Section IS [INTERVIEW SETUP] Sequence: 1

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1 NHATS Round 5 Section IS [INTERVIEW SETUP] Sequence: IS IS NOT ON FILE Display Instructions: If New SAMPLE flag= (YES), display REMINDER FOR THIS NEW SAMPLE CASE: OBTAIN SIGNED CONSENT FROM THE SP OR PROXY BEFORE CONTINUING WITH THE INTERVIEW in underlined red. YOU HAVE SELECTED CASE {CASE ID} FOR {SP}. IF THIS IS CORRECT, PRESS AND ENTER TO CONTINUE TO SELECT ANOTHER CASE, BREAKOFF AND SELECT THE CORRECT CASE ID FROM THE IMS. {REMINDER FOR THIS NEW SAMPLE CASE: OBTAIN SIGNED CONSENT FROM THE SP OR PROXY BEFORE CONTINUING WITH THE INTERVIEW} IS is5resptype op5proxy R5 IS TYPE OF RESPONDENT R5 IS PROXY SELECT TYPE OF RESPONDENT SAMPLE PERSON (SP) PROXY BOX ISC If IS= (PROXY), SET PROXY flag = (YES) AND DISPLAY APPROPRIATE PROXY DISPLAYS FOR ALL QUESTIONNAIRE ITEMS. ISA is5reasnprx is5reasnprx is5reasnprx3 is5reasnprx4 is5reasnprx5 is5reasnprx6 is5reasnprx7 is5reasnprx9 R5 ISA PROXY REAS SP DEMENTIA R5 ISA PROXY REAS SP ILL R5 ISA PRXY REAS SP SPCH IMPAIR R5 ISA PRXY REAS SP HEAR IMPAIR R5 ISA PROXY REAS LANG BARRIER R5 ISA PROXY REAS TEMP UNAVAIL R5 ISA PROXY REAS DECEASED R5 ISA PROXY REAS OTHER Page of

2 SPECIFY REASON FOR PROXY SELECT ALL THAT APPLY DEMENTIA/COGNITIVE/MENTAL IMPAIRMENT REPORTED BY PROXY SP TOO ILL/MAJOR PHYSICAL HELATH ISSUES SP SPEECH IMPAIRED SP HEARING IMPAIRED LANGUAGE BARRIER SP TEMPORARILY UNAVAILABLE SP DECEASED OTHER (SPECIFY) BOX ISC BOX ISC BOX ISC BOX ISC BOX ISC ISBC BOX ISC Allow select all that apply. If ISA = 7 (DECEASED), display soft error message "YOU HAVE SELECTED SP DECEASED. IF SP IS STILL LIVING, SELECT A DIFFERENT OPTION. IF SP IS DECEASED, SELECT SUPPRESS TO CONFIRM.". If ISA = 7 (DECEASED) AND -6 OR 9, display error message "INCONSISTENT ANSWER. SP DECEASED CANNOT BE SELECTED WITH OTHER PROXY REASONS.". If ISA = 7 (DECEASED), set DECEASED flag = (YES). ISB ISB NOT ON FILE SPECIFY REASON FOR PROXY Length 50 PROGRAMMER INSTRUCTIONS If ISA = 6 (SP UNAVAILABLE), go to ISB. Otherwise, go to BOX ISC ISB is5tempres R5 ISB TEMPORARY RESIDENCE SPECIFY WHERE SP IS TEMPORARILY RESIDING IF NEEDED, ASK: Where is {SP} currently residing or staying? 9 HOSPITAL NURSING HOME/REHAB CENER OTHER (SPECIFY) BOX ISC BOX ISC BOX ISC BOX ISC Page of

3 ISB3 ISB3 NOT ON FILE SPECIFY OTHER PLACE SP IS TEMPORARILY RESIDING. Length 50 BOX ISC BOX ISC NOT ON FILE IF CASE IS A RESTART (CAPI STATUS CODE ) AND IS= (SP) AND (SP AUDIO ASSENT= (YES) OR SP AUDIO ASSENT= (NO)), GO TO IS3. ELSE IF CASE IS A RESTART (CAPI STATUS CODE ) AND IS= (PROXY) AND (PROXY AUDIO ASSENT= (YES) OR PROXY AUDIO ASSENT= (NO)), GO TO IS3. ELSE GO TO ISC. ISC ISC NOT ON FILE DO NOT DISPLAY RESPONSE AND LABELS During the course of the study, we would like to record some of the questions and answers for training and data quality. I'd like to continue now, unless you have any questions. PRESS AND ENTER TO CONTINUE IF RESPONDENT REFUSES TO ALLOW AUDIO RECORDING, PRESS 7 AND ENTER 7 CONSENT TO RECORDING REFUSE CONSENT TO RECORD IS3 ISD IF ISc= (OK TO RECORD), SET AUDIORECORDING FLAG= (YES). IF RESPONDENT TYPE AT IS= (SP), SET SPAUDIOASSENT FLAG= (YES). IF RESPONDENT TYPE AT IS= (PROXY), SET PROXYAUDIOASSENT FLAG= (YES). ELSE IF ISc=7 ( TO RECORD), SET AUDIORECORDING FLAG = (NO). IF RESPONDENT TYPE AT IS= (SP), SET SPAUDIOASSENT FLAG = (NO). IF RESPONDENT TYPE AT IS= (PROXY), SET PROXYAUDIOASSENT= (NO). DO NOT DISPLAY THIS SCREEN ON BACK UP OR RESTARTS (CASE STATUS = (STARTED) UNLESS RESPONDENT TYPE IS CHANGED AT IS ON RESTART (CASE STATUS = (STARTED). ISD ISD NOT ON FILE That s fine. The interview will not be recorded. PRESS AND ENTER TO CONTINUE Page 3 of

