable, we don’t have a production site ...................................... n
Don’t know ............................................................................................... d
REQUIRED
IF A1 INCLUDES HOME DELIVERED NUTRITION SERVICES. ELSE SKIP TO E6
E4.
How are home-delivered meals delivered to program participants’ homes?
Select all that apply
□
□
□
□
Drivers use their own vehicles ................................................................. 1
Vehicles are provided by our organization ............................................... 2
Other (Please Specify) ............................................................................. 3
Don’t know ............................................................................................... d
HARD CHECK: IF E4 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
Prepared by Mathematica Policy Research
12
(5/24/12)
REQUIRED
IF A1 INCLUDES HOME DELIVERED NUTRITION SERVICES.
E5.
Does your organization reimburse home-delivered nutrition program drivers for gas or
mileage when using their own vehicles?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
Not applicable (i.e., drivers do not use their own vehicles) ..................... n
REQUIRED
ALL
E6.
Does your organization provide stipends or other monetary rewards to volunteers (other
than gas or mileage)?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
REQUIRED
IF A1 INCLUDES HOME DELIVERED NUTRITION SERVICES.
E7.
Has your organization reduced or stopped reimbursement of program drivers for
gas/mileage when using their own vehicle within the last 3 years?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
Not applicable (i.e., drivers do not use their own vehicles) ..................... n
REQUIRED
ALL
E8.
Has your organization reduced or stopped providing stipends or other monetary rewards
to volunteers within the last 3 years?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
13
(5/24/12)
SECTION F. ACCESS TO SERVICES
REQUIRED
ALL
F1a.
Is your organization responsible for prioritizing clients (i.e., using characteristics to base
decisions for serving some individuals before others when resources are limited) for the
elderly nutrition service programs you provide?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
REQUIRED
ALL
F1b.
Does your organization have specific prioritization criteria (i.e., characteristics to base
decisions on for serving some individuals before others when resources are limited) for
the elderly nutrition service programs you provide?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
Not applicable .......................................................................................... n
REQUIRED
ALL
F1c.
Did your organization have to prioritize who received services during the past year?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
Not applicable .......................................................................................... n
Prepared by Mathematica Policy Research
14
(5/24/12)
REQUIRED
IF F1b or F1c = YES AND A1 INCLUDES CONGREGATE NUTRITION AND HOME-DELIVERED
NUTRITION. ELSE SKIP TO F3
F2.
Which of the following criteria do you currently use for prioritization?
CONGREGATE
NUTRITION
PRIORITIZATION
CRITERIA
CHARACTERISTIC
a. ADL cut-off
1
b. IADL cut-off
1
c.
1
Lack of informal/family support
d. Geographic isolation
1
e. Social isolation
1
f.
1
Chronic health condition
g. Poor housing/lack kitchen access
1
h. Homebound
1
i.
Racial/ethnic minority
1
j.
Advanced age
1
k.
Low Income
1
l.
Limited English Proficiency
1
m. Dementia/Cognitive Impairment
1
n. Food insecure/hungry
1
o. Nutrition Risk Assessment
1
p. Adult day care participation
1
q. Long-term need for service
1
r.
Other
1
s.
Do not prioritize for this type of service
1
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
HOME-DELIVERED
NUTRITION
PRIORITIZATION
CRITERIA
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
HARD CHECK: IF NO ANSWER CATEGORY IS CHECKED IN A COLUMN, At least one response is
required in each column.
HARD CHECK: IF DO NOT PRIORITIZE FOR THIS TYPE OF SERVICE AND ANY OTHER RESPONSE
IS CHECKED, Do not prioritize for this type of service cannot be selected with other response
options.
Prepared by Mathematica Policy Research
15
(5/24/12)
REQUIRED
IF F1b or F1c = YES AND A1 INCLUDES CONGREGATE NUTRITION BUT NOT HOME-DELIVERED
NUTRITION. ELSE SKIP TO F3
F2.1
Which of the following criteria do you currently use for prioritization?
CONGREGATE
NUTRITION
PRIORITIZATION
CRITERIA
CHARACTERISTIC
a. ADL cut-off
1
b. IADL cut-off
1
c.
1
Lack of informal/family support
d. Geographic isolation
1
e. Social isolation
1
f.
1
Chronic health condition
g. Poor housing/lack kitchen access
1
h. Homebound
1
i.
Racial/ethnic minority
1
j.
Advanced age
1
k.
Low Income
1
l.
Limited English Proficiency
1
m. Dementia/Cognitive Impairment
1
n. Food insecure/hungry
1
o. Nutrition Risk Assessment
1
p. Adult day care participation
1
q. Long-term need for service
1
r.
Other
1
s.
Do not prioritize for this type of service
1
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
HARD CHECK: IF NO ANSWER CATEGORY IS CHECKED, At least one response is required.
HARD CHECK: IF DO NOT PRIORITIZE FOR THIS TYPE OF SERVICE AND ANY OTHER RESPONSE
IS CHECKED, Do not prioritize for this type of service cannot be selected with other response
options.
Prepared by Mathematica Policy Research
16
(5/24/12)
REQUIRED
IF F1b or F1c = YES AND A1 INCLUDES HOME-DELIVERED NUTRITION BUT NOT CONGREGATE
NUTRITION. ELSE SKIP TO F3
F2.2
Which of the following criteria do you currently use for prioritization?
HOME-DELIVERED
NUTRITION
PRIORITIZATION
CRITERIA
CHARACTERISTIC
a. ADL cut-off
2
b. IADL cut-off
2
c.
2
Lack of informal/family support
d. Geographic isolation
2
e. Social isolation
2
f.
2
Chronic health condition
g. Poor housing/lack kitchen access
2
h. Homebound
2
i.
Racial/ethnic minority
2
j.
Advanced age
2
k.
Low Income
2
l.
Limited English Proficiency
2
m. Dementia/Cognitive Impairment
2
n. Food insecure/hungry
2
o. Nutrition Risk Assessment
2
p. Adult day care participation
2
q. Long-term need for service
2
r.
Other
2
s.
Do not prioritize for this type of service
1
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
HARD CHECK: IF NO ANSWER CATEGORY IS CHECKED, At least one response is required.
HARD CHECK: IF DO NOT PRIORITIZE FOR THIS TYPE OF SERVICE AND ANY OTHER RESPONSE
IS CHECKED, Do not prioritize for this type of service cannot be selected with other response
options.
Prepared by Mathematica Policy Research
17
(5/24/12)
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES
F3.
What method is used by participants to access congregate nutrition services?
Select all that apply
□
□
□
□
□
Pre-approval mechanism ......................................................................... 1
Participants sign-up ahead/make a reservation ....................................... 2
First come, first served at site .................................................................. 3
Other (Please Specify) ............................................................................. 4
Don’t know ............................................................................................... d
HARD CHECK: IF F3 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES. ELSE SKIP TO F5
F4.
Does your organization provide transportation directly or arrange transportation services
such as free or low cost cabs, vans, or buses for clients of the congregate nutrition
program?
Select all that apply
□
□
□
□
□
Organization directly provides transportation .......................................... 1
Organization arranges transportation services ........................................ 2
Transportation available through other entity .......................................... 3
Participant arranges for their own transportation ..................................... 4
Don’t know ............................................................................................... d
HARD CHECK: IF F4 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
Prepared by Mathematica Policy Research
18
(5/24/12)
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES. ELSE SKIP TO G1.
F5.
Who authorizes home-delivered nutrition services for a new client?
Select all that apply
□
□
□
□
Your organization authorizes clients to receive services using funding that
includes Older Americans Act funds ........................................................ 1
The Area Agency on Aging authorizes clients to receive services using
funding that includes OAA funds .............................................................. 2
Other authorizing system (Please Specify) .............................................. 3
Don’t know ............................................................................................... d
HARD CHECK: IF F5 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
F6.
Please identify up to three sources that provided the most referrals for the home-delivered
nutrition program during your most recently completed fiscal year.
Select all that apply
□
□
□
□
□
□
□
□
□
□
□
□
□
Family/Friends .......................................................................................... 1
Hospital/health care facility/discharge planner ........................................ 2
Nursing homes ......................................................................................... 3
Physician .................................................................................................. 4
Case management system ...................................................................... 5
Aging and Disability Resource Center (ADRC) ....................................... 6
Information and Assistance system ......................................................... 7
Medicaid Waiver....................................................................................... 8
Other food or nutrition program................................................................ 9
Faith-based organizations ...................................................................... 10
Self ......................................................................................................... 11
Other (Please Specify) ........................................................................... 12
Don’t know the three sources that provided the most referrals ............... d
HARD CHECK: IF F6 = DON’T KNOW THE THREE SOURCES THAT PROVIDED THE MOST
REFERRALS and any other answer category is selected, Don’t know the three sources that provided
the most referrals cannot be selected along with other response options.
SOFT CHECK: IF RESPONDENT CHECKS LT 3 SELECTIONS FROM LIST, You have selected fewer
than three sources. Is that correct?
HARD CHECK: IF RESPONDENT CHECKS GT 3 SELECTIONS FROM LIST, You have selected more
than three sources. Please select the three sources that provided the most referrals for the homedelivered nutrition program.
Prepared by Mathematica Policy Research
19
(5/24/12)
SECTION G. WAITING LISTS
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION AND HOME-DELIVERED NUTRITION
G1.
Does your organization currently maintain waiting lists for the congregate nutrition or
home-delivered nutrition programs?
MAINTAINS WAITING LIST FOR CONGREGATE
NUTRITION PROGRAM
YES
1
NO
0
MAINTAINS WAITING LIST FOR HOME-DELIVERED
NUTRITION PROGRAM
DON’T KNOW
d
YES
1
NO
0
DON’T KNOW
d
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION AND A1 DOES NOT INCLUDE HOME-DELIVERED
NUTRITION
G1.1
Does your organization currently maintain a waiting list for the congregate nutrition
program?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION AND A1 DOES NOT INCLUDE CONGREGATE
NUTRITION
G1.2
Does your organization currently maintain a waiting list for the home-delivered nutrition
program?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
20
(5/24/12)
REQUIRED
IF G1 = YES FOR CONGREGATE NUTRITION AND G1 = YES FOR HOME-DELIVERED NUTRITION.
G2.
What is the current waiting list policy for congregate and home-delivered nutrition?
CONGREGATE
NUTRITION
HOME-DELIVERED
NUTRITION
a. The waiting list contains everyone who requested
service without screening for service eligibility or
need, ordered by date of request
1
1
b. The waiting list contains everyone who is screened
eligible for services on a first-come first-served basis
2
2
3
3
d. Other (Please Specify)
4
4
e. There is no waiting list policy
5
5
f.
d
d
c.
The waiting list contains everyone who is screened
eligible and in priority order (by priority criteria)
Don’t know
REQUIRED
IF G1 OR G1.1 = YES FOR CONGREGATE NUTRITION AND BOTH G1 AND G1.2 NOT YES FOR
HOME-DELIVERED NUTRITION.
G2.1
What is the current waiting list policy for congregate nutrition?
CONGREGATE
NUTRITION
a. The waiting list contains everyone who requested service without
screening for service eligibility or need, ordered by date of request
1
b. The waiting list contains everyone who is screened eligible for services
on a first-come first-served basis
2
3
d. Other (Please Specify)
4
e. There is no waiting list policy
5
f.
d
c.
The waiting list contains everyone who is screened eligible and in
priority order (by priority criteria)
Don’t know
Prepared by Mathematica Policy Research
21
(5/24/12)
REQUIRED
IF G1 OR G1.2 = YES FOR HOME-DELIVERED NUTRITION AND BOTH G1 AND G1.1 NOT YES FOR
CONGREGATE NUTRITION.
G2.2
What is the current waiting list policy for home-delivered nutrition?
HOME-DELIVERED
NUTRITION
a. The waiting list contains everyone who requested service without
screening for service eligibility or need, ordered by date of request
1
b. The waiting list contains everyone who is screened eligible for services
on a first-come first-served basis
2
3
d. Other (Please Specify)
4
e. There is no waiting list policy
5
f.
d
c.
The waiting list contains everyone who is screened eligible and in
priority order (by priority criteria)
Don’t know
Prepared by Mathematica Policy Research
22
(5/24/12)
SECTION H. REFERRALS AND NEEDS ASSESSMENTS
REQUIRED
A1 INCLUDES CONGREGATE NUTRITION AND HOME DELIVERED NUTRITION
H1.
Does your organization currently have a formal process for assessing service needs for
Elderly Nutrition Program participants (e.g., transportation, SNAP, housing, etc.)?
NUTRITION NEEDS
Service Type
YES
NO
NON-NUTRITION NEEDS
DON’T
KNOW
YES
NO
DON’T
KNOW
Congregate nutrition
1
0
d
1
0
d
Home-delivered nutrition
1
0
d
1
0
d
REQUIRED
A1 INCLUDES CONGREGATE NUTRITION AND A1 DOES NOT INCLUDE HOME-DELIVERED
NUTRITION
H1.1
Does your organization currently have a formal process for assessing service needs for
Elderly Nutrition Program participants (e.g., transportation, SNAP, housing, etc.)?
CONGREGATE NUTRITION
YES
NO
DON’T
KNOW
Nutrition needs
1
0
d
Non-nutrition needs
1
0
d
REQUIRED
A1 INCLUDES HOME-DELIVERED NUTRITION AND A1 DOES NOT INCLUDE CONGREGATE
NUTRITION
H1.2
Does your organization currently have a formal process for assessing service needs for
Elderly Nutrition Program participants (e.g., transportation, SNAP, housing, etc.)?
HOME-DELIVERED
NUTRITION
YES
NO
DON’T
KNOW
Nutrition needs
1
0
d
Non-nutrition needs
1
0
d
Prepared by Mathematica Policy Research
23
(5/24/12)
REQUIRED
IF H1=YES FOR CONGREGATE NUTRITION FOR EITHER NUTRITION OR NON-NUTRITION NEEDS
AND IF H1=YES FOR HOME-DELIVERED NUTRITION FOR EITHER NUTRITION OR NONNUTRITION NEEDS
H2.
How often are Elderly Nutrition Program participants re-assessed for service needs (both
nutrition and non-nutrition services)?
Select all that apply for each column
Congregate nutrition
program participants
No policy (frequency determined by staff)
1
At least yearly (1 or more assessments per year)
2
Less than once per year
3
After acute care episode (hospital, ER visit)
4
Other (Specify)
5
Don’t know
d
□
□
□
□
□
□
Home-delivered
nutrition program
participants
1
2
3
4
5
d
□
□
□
□
□
□
HARD CHECK: IF H2 = DK AND ANY OTHER CATEGORY IS SELECTED, SHOW VALIDATION
MESSAGE, Don’t know cannot be selected along with other response options.
Prepared by Mathematica Policy Research
24
(5/24/12)
REQUIRED
(IF H1=YES FOR CONGREGATE NUTRITION FOR EITHER NUTRITION OR NON-NUTRITION NEEDS
AND IF H1<>YES FOR HOME-DELIVERED NUTRITION FOR NEITHER NUTRITION NOR NONNUTRITION NEEDS) OR (H1.1=YES FOR CONGREGATE NUTRITION FOR EITHER NUTRITION OR
NON-NUTRITION NEEDS)
H2.1
How often are Elderly Nutrition Program participants re-assessed for service needs (both
nutrition and non-nutrition services)?
Select all that apply
Congregate nutrition program participants
No policy (frequency determined by staff)
1
At least yearly (1 or more assessments per year)
2
Less than once per year
3
After acute care episode (hospital, ER visit)
4
Other (Specify)
5
Don’t know
d
□
□
□
□
□
□
HARD CHECK: IF H2.1 = DK AND ANY OTHER CATEGORY IS SELECTED, SHOW VALIDATION
MESSAGE, Don’t know cannot be selected along with other response options.
Prepared by Mathematica Policy Research
25
(5/24/12)
REQUIRED
(IF H1=YES FOR HOME-DELIVERED NUTRITION FOR EITHER NUTRITION OR NON-NUTRITION
NEEDS AND IF H1<>YES FOR CONGREGATE NUTRITION FOR NEITHER NUTRITION NOR NONNUTRITION NEEDS) OR (H1.2=YES FOR HOME-DELIVERED NUTRITION FOR EITHER NUTRITION
OR NON-NUTRITION NEEDS)
H2.2
How often are Elderly Nutrition Program participants re-assessed for service needs (both
nutrition and non-nutrition services)?
Select all that apply
Home-delivered nutrition program participants
No policy (frequency determined by staff)
1
At least yearly (1 or more assessments per year)
2
Less than once per year
3
After acute care episode (hospital, ER visit)
4
Other (Specify)
5
Don’t know
d
□
□
□
□
□
□
HARD CHECK: IF H2.2 = DK AND ANY OTHER CATEGORY IS SELECTED, SHOW VALIDATION
MESSAGE, Don’t know cannot be selected along with other response options.