4 IS3 IS3 NOT ON FILE If ISA=7 (SP DECEASED), display "was". Otherwise, display "is". Before we start, I just want to confirm that {your/sp s} name {is/was} {SP S FIRST NAME} {SP S MIDDLE NAME} {SP S LAST NAME}. Is that correct? SPELL OUT SP S NAME. CONFIRM SPELLING. YES NO BOX IS4 If Breakoff at or before this screen, do not save any data and set case status = (READY). IS3A IS3A NOT ON FILE Display preloaded SP name in the response fields. Display "FIRST" in bold underlined text. Display SP first name in fill as bold underlined. If ISA=7 (SP DECEASED), display "was". Otherwise, display "is". What {is/was} the correct spelling of {your/sp s} full name? {FIRST NAME} {MIDDLE NAME} {LAST NAME} CORRECT FIRST NAME. CONFIRM SPELLING Length 45 Display IS3a, 3b, and 3c on the same screen. IS3B IS3B NOT ON FILE Display "MIDDLE" in bold underlined text. Display SP middle name in fill as bold underlined. If ISA=7 (SP DECEASED), display "was". Otherwise, display "is". What {is/was} the correct spelling of {your/sp s} full name? {FIRST NAME} {MIDDLE NAME} {LAST NAME} CORRECT MIDDLE NAME. CONFIRM SPELLING PRESS ENTER IF NO MIDDLE NAME OR INITIAL Page 4 of

5 Length 5 Display IS3a, 3b, and 3c on the same screen. Allow empty. IS3C IS3C NOT ON FILE Display "LAST" in bold underlined text. Display SP last name in fill as bold underlined. If ISA=7 (SP DECEASED), display "was". Otherwise, display "is". What {is/was} the correct spelling of {your/sp s} full name? {FIRST NAME} {MIDDLE NAME} {LAST NAME} CORRECT LAST NAME. CONFIRM SPELLING Length 5 BOX IS4 BOXIS4 NOT ON FILE If NEWSAMPLE flag = (YES), go to IS4. Otherwise, go to BOX IS8. IS4 r5dgender R5 D GENDER OF SP THE SP IS LISTED AS A {MALE/FEMALE} IF GENDER IS OBVIOUS, CODE WITHOUT ASKING CODE OTHERWISE ASK: {Are you/is SP} male or female? MALE FEMALE BOX IS4A BOXIS4A NOT ON FILE Compare preloaded gender of SP with IS4 value just entered. If they are the same, go to IS6. Otherwise, go to IS4a Page 5 of

6 IS4A IS4A NOT ON FILE YOU JUST CHANGED SP S GENDER FROM {PRELOADED GENDER MALE/FEMALE} TO {FEMALE/MALE FROM IS4}. DID YOU INTEND TO DO THAT? CODE YES NO IS4 If IS4A= (NO), display hard error message SELECT "GO TO" TO RETURN TO IS4 AND RE-ENTER RESPONSE. IS6 r5dbirthmth (Sensitive) r5dbirthyr (Sensitive R5 D BIRTH MONTH OF SP R5 D BIRTH YEAR OF SP Display preloaded DOB from CMS in the response field. What is {your/sp s} date of birth? ENTER MONTH, DAY, AND YEAR (MM-DD-YYYY) Use mask to collect DOB. Separate mm/dd/yyyy with hyphens for data entry. MONTH range: - DAY range: -3 YEAR range: (CURRENT YEAR-65) - (CURRENT YEAR-0) IS7 r5dintvwrage (Sensitive) r5dintvrage R5 D AGE OF SP AT INTERVIEW R5 D SP CAT AGE AT INTVW COMPUTE AGE AS (CURRENT DATE IS6 DOB). That makes {you/sp} {CALCULATED AGE} today. Is that correct? YES NO If IS7= (NO), display hard error message SELECT "GO TO" TO RETURN TO IS4 AND RE-ENTER RESPONSE. BOX IS8 BOX IS8 NOT ON FILE IS6 Write SP name (preloaded or if corrected at IS3a-c) to the PERSON ROSTER. If NEW SAMPLE flag =, write SP DOB (from IS6) and calculated age from IS7 and SP gender (from IS4) to the PERSON ROSTER and set relationship to SP = (SAMPLE PERSON). Page 6 of