Prepared by Mathematica Policy Research
26
(5/24/12)
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION
H3.1
Currently, which of the following services does your organization actively assist Elderly
Nutrition Program participants to access? Active assistance involves more than providing
reading materials and brochures.
Select all that apply
Congregate nutrition
program
Service
a. Medicaid Waiver programs
1
b. Medicaid (non-waiver)
1
c.
1
Medicare Parts A or B
d. Medicare Part D
1
e. Housing programs
1
f.
1
Transportation services
g. Low Income Home Energy Assistance Program (LIHEAP)
1
h. Supplemental Security Income
1
i.
Other supportive services (chore, homemaker)
1
j.
SNAP (Food Stamps)
1
k.
Other food or nutrition services (food pantry)
1
l.
Veterans Affairs services
1
m. Adult Protective Services
1
n. Evidence-based health promotion and disease prevention programs
1
o. Other
1
p. Do not provide this type of assistance
1
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
HARD CHECK: IF H3p = CONGREGATE AND ANY H3a-o = CONGREGATE, SHOW VALIDATION
MESSAGE, Do not provide this type of assistance cannot be selected along with other response
options.
HARD CHECK: AT LEAST ONE RESPONSE MUST BE SELECTED, At least one response must be
selected.
Prepared by Mathematica Policy Research
27
(5/24/12)
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION
H3.2
Currently, which of the following services does your organization actively assist Elderly
Nutrition Program participants to access? Active assistance involves more than providing
reading materials and brochures.
Select all that apply
Home-delivered nutrition
program
Service
a. Medicaid Waiver programs
b. Medicaid (non-waiver)
c.
Medicare Parts A or B
d. Medicare Part D
e. Housing programs
f.
Transportation services
g. Low Income Home Energy Assistance Program (LIHEAP)
h. Supplemental Security Income
i.
Other supportive services (chore, homemaker)
j.
SNAP (Food Stamps)
k.
Other food or nutrition services (food pantry)
l.
Veterans Affairs services
□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1□
1
m. Adult Protective Services
n. Evidence-based health promotion and disease prevention programs
o. Other
p. Do not provide this type of assistance
HARD CHECK: AT LEAST ONE RESPONSE MUST BE SELECTED, At least one response must be
selected.
HARD CHECK: I IF H3p = HOME-DELIVERED AND ANY H3a-o = HOME-DELIVERED, SHOW
VALIDATION MESSAGE, Do not provide this type of assistance cannot be selected along with
other response options.
Prepared by Mathematica Policy Research
28
(5/24/12)
REQUIRED
IF SUM OF SELECTIONS FROM H3.1 IS GREATER THAN 3.
H4.1
Please identify the three most common programs or services that your organization refers
Elderly Nutrition Program participants.
MARK ONLY THREE
PROGRAMMER: DISPLAY ALL CHECKED SELECTIONS FROM H3.1
HARD CHECK: IF RESPONDENT DOES NOT CHECK 3 ITEMS FROM LIST, SHOW VALIDATION
MESSAGE, Please select the three most common programs or services.
REQUIRED
IF SUM OF SELECTIONS FROM H3.2 IS GREATER THAN 3.
H4.2
Please identify the three most common programs or services that your organization refers
Elderly Nutrition Program participants.
MARK ONLY THREE
PROGRAMMER: DISPLAY ALL CHECKED SELECTIONS FROM H3.2
HARD CHECK: IF RESPONDENT DOES NOT CHECK 3 ITEMS FROM LIST, SHOW VALIDATION
MESSAGE, Please select the three most common programs or services.
REQUIRED
IF H3.1 OR H3.2 DOES NOT EQUAL DO NOT PROVIDE THIS TYPE OF ASSISTANCE
H5.
Is follow-up done on active referrals?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
29
(5/24/12)
SECTION I. NUTRITION SERVICE OPERATION AND QUALITY ASSURANCE
REQUIRED
ALL
I1.
Which of the following does your organization currently use to contribute to the nutrient
quality of meals?
Select all that apply
□
□
□
□
□
□
□
□
Computer-assisted menu analysis ........................................................... 1
Meal patterns ........................................................................................... 2
Use of dietician or state credentialed nutrition professional .................... 3
Area Agency on Aging guidance.............................................................. 4
State Unit on Aging guidance .................................................................. 5
Older Americans Act guidance ................................................................ 6
None of the above .................................................................................... 0
Don’t know ............................................................................................... d
HARD CHECK: IF I1 = NONE OF THE ABOVE AND ANY OTHER CATEGORY IS SELECTED, SHOW
VALIDATION MESSAGE, None of the above cannot be selected along with other response options.
HARD CHECK: IF I1 = DK AND ANY OTHER CATEGORY IS SELECTED, SHOW VALIDATION
MESSAGE, Don’t know cannot be selected along with other response options.
Prepared by Mathematica Policy Research
30
(5/24/12)
REQUIRED
ALL
I2.
Which of the following does your organization currently use to contribute to the overall
food service quality provided by your organization, caterers, or vendors?
Select all that apply
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Food service license/safety inspections......................................................... 1
Training of staff .............................................................................................. 2
Survey of program participants ...................................................................... 3
Program participant feedback mechanism (comment box/card,
complaint mechanism, etc.) ........................................................................... 4
Regularly scheduled site visits either to production location and/or
service location .............................................................................................. 5
Visit to home of home-delivered nutrition client ............................................. 6
Program participant advisory/menu committee ............................................. 7
Food quality specifications ............................................................................. 8
Use of dietician or state credentialed nutrition professional .......................... 9
Area Agency on Aging guidance................................................................... 10
State Unit on Aging guidance ....................................................................... 11
Older Americans Act guidance ..................................................................... 12
None of the above .......................................................................................... 0
Don’t know ..................................................................................................... d
HARD CHECK: IF I2 = NONE OF THE ABOVE AND ANY OTHER CATEGORY IS SELECTED, SHOW
VALIDATION MESSAGE, None of the above cannot be selected along with other response options.
HARD CHECK: IF I2 = DK AND ANY OTHER CATEGORY IS SELECTED, SHOW VALIDATION
MESSAGE, Don’t know cannot be selected along with other response options.
Prepared by Mathematica Policy Research
31
(5/24/12)
SECTION J. EMERGENCY PLANNING
REQUIRED
ALL
J1.
Does your organization currently have an emergency plan that includes providing nutrition
services?
Select all that apply
□
□
□
□
Yes, for short-term emergencies .............................................................. 1
Yes, for long-term emergencies ............................................................... 2
No ............................................................................................................. 0
Don’t know ............................................................................................... d
HARD CHECK: IF J1 = NO AND ANY OTHER CATEGORY IS SELECTED, SHOW VALIDATION
MESSAGE, No cannot be selected along with other response options.
HARD CHECK: IF J1 = DK AND ANY OTHER CATEGORY IS SELECTED, SHOW VALIDATION
MESSAGE, Don’t know cannot be selected along with other response options.
REQUIRED
ALL
J2.
Has your organization experienced a disaster (natural or manmade) in the past 3 years?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
REQUIRED
IF J1 = 1 OR 2 AND J2 = YES. ELSE, SKIP TO K1.
J3.
During the disaster did your organization initiate an emergency plan?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Did not have an emergency plan at the time ........................................... 2
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
32
(5/24/12)
REQUIRED
IF J3 = YES
J4.
Please rate the effectiveness of the emergency plan.
Very effective ........................................................................................... 1
Effective ................................................................................................... 2
Somewhat effective .................................................................................. 3
Not very effective ..................................................................................... 4
Not effective ............................................................................................. 5
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
33
(5/24/12)
SECTION K. PARTNERSHIP DEVELOPMENT
REQUIRED
ALL
K1.
Please select all of your partners for the Elderly Nutrition Program during your most
recently completed fiscal year. Partners are organizations or groups in which you may
jointly engage in some of the following activities: fundraising, shared resources,
advocacy, strategic planning, public education, referrals, senior activities, service
delivery, shared outreach, targeting special populations, training or technical assistance,
or volunteer recruitment or retention.