7 If NEW SAMPLE flag = (YES) and IS= (PROXY), go to IS8A. Else, if IS= (PROXY), go to IS8. Otherwise, go to Section RE - Residence. IS8 IS8 NOT ON FILE Display PERSON ROSTER with FIRST NAME, LAST NAME, and RELATIONSHIP TO SP. Display NOT ON LIST as first roster option. What is your name? CHOOSE PERSON FROM LIST. If existing ROSTER MEMBER selected, set PROXY RESP CURRENT INT FLAG = for ROSTER MEMBER and go to IS. Otherwise, go to IS8A. IS8A IS8A NOT ON FILE Display "first" in bold underlined text. What is your full name? ENTER FIRST NAME. CONFIRM SPELLING Length 45 Display IS8A, IS8B, and IS8C on the same screen. Write ROSTER MEMBER to next open position on PERSON ROSTER. Set PROXY RESP CURRENT INT FLAG = for ROSTER MEMBER. IS8B IS8B NOT ON FILE Display "middle" in bold underlined text. ENTER MIDDLE NAME. CONFIRM SPELLING. PRESS ENTER IF NO MIDDLE NAME OR INITIAL. Length 5 Display IS8A, IS8B, and IS8C on the same screen. Allow empty. Page 7 of

8 IS8C IS8C NOT ON FILE Display "last" in bold underlined text. ENTER LAST NAME. CONFIRM SPELLING Length 5 Display IS8A, IS8B, and IS8C on the same screen. IS9 is5prxyrelat op5relatnshp Display PROXY RELATIONSHIP CODE LIST. R5 PROXY RELATIONSHIP TO SP R5 RELASHIP TO SP UPDATE AND NEW How are you related to {SP}? IF NEEDED: Are you {his/her}..? CODE RELATIONSHIP OF PROXY TO SP PRESS F FOR HELP SCREEN SPOUSE/PARTNER DAUGHTER SON DAUGHTER-IN-LAW SON-IN-LAW STEPDAUGHTER STEPSON SISTER BROTHER SISTER-IN-LAW BROTHER-IN-LAW MOTHER STEPMOTHER MOTHER-IN-LAW FATHER STEPFATHER FATHER-IN-LAW GRANDDAUGHTER GRANDSON NIECE NEPHEW AUNT UNCLE COUSIN STEPDAUGHTER S SON/DAUGHTER STEPSON S SON/DAUGHTER Page 8 of

9 DAUGHTER-IN-LAW S SON/DAUGHTER SON-IN-LAW S SON/DAUGHTER BOARDER/RENTER PAID AIDE/HOUSEKEEPER/EMPLOYEE ROOMMATE EX-WIFE/EX-HUSBAND BOYFRIEND/GIRLFRIEND NEIGHBOR FRIEND SOMEONE/SERVICE AT THE PLACE SP LIVES/LIVED OTHER RELATIVE OTHER NONRELATIVE If NEW SAMPLE flag <> (YES) and code = (SPOUSE/PARTNER), 3 (DAUGHTER), 4 (SON), 7 (STEPDAUGHTER), OR 8 (STEPSON) selected for new addition to the roster, display soft error message, "UNLIKELY RESPONSE. REVIEW NAMES AND RELATIONSHIPS ON ROSTER AT IS8 TO MAKE SURE PERSON DOESN'T ALREADY EXIST ON THE ROSTER." If IS9 = (SPOUSE/PARTNER), set SPOUSE/PARTNER flag = (YES) for ROSTER MEMBER ADDED AT IS9, and for ROSTER MEMBER that had LAST INT RELATIONSHIP CODE= (SPOUSE/PARTNER), set CURRENT INT RELATIONSHIP CODE = 33 (EX-SPOUSE/PARTNER). If 3 (daughter), 5 (daughter-in-law), 7 (stepdaughter), 9 (sister), (sister-in-law), 3 (mother), 4 (stepmother), 5 (mother-in-law), 9 (granddaughter), (niece), or 3 (aunt) selected, set IS0= (female) and go to BOX IS. ELSE If 4 (son), 6(son-in-law), 8 (stepson), 0 (brother), (brother-in-law), 6 (father), 7 (stepfather), 8 (father-in-law), 0 (grandson), (nephew), or 4 (uncle) selected, set IS0 = (male) and go to BOX IS. If IS9 = 9 or 9, go to IS9a. Otherwise, GO TO IS0. IS9A IS9A NOT ON FILE SPECIFY RELATIONSHIP OF PROXY TO {SP} IS0 Length 50 is5prxygender R5 IS0 PROXY GENDER op5dgender R5 D GENDER UPDATE AND NEW CODE GENDER OF PROXY IF GENDER IS OBVIOUS, CODE WITHOUT ASKING OTHERWISE ASK: Are you male or female? MALE FEMALE Page 9 of