Select all that apply
□ Hospitals, nursing facilities, including discharge planning and
emergency room care .............................................................................................1
□ Home health agencies ............................................................................................2
□ Transportation (public services – county/municipal) ...............................................3
□ Medicare .................................................................................................................4
□ Medicaid (Non-waiver) ............................................................................................5
□ Medicaid Waiver......................................................................................................6
□ Veterans Affairs.......................................................................................................7
□ Social Security ........................................................................................................8
□ Public housing and related services, including senior housing ..............................9
□ Homeless shelters................................................................................................. 10
□ SNAP (Food Stamps)/SNAP Ed (Food Stamp Nutrition Education) .................... 11
□ Senior farmers market........................................................................................... 12
□ Other food and nutrition programs (e.g., Commodity Supplemental
Nutrition Program, emergency food service programs including food
banks and pantries)............................................................................................... 13
□ Title VI (Native American) program....................................................................... 14
□ Other Older Americans Act programs ................................................................... 15
□ Aging and Disability Resource Center .................................................................. 16
□ Non OAA funded Meals on Wheels ...................................................................... 17
□ Community health centers .................................................................................... 18
□ Public health services ........................................................................................... 19
□ City or county social services agency ................................................................... 20
□ City or county regional planning office .................................................................. 21
□ County/city/local public service providers such as EMS, police/fire
departments .......................................................................................................... 22
□ Elder Abuse Prevention programs or Adult Protective Services
(APS) ..................................................................................................................... 23
□ Legal services for older adults .............................................................................. 24
□ Energy assistance (LIHEAP) ................................................................................ 25
□ Churches, synagogues, mosques, faith-based organizations .............................. 26
□ College or university.............................................................................................. 27
□ Volunteer bureaus/organizations .......................................................................... 28
□ Civic organization .................................................................................................. 29
□ Local business (Please specify the type) .............................................................. 30
□ Other (Please Specify) .......................................................................................... 31
□
□
Do not have any partners ...................................................................................... 32
Don’t know ..............................................................................................................d
HARD CHECK: IF K1 = DON’T KNOW and any other category is selected, Don’t know cannot be
selected along with other response options.
HARD CHECK: IF K1 = DO NOT HAVE ANY PARTNERS and any other category is selected, Do not
have any partners cannot be selected along with other response options.
Prepared by Mathematica Policy Research
34
(5/24/12)
REQUIRED
IF GT 5 SELECTIONS FOR K1. ELSE, GO TO K3
K2.
Please select the five most important Elderly Nutrition Program partners you had during
your most recently completed fiscal year.
SELECT ONLY FIVE
PROGRAMMER: DISPLAY ALL CHECKED SELECTIONS FROM K1. IF RESPONDENT
CHECKED “Local business” or “Other”, ALSO DISPLAY TEXT IN “Specify” FIELD.
HARD CHECK: IF RESPONDENT CHECKS GT FIVE SELECTIONS FROM LIST, SHOW VALIDATION
MESSAGE, You have selected more than five partners. Please select your five most important
partners.
HARD CHECK: IF RESPONDENT CHECKS LT FIVE SELECTIONS FROM LIST, SHOW VALIDATION
MESSAGE, You have selected less than five partners. Please select your five most important
partners.
Prepared by Mathematica Policy Research
35
(5/24/12)
REQUIRED
ALL
K3.
For each partnership listed, please indicate which activities you jointly engaged in for the
Elderly Nutrition Program during your most recently completed fiscal year.
PROGRAMMER: IF MORE THAN 5 SELECTIONS FOR K1, FILL
PARTNERSHIP NAME WITH CHECKED SELECTIONS FROM K2. ELSE, FILL
PARTNERSHIP NAMES FROM K1 [MAY BE LESS THAN 5].
[Partnership 1
Name]
a. Fundraising
1
b. Shared resources
1
c.
1
Advocacy
d. Strategic planning
1
e. Public education
1
f.
1
Referrals
g. Senior activities
1
h. Service delivery
1
i.
Shared outreach
1
j.
Targeting special
populations
1
Training/technical
assistance
1
Volunteer recruitment or
retention
1
k.
l.
m. None of the above
1
□
□
□
□
□
□
□
□
□
□
□
□
□
[Partnership 2
Name]
2
2
2
2
2
2
2
2
2
2
2
2
2
□
□
□
□
□
□
□
□
□
□
□
□
□
[Partnership 3
Name]
3
3
3
3
3
3
3
3
3
3
3
3
3
□
□
□
□
□
□
□
□
□
□
□
□
□
[Partnership 4
Name]
4
4
4
4
4
4
4
4
4
4
4
4
4
□
□
□
□
□
□
□
□
□
□
□
□
□
[Partnership 5
Name]
5
5
5
5
5
5
5
5
5
5
5
5
5
□
□
□
□
□
□
□
□
□
□
□
□
□
HARD CHECK: IF K3 = NONE OF THE ABOVE, and any other category is selected, None of the above
cannot be selected along with other response options.
Prepared by Mathematica Policy Research
36
(5/24/12)
REQUIRED
IF PARTNERSHIPS LISTED FOR K3 NE “Title VI (Native American) program” OR IF K1 = DK OR DO
NOT HAVE ANY PARTNERS AND A7 = YES.
K4.
What are the major areas in which your organization collaborated with Title VI programs
during your most recently completed fiscal year?
Select all that apply
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Fundraising .............................................................................................. 1
Shared resources ..................................................................................... 2
Advocacy.................................................................................................. 3
Strategic planning .................................................................................... 4
Public education ....................................................................................... 5
Referrals ................................................................................................... 6
Senior activities ........................................................................................ 7
Service delivery ........................................................................................ 8
Meal production........................................................................................ 9
Shared outreach..................................................................................... 10
Targeting special populations ................................................................ 11
Training/technical assistance ................................................................. 12
Volunteer recruitment or retention ......................................................... 13
Other (Please Specify) ........................................................................... 14
Don’t collaborate with Title VI programs ................................................ 15
Don’t know ............................................................................................... d
HARD CHECK: IF K4 = DON’T COLLABORATE WITH TITLE VI PROGRAMS AND ANY OTHER
CATEGORY IS SELECTED, SHOW VALIDATION MESSAGE, Don’t collaborate with Title VI
programs cannot be selected with other response options.
HARD CHECK: IF K4 = DK AND ANY OTHER CATEGORY IS SELECTED, SHOW VALIDATION
MESSAGE, Don’t know cannot be selected along with other response options.
Prepared by Mathematica Policy Research
37
(5/24/12)
SECTION L. PRIVATE PAY/FEE-FOR-SERVICE AND MEDICAID WAIVER
The next series of questions are about private pay/fee-for-service and Medicaid Waiver
participation.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES. ELSE SKIP TO L6.
L1.
Does your organization have a private pay/fee-for-service meal program in the congregate
nutrition program?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
REQUIRED
IF L1 = YES. ELSE SKIP TO L6.
L2.
How is the private pay/fee-for-service program’s meal price calculated in the congregate
nutrition program?
Cost-reimbursement................................................................................. 1
Fair market value ..................................................................................... 2
Other ........................................................................................................ 3
Don’t know ............................................................................................... d
REQUIRED
IF L1 = YES
L3.
What is the average price of the private pay/fee-for-service lunch meal in the congregate
nutrition program?
PRICE OF PRIVATE PAY MEAL (0-99.99)
$
□
Don’t know ............................................................................................... d
SOFT CHECK: IF L3 GT 10.00, SHOW VALIDATION, You indicated an average price over $10. Is this
correct?
HARD CHECK: IF L3 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
Prepared by Mathematica Policy Research
38
(5/24/12)
REQUIRED
IF L1 = YES
L4.
Are OAA clients in the congregate nutrition program offered the same meal as private
pay/fee-for-service customers?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
REQUIRED
IF L1 = YES
L5.
Is the private pay/fee-for-service meal offered at the same site as the congregate meal?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES. ELSE SKIP TO L8.
L6.
Does your organization have a private pay/fee-for-service meal program in the homedelivered nutrition program?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
REQUIRED
IF L6 = YES.
L7.
How is the private pay/fee-for-service program’s meal price calculated in the homedelivered nutrition program?
Cost-reimbursement................................................................................. 1
Fair market value ..................................................................................... 2
Other ........................................................................................................ 3
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
39
(5/24/12)
REQUIRED
IF L6 = YES
L7a.
What is the average price of the private pay/fee-for-service meal in the home-delivered
nutrition program?
PRICE OF PRIVATE PAY MEAL (0-99.99)
$
□
Don’t know .................................................................................................................. d
SOFT CHECK: IF L7a GT 10.00, SHOW VALIDATION, You indicated an average price over $10. Is
this correct?
HARD CHECK: IF L7a = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t
know cannot be selected if a number is entered.
REQUIRED
IF L6 = YES
L7b.
Are OAA clients in the home-delivered nutrition program offered the same meal as private
pay/fee-for-service customers?
Yes .............................................................................................................................. 1
No ................................................................................................................................ 0
Don’t know .................................................................................................................. d
REQUIRED
ALL
L8.
Is your organization a provider of Medicaid nutrition services to the elderly?
Select all that apply
□
□
□
□
Yes, we are a provider of Medicaid Waiver nutrition services to the elderly .............. 1
Yes, we are a provider of non-waiver Medicaid nutrition services to the elderly ........ 2
No, we do not provide Medicaid Waiver or non-waiver nutrition services to the
elderly .......................................................................................................................... 0
Don’t know .................................................................................................................. d
HARD CHECK: IF L8 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
HARD CHECK: IF L8 = NO and any other answer category is selected, No cannot be selected along
with other response options.
Prepared by Mathematica Policy Research
40
(5/24/12)
SECTION M. NUTRITION EDUCATION AND NUTRITION COUNSELING
The next series of questions are about nutrition education and nutrition counseling services that
your organization may provide.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICE
M1.
How many congregate nutrition sites operated by your organization currently provide
nutrition education (i.e., presented in a group setting) to eligible program participants?
The nutrition education may be offered by your organization or coordinated with another
organization.
SITES (0-999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF M1 GT 200, You indicated that more than 200 congregate nutrition sites operated by
your organization currently provide nutrition education. Is that correct?
HARD CHECK: IF M1 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICE
M2.
Currently, what is the availability of nutrition education for home-delivered nutrition
program participants? The nutrition education may be offered by your organization or
coordinated with another organization.
Available throughout your service area.................................................... 1
Available in a portion of your service area ............................................... 2
Not available in your service area ........................................................... 3
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
41
(5/24/12)
REQUIRED
IF M1 GE 1
M3.
How often is nutrition education provided to program participants by your organization or
coordinated with another organization?
CONGREGATE
NUTRITION
PROGRAM
PARTICIPANTS
a. Yearly (1 session per year)
1
b. Twice per year (2 sessions per year)
1
c.
Quarterly (4 sessions per year)
1
d. Monthly (12 sessions per year)
1
e. More than monthly (12+ sessions per year)
1
f.
1
d
Other
g. Don’t know
REQUIRED
IF M2 = 1 OR 2
M3.1
How often is nutrition education provided to program participants by your organization or
coordinated with another organization?
HOME-DELIVERED
NUTRITION
PROGRAM
PARTICIPANTS
a. Yearly (1 session per year)
2
b. Twice per year (2 sessions per year)
2
c.
Quarterly (4 sessions per year)
2
d. Monthly (12 sessions per year)
2
e. More than monthly (12+ sessions per year)
2
f.
2
d
Other
g. Don’t know
Prepared by Mathematica Policy Research
42
(5/24/12)
REQUIRED
IF M1 GE 1 OR M2 = 1 OR 2
M4.
Which of the following does your organization currently use to contribute to the quality of
nutrition education?
Select all that apply
□
□
□
□
□
□
□
Use credentialed nutrition professional to conduct education ................. 1
Conduct a survey of program participant need ........................................ 2
Use evidence-based education programs ............................................... 3
Use cooperative extension materials ....................................................... 4
Use curricula from a reliable, science-based organization (academia,
government, American Heart Association, American Diabetic
Association) .............................................................................................. 5
None of the above .................................................................................... 0
Don’t know ............................................................................................... d
HARD CHECK: IF M4 = NONE OF THE ABOVE AND ANY OTHER ANSWER CATEGORY IS
SELECTED, SHOW VALIDATION MESSAGE, None of the above cannot be selected along with
other response options.
HARD CHECK: IF M4 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICE
M5.
How many of your congregate nutrition sites currently provide nutrition counseling (i.e.
working one-on-one with an individual to provide support for dietary issues) to eligible
program participants? The nutrition counseling may be offered by your organization or
coordinated with another organization.
SITES (0-999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF M1 GT 200, You indicated that more than 200 congregate nutrition sites operated by
your organization currently provide nutrition counseling. Is that correct?
HARD CHECK: IF M5 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
Prepared by Mathematica Policy Research
43
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REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICE
M6.
Currently, what is the availability of nutrition counseling for home-delivered nutrition
program participants? The nutrition counseling may be offered by your organization or
coordinated with another organization.
Available throughout your service area.................................................... 1
Available in a portion of your service area ............................................... 2
Not available in your service area ............................................................ 3
Don’t know ............................................................................................... d
REQUIRED
IF M5 GT 0 OR M6 = AVAILABLE THROUGHOUT YOUR SERVICE AREA OR AVAILABLE IN A
PORTION OF YOUR SERVICE AREA. ELSE, SKIP TO SECTION N.
M7.
How is the current need for nutrition counseling determined?
Select all that apply
□
□
□
□
□
□
Nutrition needs assessment ..................................................................... 1
Nutrition Screening Initiative (NSI) score ................................................. 2
Presence of nutrition related chronic disease .......................................... 3
Food insecurity assessment .................................................................... 4
Other criteria ............................................................................................ 5
Don’t know ............................................................................................... d
HARD CHECK: IF M7 = DK AND OTHER CATEGORY IS ENTERED, SHOW VALIDATION MESSAGE,
Don’t know cannot be selected along with other response options.
Prepared by Mathematica Policy Research
44
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REQUIRED
IF M5 GT 0 OR M6 = AVAILABLE THROUGHOUT YOUR SERVICE AREA OR AVAILABLE IN A
PORTION OF YOUR SERVICE AREA.
M8.
Which of the following does your organization currently use to contribute to the quality of
nutrition counseling?
Select all that apply
□
□
□
□
□
Use credentialed nutrition professional to conduct the counseling.......... 1
Use credentialed non-nutrition professionals to conduct the counseling
(e.g., nurses, diabetes educators, etc.).................................................... 2
Use protocols approved by a respected source such as the American
Dietetic Association, Patient Education Association, or Association of
Diabetic Educators ................................................................................... 3
None of the above .................................................................................... 4
Don’t know ............................................................................................... d
HARD CHECK: IF M8 = NONE OF THE ABOVE AND ANY OTHER ANSWER CATEGORY IS
SELECTED, SHOW VALIDATION MESSAGE, None of the above cannot be selected along with
other response options.
HARD CHECK: IF M8 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
REQUIRED
IF M5 GT 0 OR M6 = AVAILABLE THROUGHOUT YOUR SERVICE AREA OR AVAILABLE IN A
PORTION OF YOUR SERVICE AREA.
M9.
How frequently is the need for nutrition counseling assessed with Elderly Nutrition
Program participants?
Select all that apply
□
□
□
□
□
□
□
At program enrollment/entry only ............................................................. 1
On a regular basis (e.g., annually) (Please Specify) ............................... 2
When staff notice a change in the participant .......................................... 3
Program participant/caregiver/family request .......................................... 4
Healthcare professional request .............................................................. 5
Other (Please Specify) ............................................................................. 6
Don’t know ............................................................................................... d
HARD CHECK: IF M9 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
Prepared by Mathematica Policy Research
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(5/24/12)
REQUIRED
IF M5 GT 0 OR M6 = AVAILABLE THROUGHOUT YOUR SERVICE AREA OR AVAILABLE IN A
PORTION OF YOUR SERVICE AREA.
M10.
Does your organization have a formal mechanism for following-up with program
participants who have had nutrition counseling?
Yes ........................................................................................................... 1
No ............................................................................................................. 0
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
46
(5/24/12)
SECTION N. TITLE III-C ELDERLY NUTRITION PROGRAM CONGREGATE NUTRITION
CHARACTERISTICS AND OPERATIONS
The next series of questions are about the characteristics and operations of the congregate
nutrition program operated by your organization.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES. ELSE SKIP TO O1.
N1.
For how many years has your organization offered congregate nutrition services?
YEARS (0-99)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF N1 GT 50 SHOW VALIDATION MESSAGE, You indicated your organization has
offered congregate nutrition services for more than 50 years. Is that correct?
HARD CHECK: IF N1 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N2.
How many different congregate nutrition sites does your organization currently operate?
NUMBER OF CONGREGATE NUTRITION SITES (0-999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF N2 = 0, SHOW VALIDATION MESSAGE, You have indicated that your organization
currently operates 0 congregate nutrition sites. Is this correct?
SOFT CHECK: IF GT 100, SHOW VALIDATION MESSAGE, You have indicated that your
organization operates more than 100 congregate nutrition sites. Is this correct?
HARD CHECK: IF N2 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
Prepared by Mathematica Policy Research
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REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N3.