10 BOX IS BOX IS NOT ON FILE Write PROXY relationship and gender to PERSON ROSTER. IS is5famrrutin R5 IS FAMILRTY SP DAILY ROUTIN If ISA=7 (SP DECEASED), display "were" and "in the last month of {his/her} life" and "Were" Otherwise, display "are" and "Are". How familiar {are/were} you with {SP} s daily routine {in the last month of {his/her} life}? {Are/Were} you very familiar, somewhat familiar, a little familiar, or not at all familiar? 3 4 VERY FAMILIAR SOMEWHAT FAMILIAR A LITTLE FAMILIAR NOT AT ALL FAMILIAR BOX ISA BOX ISA NOT ON FILE If ISA=7 (DECEASED), go to BOX ISA. Else if IS = (PROXY) and PROXY PERSON S relationship to SP = 35 or 37-40, go to BOX ISA. Otherwise, go to ISA. ISA is5proxlivsp op5prsninhh R5 ISA PROXY LIVES W SP R5 OP IN HOUSEHOLD UPDATE AND NEW Do you live here with {SP}? YES NO If ISA = (YES), set INHOUSEHOLD flag = (YES) for PROXY PERSON. BOX ISA BOX ISA NOT ON FILE If DOB MONTH, DOB DAY, or DOB YEAR is missing for ROSTER MEMBER with PROXY RESP CURRENT INT flag = (YES), go to ISa. Otherwise, go to Section RE Residence. Page 0 of

11 ISA op5birthmth (Sensitive) R5 OTHER PERSON MONTH OF BIRTH Display MONTH in underline text. What is your date of birth? ENTER MONTH ENTER NUMBER Range Soft Range to to Display ISA, ISB, and ISc on the same screen. ISB ISB NOT ON FILE Display DAY in underline text. [What is your date of birth?] ENTER DAY ENTER NUMBER Range Soft Range Display ISA, ISB, and ISc on the same screen. to 3 to 3 ISC op5birthyear(sensitive) R5 OTHER PERSON YEAR OF BIRTH Display YEAR in underline text. [What is your date of birth?] ENTER YEAR ENTER NUMBER Display ISA, ISB, and ISC on the same screen. Hard range: CURRENT YEAR - 0. Soft range: (CURRENT YEAR - 0) - (CURRENT YEAR - 75). If ISC violates hard range, display error message "YEAR OF BIRTH OUTSIDE OF RANGE. VERIFY WITH RESPONDENT AND RE-ENTER." Write birth month, day, and year from ISa, b, and c to the PERSON ROSTER for roster member. If ISA and ISB and ISC <> RF or DK, compute PERSON AGE as (CURRENT DATE - ISa-c DOB) and prefill IS3. Otherwise, go to IS4. Page of

12 IS3 op5age (Sensitive) op5dage For CALCULATED AGE, display age computed at IS. That makes you {CALCULATED AGE} today. Is that correct? R5 OTH PERSON AGE UPDATE AND NEW R5 D OP CAT AGE UPDATE AND NEW YES NO Section RE ISA Section RE Section RE If IS3 = (YES), write PERSON AGE to PERSON ROSTER. If IS3 = (NO), display error message, PLEASE ENTER THE CORRECT DATE. IS4 op5age (Sensitive) op5dage R5 OTH PERSON AGE UPDATE AND NEW R5 D OP CAT AGE UPDATE AND NEW How old are you? ENTER AGE ENTER NUMBER Range 8 to 0 DON'T KNOW Hard range: 8-0. If IS4 violates hard range, display error message "AGE OUTSIDE OF RANGE. VERIFY WITH RESPONDENT AND RE-ENTER." Write PERSON AGE to PERSON ROSTER. Go to Section RE Residence. Derived Variables From Items in IS Section R5 D SP CAT AGE AT INTVW r5dintvrage R5 D AGE OF SP AT INTERVIEW r5dintvwrage (Sensitive) is5dproxyid R5 D PROXY OPID op5dage R5 D OP CAT AGE UPDATE AND NEW op5dgender R5 D GENDER UPDATE AND NEW Page of

Section RE [RESIDENCE] Sequence: 2

NHATS Round 5 Section RE [RESIDENCE] Sequence: RE3 RE3 NOT ON FILE If ISA=7 (SP DECEASED), display at the time {he/she} died and lived. Otherwise, display lives. Display updated IMS Address, Address, City,