How many different congregate nutrition sites offer meals…
NUMBER OF CONGREGATE
NUTRITION SITES
DON’T
KNOW
a. More than 5 days per week
(0-999)
d
b. Only 5 days per week
(0-999)
d
c.
Only 4 days per week
(0-999)
d
d. Only 3 days per week
(0-999)
d
e. Only 2 days per week
(0-999)
d
f.
(0-999)
d
Only 1 day per week
SOFT CHECK: IF GT 100, SHOW VALIDATION MESSAGE, You have indicated that your
organization operates more than 100 congregate nutrition sites that offer meals [more than 5 days
per week, only 5 days per week, only 4 days per week, only 3 days per week, only 2 days per
week, only 1 day per week]. Is this correct?
HARD CHECK: IF SUM OF N3a-f GT NUMBER OF CONGREGATE NUTRITION SITES FROM N2 AND
N2 DNE DK, SHOW VALIDATION MESSAGE, The total cannot be more than the number of sites
your organization operates.
HARD CHECK: IF N3a-f = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t
know cannot be selected if a number is entered.
Prepared by Mathematica Policy Research
48
(5/24/12)
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N4.
How many different congregate nutrition sites offer…
NUMBER OF CONGREGATE
NUTRITION SITES
DON’T
KNOW
a. Breakfast
(0-999)
d
b. Lunch
(0-999)
d
c.
(0-999)
d
Dinner
SOFT CHECK: IF GT 100, SHOW VALIDATION MESSAGE, You have indicated that more than 100
congregate nutrition sites offer [breakfast, lunch, dinner]. Is this correct?
HARD CHECK: IF ANY INDIVIDUAL ROW N4a-c GT NUMBER OF CONGREGATE NUTRITION SITES
FROM N2, SHOW VALIDATION MESSAGE, Please enter a number that does not exceed the number
of sites your organization operates.
HARD CHECK: IF N4a-c = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t
know cannot be selected if a number is entered.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N5.
How many different congregate nutrition sites offer meals on weekends?
NUMBER OF CONGREGATE NUTRITION SITES (0-999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF GT 100, SHOW VALIDATION MESSAGE, You have indicated that more than 100
congregate nutrition sites offer meals on weekends. Is this correct?
HARD CHECK: IF N5 GT NUMBER OF CONGREGATE NUTRITION SITES FROM N2, SHOW
VALIDATION MESSAGE, Please enter a number that does not exceed the number of sites your
organization operates.
HARD CHECK: IF N5 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
Prepared by Mathematica Policy Research
49
(5/24/12)
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N6.
How many different congregate nutrition sites meet the Americans with Disabilities Act
standards for accessible design?
NUMBER OF CONGREGATE NUTRITION SITES (0-999)
□
Don’t know ...............................................................................................
d
SOFT CHECK: IF GT 100, SHOW VALIDATION MESSAGE, You have indicated more than 100
different congregate nutrition sites meet the American with Disabilities Act standards for
accessible design. Is this correct?
HARD CHECK: IF N6 GT NUMBER OF CONGREGATE NUTRITION SITES FROM N2, SHOW
VALIDATION MESSAGE, Please enter a number that does not exceed the number of sites your
organization operates.
HARD CHECK: IF N6 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N7.
How many total individuals can your organization serve at one lunch meal in the
congregate nutrition program? Please include all congregate nutrition sites and calculate
the maximum number of lunches that can be served in one sitting if all sites are open and
operating.
MAXIMUM NUMBER OF INDIVIDUALS (0-9999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF N7 GT 5000 SHOW VALIDATION MESSAGE, You indicated that your organization
can serve more than 5,000 individuals at one lunch meal. Is this correct?
HARD CHECK: IF N7 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
Prepared by Mathematica Policy Research
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(5/24/12)
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N7a.
How many individuals can your largest congregate nutrition site serve at one lunch meal?
MAXIMUM NUMBER OF INDIVIDUALS (0-9999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF GT 500, SHOW VALIDATION MESSAGE, You indicated your largest congregate
nutrition site can serve more than 500 people at one lunch meal. Is this correct?
HARD CHECK: IF N7a GT NUMBER OF INDIVIDUALS FROM N7, SHOW VALIDATION MESSAGE,
Please enter a number that does not exceed the number of individuals your organization can
serve.
HARD CHECK: IF N7a = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t
know cannot be selected if a number is entered.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N7b.
How many individuals can your smallest congregate nutrition site serve at one lunch
meal?
MAXIMUM NUMBER OF INDIVIDUALS (0-9999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF GT 100, SHOW VALIDATION MESSAGE, You indicated your smallest congregate
nutrition site can serve more than 100 people at one lunch meal. Is this correct?
HARD CHECK: IF N7b GT NUMBER OF INDIVIDUALS FROM N7, SHOW VALIDATION MESSAGE,
Please enter a number that does not exceed the number of individuals your organization can
serve.
HARD CHECK: IF N7b GT NUMBER OF INDIVIDUALS FROM N7a, SHOW VALIDATION MESSAGE,
Please enter a number that does not exceed the number of individuals your largest congregate
nutrition site can serve.
HARD CHECK: IF N7b = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t
know cannot be selected if a number is entered.
Prepared by Mathematica Policy Research
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(5/24/12)
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N8.
How many total lunches did your organization serve last week?
NUMBER OF LUNCHES (0-99999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF GT 5000, SHOW VALIDATION MESSAGE, You indicated your organization served
more than 5,000 meals last week. Is this correct?
HARD CHECK: IF N8 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N9.
How many of your agency’s congregate nutrition sites have closed, opened, reduced or
expanded in the last 3 years?
DON’T
KNOW
NUMBER OF SITES
a. Number of sites that have closed
(0-999)
d
b. Number of sites that have reduced service
(fewer days open, fewer meals served)
(0-999)
d
c.
(0-999)
d
(0-999)
d
Number of sites that have opened
d. Number of sites that have expanded service
(more days open, more meals served)
SOFT CHECK: IF any N9 GT 100 SHOW VALIDATION MESSAGE, You have indicated that more
than 100 [sites that have closed, sites that have reduced service, sites that have opened, sites that
have expanded service]. Is this correct?
HARD CHECK: IF N9 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
Prepared by Mathematica Policy Research
52
(5/24/12)
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N10.
Which of the following methods are used for meal production in your congregate nutrition
sites?
YES
NO
DON’T
KNOW
a. Central kitchen
1
0
d
b. On-site production
1
0
d
c. Catering/vendor contract
1
0
d
d. Restaurant vouchers
1
0
d
HARD CHECK: ONE RESPONSE MUST BE SELECTED IN EACH ROW, One response must be
selected in each row.
Prepared by Mathematica Policy Research
53
(5/24/12)
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N11.
Which of the following best describes the menu provided by your congregate nutrition
program?
Set menu that does not offer the participant any choice of food items ... 1
Choice of different complete meal options (ex. Meal A or Meal B) ......... 2
A choice of different food items within the meal (ex. Choice of entrée,
choice of vegetables, fruit, dessert, salad bar) ........................................ 3
Don’t know ............................................................................................... d
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N12.
Are any sites that offer congregate nutrition services operated for specific populations,
religious, cultural or ethnic groups (e.g., Somali, Chinese, Buddhist, or Orthodox Jewish
communities)?
Yes........................................................................................................... 1
No ............................................................................................................ 0
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
54
(5/24/12)
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N13.
Which of the following special or therapeutic diets does your organization offer in the
congregate nutriton program?
Select all that apply
□
□
□
□
□
□
□
□
□
Diabetic ............................................................................................ 1
Low sodium/salt ............................................................................... 2
Modified texture ............................................................................... 3
Vegetarian ........................................................................................ 4
Kosher .............................................................................................. 5
Halal ................................................................................................. 6
Do not offer special or therapeutic diets .......................................... 7
Other (Please Specify) ..................................................................... 8
Don’t know ....................................................................................... d
HARD CHECK: IF N13 = Do not offer special or therapeutic diets AND ANY OTHER ANSWER
CATEGORY IS SELECTED, SHOW VALIDATION MESSAGE, Do not offer special or therapeutic
diets cannot be selected along with other response options.
HARD CHECK: IF N13 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES.
N14.
What is the recommended contribution for congregate nutrition program participants for a
single meal?
RECOMMENDED CONTRIBUTION (0-9.99)
□
□
No dollar amount is recommended .......................................................... 0
Don’t know ............................................................................................... d
SOFT CHECK: IF N14 GT 5.00, SHOW VALIDATION, You indicated the recommended contribution
for congregate nutrition program participants is more than $5 for a single meal. Is that correct?
HARD CHECK: IF N14 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
HARD CHECK: IF N14 = DK AND NUMBER IS ENTERED SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
HARD CHECK: IF N14 = NO DOLLAR AMOUNT IS RECOMMENDED AND NUMBER IS ENTERED
SHOW VALIDATION MESSAGE, No dollar amount is recommended cannot be selected if a number is
entered.
Prepared by Mathematica Policy Research
55
(5/24/12)
REQUIRED
IF G1 OR G1.1 = YES FOR CONGREGATE NUTRITION PROGRAM
N15.
How many people are currently on the waiting list for the congregate nutrition program?
PEOPLE (0-9999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF LT 1, SHOW VALIDATION MESSAGE, You have indicated that there are currently
0 people on the waiting list. Is this correct?
SOFT CHECK: IF GT 1000, SHOW VALIDATION MESSAGE, You have indicated that there are
currently more than 1000 people on the waiting list. Is this correct?
HARD CHECK: IF N15 = DK AND NUMBER IS ENTERED SHOW VALIDATION MESSAGE, Don’t know
cannot be selected along with other response options.
REQUIRED
IF N15 GE 1
N16.
What is the longest time a person has been on the current congregate nutrition program
waiting list in your service area?
DAYS/WEEKS/MONTHS/YEARS [DROP DOWN BOX]
□
Don’t know ............................................................................................... d
SOFT CHECK: IF GT 5 YEARS, SHOW VALIDATION MESSAGE, You have indicated that the longest
time a person has been on the current waiting list is more than 5 years. Is this correct?
HARD CHECK: IF LT 1 DAY OR GT 10 YEARS, SHOW VALIDATION MESSAGE, The length of time
on the waiting list must be between 1 day and 10 years.
HARD CHECK: IF NUMBER FIELD IS FILLED BUT DROP DOWN IS NOT SELECTED, SHOW
VALIDATION MESSAGE, Please select days, weeks, months or years from the drop down menu.
HARD CHECK: IF N16 = DK AND NUMBER IS ENTERED SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
Prepared by Mathematica Policy Research
56
(5/24/12)
REQUIRED
IF G1 OR G1.1 = YES FOR CONGREGATE NUTRITION PROGRAM
N17.
On average, how often is the waiting list for the congregate nutrition program checked for
duplicates and those no longer eligible or in need and then updated?
Weekly ..................................................................................................... 1
Monthly ..................................................................................................... 2
Quarterly .................................................................................................. 3
Semi-annually .......................................................................................... 4
Yearly ....................................................................................................... 5
Never ........................................................................................................ 0
Other (Please Specify) ............................................................................. 6
Don’t know ............................................................................................... d
Prepared by Mathematica Policy Research
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SECTION O. TITLE III-C ELDERLY NUTRITION PROGRAM HOME-DELIVERED NUTRITION
CHARACTERISTICS AND OPERATIONS
The next series of questions are about the characteristics and operations of the home-delivered
nutrition program operated by your organization.
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES. ELSE SKIP TO SECTION P.
O1.
For how many years has your organization offered home-delivered nutrition services?
YEARS (0-99)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF O1 GT 50 SHOW VALIDATION MESSAGE, You indicated your organization has
offered home-delivered nutrition services for more than 50 years. Is that correct?
HARD CHECK: IF O1 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O2.
Which meals does your organization provide in home-delivered nutrition services?
Select all that apply
□
□
□
□
Breakfast .................................................................................................. 1
Lunch ....................................................................................................... 2
Dinner ....................................................................................................... 3
Don’t know ............................................................................................... d
HARD CHECK: IF O2 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
Prepared by Mathematica Policy Research
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(5/24/12)
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O3.
How many clients can your organization provide meals to through home-delivered
nutrition services for a single meal?
MAXIMUM NUMBER OF CLIENTS (0-9999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF O3 GT 1,000 SHOW VALIDATION MESSAGE, You indicated that your organization
can provide meals to more than 1000 clients for a single meal. Is this correct?
HARD CHECK: IF O3 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O3a.
On an average day when your organization makes deliveries, how many clients receive
meals through home-delivered nutrition services for a single meal?
NUMBER OF CLIENTS SERVED ON AN AVERAGE DAY (0-9999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF O3a GT 1,000 SHOW VALIDATION MESSAGE, You indicated that on an average day,
more than 1000 clients receive meals through home-delivered nutrition services for a single meal. Is this
correct?
HARD CHECK: IF O3a GT NUMBER OF INDIVIDUALS FROM O3, SHOW VALIDATION MESSAGE,
Please enter a number that does not exceed the number of individuals your organization can
serve.
HARD CHECK: IF O3a = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t
know cannot be selected if a number is entered.
Prepared by Mathematica Policy Research
59
(5/24/12)
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O4.
How many days per week are meal deliveries made to clients’ homes?
NUMBER OF DAYS PER WEEK (0-7)
□
Don’t know ............................................................................................... d
HARD CHECK: IF O4 GT 7, SHOW VALIDATION MESSAGE, The number of days per week cannot
be greater than seven.
HARD CHECK: IF O4 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O4a.
How many meals are usually provided to a client at each visit?
NUMBER OF MEALS PROVIDED AT ONE VISIT (1-99)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF O4a GT 5 SHOW VALIDATION MESSAGE, You indicated that clients receive more
than 5 meals each visit. Is this correct?
HARD CHECK: IF O4a LT 1 OR GT 10, SHOW VALIDATION MESSAGE, Please enter a number
between 1 and 10.
HARD CHECK: IF O4a = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t
know cannot be selected if a number is entered.
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O4b.
Are meal deliveries made to clients’ homes on the weekends?
Yes..................................................................................................... 1
No ...................................................................................................... 0
Don’t know ......................................................................................... d
Prepared by Mathematica Policy Research
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REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O5.
How many of the following types of meals were delivered in your most recently completed
week in the home-delivered nutrition program?
NUMBER OF MEALS
DON’T KNOW
a. Hot meals
(0-9999)
d
b. Frozen meals
(0-9999)
d
c.
(0-9999)
d
d. Shelf stable meals
(0-9999)
d
e. Combination
(0-9999)
d
(0-9999)
d
f.
Cold meals
Other (Please Specify)
SOFT CHECK: IF any O5 GT 1000 SHOW VALIDATION MESSAGE, You have entered more than 1000
[hot meals, frozen meals, cold meals, shelf stable meals, combination, other meals]. Is this correct?
HARD CHECK: IF O5a-f = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t
know cannot be selected if a number is entered.
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O6.
What is the total mileage on the longest route for which your organization provides homedelivered nutrition services?
MILES (0-999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF O6 GT 300, SHOW VALIDATION MESSAGE, You indicated your longest route is
over 300 miles. Is this correct?
HARD CHECK: IF O6 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
Prepared by Mathematica Policy Research
61
(5/24/12)
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O6a.
What is the total mileage on the shortest route for which your organization provides homedelivered nutrition services?
MILES (0-999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF O6a GT 100, SHOW VALIDATION MESSAGE, You indicated your shortest route is
over 100 miles. Is this correct?
HARD CHECK: IF O6a = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t
know cannot be selected if a number is entered.
HARD CHECK: IF O6a GT MILES FROM O6 AND O6 DNE DON’T KNOW, Please enter a number that
does not exceed the total mileage on the longest route.
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O7.
Have you increased or started using frozen meals in your home-delivered nutrition
program in the past 3 years?
Yes..................................................................................................... 1
No ...................................................................................................... 0
Don’t know ......................................................................................... d
Prepared by Mathematica Policy Research
62
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REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O8.
Which of the following changes has your agency’s home-delivered nutrition program
experienced in the past 3 years?
Select all that apply
□
□
□
□
□
□
□
□
Service area has been reduced ........................................................ 1
Frequency of meal delivery has been reduced ................................. 2
Number of meals delivered per customer has been reduced ........... 3
Service area has been expanded ...................................................... 4
Frequency of meal delivery has been increased ............................... 5
Number of meals served per customer has been increased ............. 6
None of the above ............................................................................. 0
Don’t know ......................................................................................... d
HARD CHECK: IF O8 = NONE OF THE ABOVE AND ANY OTHER CATEGORY IS SELECTED, SHOW
VALIDATION MESSAGE, None of the above cannot be selected along with other response options.
HARD CHECK: IF O8 = DK AND ANY OTHER CATEGORY IS SELECTED, SHOW VALIDATION
MESSAGE, Don’t know cannot be selected along with other response options.
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O9.
Which of the following methods are used for meal production in your home-delivered
nutrition program?
YES
NO
DON’T KNOW
a. Central kitchen
1
0
d
b. On-site production (e.g., CM site)
1
0
d
c. Catering/vendor contract including restaurants
1
0
d
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HARD CHECK: ONE RESPONSE MUST BE SELECTED IN EACH ROW, One response must be
selected in each row.
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O10.
Which of the following best describes the menu provided by your home-delivered nutrition
program?
Set menu that does not offer the participant any choice of food items ...................1
Choice of different complete meal options (ex. Meal A or Meal B) .........................2
A choice of different food items within the meal (ex. Choice of entrée, choice
of vegetables, fruit, dessert) ....................................................................................3
Don’t know ..............................................................................................................d
REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O11.
Which of the following special or therapeutic diets does your organization offer in the
home-delivered nutriton program?
Select all that apply
□
□
□
□
□
□
□
□
□
Diabetic ...................................................................................................................1
Low sodium/salt ......................................................................................................2
Modified texture.......................................................................................................3
Vegetarian ...............................................................................................................4
Kosher .....................................................................................................................5
Halal ........................................................................................................................6
Other (Please Specify) ............................................................................................7
Do not offer special or therapeutic diets .................................................................0
Don’t know ..............................................................................................................d
HARD CHECK: IF O11 = DO NOT OFFER SPECIAL OR THERAPEUTIC DIETS and any other answer
category is selected, Do not offer special or therapeutic diets cannot be selected along with other
response options.
HARD CHECK: IF O11 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
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REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES.
O12.
What is the recommended contribution for home-delivered nutrition program participants?
□
□
RECOMMENDED CONTRIBUTION (0-9.99)
No dollar amount is recommended .......................................................... 0
Don’t know ............................................................................................... d
SOFT CHECK: IF O12 GT 5.00, SHOW VALIDATION, You indicated the recommended contribution
is greater than $5.00. Is that correct?
HARD CHECK: IF O12 = DON’T KNOW and any other answer category is selected, Don’t know cannot
be selected along with other response options.
HARD CHECK: IF O12 = DK AND NUMBER IS ENTERED SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
HARD CHECK: IF O12 = NO DOLLAR AMOUNT IS RECOMMENDED AND NUMBER IS ENTERED
SHOW VALIDATION MESSAGE, No dollar amount is recommended cannot be selected if a number is
entered.
REQUIRED
IF G1 OR G1.2 = YES FOR HOME-DELIVERED NUTRITION PROGRAM
O13.
How many people are currently on the waiting list for the home-delivered nutrition
program in your service area?
PEOPLE (0-9999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF LT 1, SHOW VALIDATION MESSAGE, You have indicated that there are currently
0 people on the waiting list. Is this correct?
SOFT CHECK: IF GT 1000, SHOW VALIDATION MESSAGE, You have indicated that there are
currently more than 1000 people on the waiting list. Is this correct?
HARD CHECK: IF O13 = DK AND NUMBER IS ENTERED SHOW VALIDATION MESSAGE, Don’t
know cannot be selected if a number is entered.
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REQUIRED
IF O13 GE 1.
O14.
What is the longest time a person has been on the current home-delivered nutrition
program waiting list in your service area?
DAYS/WEEKS/MONTHS/YEARS [DROP DOWN BOX]
□
Don’t know ............................................................................................... d
SOFT CHECK: IF GT 5 YEARS, SHOW VALIDATION MESSAGE, You have indicated that the longest
time a person has been on the current waiting list is more than 5 years. Is this correct?
HARD CHECK: IF LT 1 DAY OR GT 10 YEARS, SHOW VALIDATION MESSAGE, The length of time
on the waiting list must be between 1 day and 10 years.
HARD CHECK: IF NUMBER FIELD IS FILLED BUT DROP DOWN IS NOT SELECTED, SHOW
VALIDATION MESSAGE, Please select days, weeks, months or years from the drop down menu.
HARD CHECK: IF O14 = DK AND NUMBER IS ENTERED SHOW VALIDATION MESSAGE, Don’t
know cannot be selected if a number is entered.
REQUIRED
IF G1 OR G1.2 = YES FOR HOME-DELIVERED NUTRITION PROGRAM
O15.
On average, how often is the waiting list for the home-delivered nutrition program checked
for duplicates and those no longer eligible or in need and then updated?
Weekly ..................................................................................................... 1
Monthly ..................................................................................................... 2
Quarterly .................................................................................................. 3
Semi-annually .......................................................................................... 4
Yearly ....................................................................................................... 5
Never ........................................................................................................ 0
Other (Please Specify) ............................................................................. 6
Don’t know ............................................................................................... d
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SECTION P. FOOD SAFETY
REQUIRED
ALL
P1.
Does your organization or caterer currently have a food service license for its production
facilities?
Yes ..................................................................................................... 1
No ...................................................................................................... 0
Don’t know ......................................................................................... d
REQUIRED
ALL
P2.
Are the food service personnel for the Elderly Nutrition Program in your service area
currently required to have food safety and sanitation training?
Yes..................................................................................................... 1
No ...................................................................................................... 0
Don’t know ......................................................................................... d
REQUIRED
ALL
P3.
To which of the following entities is your organization currently required to report food
borne illness incidents in the Elderly Nutrition Program?
Select all that apply
□
□
□
□
□
□
AAA.................................................................................................... 1
State Unit on Aging ............................................................................ 2
State or Local Department of Health ................................................. 3
Other .................................................................................................. 4
No requirement to report food borne illness ...................................... 0
Don’t know ......................................................................................... d
HARD CHECK: IF P3 = No requirement to report food borne illness AND ANY OTHER CATEGORY IS
SELECTED, SHOW VALIDATION MESSAGE, No requirement to report food borne illness cannot be
selected along with other response options.
HARD CHECK: IF P3 = DK AND ANY OTHER CATEGORY IS SELECTED, SHOW VALIDATION
MESSAGE, Don’t know cannot be selected along with other response options.
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REQUIRED
IF A1 INCLUDES CONGREGATE NUTRITION SERVICES. ELSE SKIP TO P6.
P4.
In the past 3 years, how many different times was the food served in the congregate
nutrition program associated with an outbreak of food borne illness?
TIMES (0-99)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF GT 10, SHOW VALIDATION MESSAGE, You have indicated that food served in the
congregate nutrition program was associated with an outbreak of food borne illness more than
10 times in the past 3 years. Is this correct?
HARD CHECK: IF P4 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
REQUIRED
IF P4 GT 0
P5.
In total, how many congregate nutrition program participants got sick in the past 3 years?
CONGREGATE NUTRITION PROGRAM PARTICIPANTS (0-9999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF GT 100, SHOW VALIDATION MESSAGE, You have indicated that more than 100
congregate nutrition program participants got sick in the past 3 years. Is this correct?
HARD CHECK: IF P4 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
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REQUIRED
IF A1 INCLUDES HOME-DELIVERED NUTRITION SERVICES. ELSE SKIP TO Q1.
P6.
In the past 3 years, how many different times was food served in the home-delivered
nutrition program associated with an outbreak of food borne illness?
TIMES (0-99)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF GT 10, SHOW VALIDATION MESSAGE, You have indicated that food served in the
home-delivered nutrition program was associated with an outbreak of food borne illness more
than 10 times in the past 3 years. Is this correct?
HARD CHECK: IF P6 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
REQUIRED
IF P6 GT 0
P7.
In total, how many home-delivered nutrition program participants got sick in the past
3 years?
HOME-DELIVERED NUTRITION PROGRAM
PARTICIPANTS (0-9999)
□
Don’t know ............................................................................................... d
SOFT CHECK: IF GT 100, SHOW VALIDATION MESSAGE, You have indicated that more than 100
home-delivered nutrition program participants got sick in the past 3 years. Is this correct?
HARD CHECK: IF P7 = DK AND NUMBER IS ENTERED, SHOW VALIDATION MESSAGE, Don’t know
cannot be selected if a number is entered.
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SECTION Q. CONTACT INFORMATION
Q1.
Please provide contact information for the person who completed this questionnaire.
REQUIRED
ALL
Contact First Name
Contact Last Name
Title or Role in local service provider
organization
Email Address
Telephone Number
HARD CHECK: IF TELEPHONE IS LT OR GT 10 DIGITS, SHOW VALIDATION, Please enter a valid
telephone number.
THANK YOU FOR COMPLETING THIS SURVEY. WE VALUE YOUR PARTICIPATION.
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| File Type | application/pdf |
| Author | BCollette |
| File Modified | 2012-09-27 |
| File Created | 2012-09-25 |