ICPSR 4248 ACTIVE (Advanced Cognitive

Training for Independent and Vital

Elderly), 1999-2001 [United States]

Sharon Tennstedt
New England Research Institutes

John Morris
Hebrew Senior Life-Boston

Frederick Unverzagt
Indiana University

George Rebok
Johns Hopkins University

Sherry Willis
Pennsylvania State University

Karlene Ball
University of Alabama-Birmingham

Michael Marsiske
University of Florida

Form 2 Screener Codebook

Inter-university Consortium for

Political and Social Research
P.O. Box 1248
Ann Arbor, Michigan 48106
www.icpsr.umich.edu
 Terms of Use
The terms of use for this study can be found at:
http://www.icpsr.umich.edu/cocoon/ICPSR/TERMS/4248.xml
 Telephone Screener
Form #2

A1. Study ID#: Label

A2. Visit #: T0

VISIT Frequency Percent Cum Freq Cum Percent

T0 2802 100.00 2802 100.00

A3. Form Version: 1 2/ 1 7 / 1 9 9 8

TELEPHONE INTRODUCTORY SCRIPT:

Hello, may I speak with (NAME)? WAIT TO SPEAK WITH SUBJECT.

My name is (TESTER) and Im calling for the ACTIVE Study at (SITE). We recently sent you a
letter about this program to help older persons to improve their abilities to concentrate, remember
and solve problems. Do you recall receiving this letter?

IF SUBJECT RECALLS LETTER: IF SUBJECT DOES NOT RECALL LETTER:

Do you have any questions?
The purpose of this program is to see if improving the
abilities of older persons to concentrate, remember and solve
problems helps them to more easily manage daily living
tasks such as managing money, preparing meals and driving.
The program is funded by the National Institutes of Health
(National Institute on Aging/National Institute of Nursing
Research) and is being offered to persons in your (town/
building/area/ community). Do you have any questions?

IF SUBJECT HAS QUESTIONS, ANSWER APPROPRIATELY AND STATE:

I am calling today to see if you are eligible for this program. I would like to ask you a few
questions which will take about 10-20 minutes. Is this a good time to talk with me?

IF YES: BEGIN TELEPHONE SCREENER.

IF NO: GET CALL BACK TIME AND STATE: Thank you. A member of our staff will
call you then.

THE FOLLOWING CONSENT/CONFIDENTIALITY STATEMENT MUST BE READ TO

ALL SUBJECTS AND INITIALED.

Before we begin, Id like to mention a few things. All of your responses are completely
confidential, and will only be seen or heard by people directly associated with the study. No
information about any specific individual will ever be reported. Your name will never appear in
any report about this study. You may refuse to answer any questions at any time. Do you have
any questions before we begin?

I HAVE READ THIS STATEMENT TO THE SUBJECT.

SIGNATURE/INITIALS OF INTERVIEWER: ________________________________________

PRINT NAME:___________________________________________ DATE:___________________

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 2

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SECTION B: SOCIODEMOGRAPHICS AND HEALTH

First, I would like to confirm some information about you.

B1. Is your name (FULL NAME)?

YES....1 NO....2 (UPDATE CONTACT RECORD)

CONFULLN Frequency Percent Cum Freq Cum Percent

-9 2 0.07 2 0.07
1 2646 94.43 2648 94.50
2 154 5.50 2802 100.00

ASK B2 (GENDER) ONLY IF NOT KNOWN OR UNABLE TO DETERMINE.

OTHERWISE, CODE B2 AND NOW ASK PREFERRED TITLE QUESTION.

B2. Are you male or female?

MALE ...........................1 [Is that Mr., Dr., Rev., or other?]

RECORD PREFERRED TITLE ON THE CONTACT
RECORD.

FEMALE.......................2 [Is that Mrs., Miss, Ms., Dr., Rev., or other?]

RECORD PREFERRED TITLE ON THE CONTACT
RECORD.

GENDER Frequency Percent Cum Freq Cum Percent

1 676 24.13 676 24.13
2 2126 75.87 2802 100.00

B3. Is your address (FULL ADDRESS)?

YES....1 NO....2 (UPDATE CONTACT RECORD)

CONFULLA Frequency Percent Cum Freq Cum Percent

1 2656 94.79 2656 94.79
2 146 5.21 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 3

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B4a. IS SUBJECTS AGE WITHIN 6 WEEKS OF 65th BIRTHDAY OR OLDER TODAY?
(USE AGE ELIGIBILITY TABLE)

YES ..............................................................1

NO................................................................2 = INELIGIBLE: READ

SCRIPT BELOW AND END
INTERVIEW.

AGEELIG Frequency Percent Cum Freq Cum Percent

1 2802 100.00 2802 100.00

AGE INELIGIBILITY CLOSE-OUT SCRIPT:

These are the only questions I need to ask. This research study is designed for people
who are age 65 or older. I would like to thank you for the time you have taken to speak
with me. We will not need to contact you again. Thank you.

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 4

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B5. What is your marital status?
[READ RESPONSE CATEGORIES IF UNABLE TO ANSWER]

MARRIED, ..................................................1

LIVING AS MARRIED, .............................2

SEPARATED, .............................................3

DIVORCED,................................................4

WIDOWED, OR ..........................................5

SINGLE, NEVER MARRIED?...................6

MARSTAT Frequency Percent Cum Freq Cum Percent

-9 2 0.07 2 0.07
1 1007 35.94 1009 36.01
3 42 1.50 1051 37.51
4 398 14.20 1449 51.71
5 1170 41.76 2619 93.47
6 183 6.53 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 5

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B6. What is the highest grade of school or level of education that you completed?
[CODE ONLY ONE RESPONSE]

DID NOT GO TO SCHOOL 00 VOCATIONAL / TRAINING /

SOME COLLEGE
GRADE 1 01 AFTER HS GRAD 13
GRADE 2 02
GRADE 3 03 ASSOCIATE DEGREE 14
GRADE 4 04
GRADE 5 05 COLLEGE GRAD/BA - BS 16
GRADE 6 06
GRADE 7 07 SOME PROFESSIONAL SCHOOL
GRADE 8 08 AFTER COLLEGE GRAD 17
GRADE 9 09
GRADE 10 10 MASTERS DEGREE 18
GRADE 11 11
GRADE 12 \ GED 12 DOCTORAL DEGREE (PhD, MD,
DVM, DDS, JD, etc.) 20

EDUCLEVL Frequency Percent Cum Freq Cum Percent

-8 1 0.04 1 0.04
-9 1 0.04 2 0.07
04 1 0.04 3 0.11
05 3 0.11 6 0.21
06 17 0.61 23 0.82
07 14 0.50 37 1.32
08 52 1.86 89 3.18
09 55 1.96 144 5.14
10 84 3.00 228 8.14
11 94 3.35 322 11.49
12 797 28.44 1119 39.94
13 786 28.05 1905 67.99
14 120 4.28 2025 72.27
16 318 11.35 2343 83.62
17 97 3.46 2440 87.08
18 281 10.03 2721 97.11
20 81 2.89 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 6

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B7. What race do you consider yourself? (PROBE: White, Black/African American, Asian,
Native Hawaiian/Pacific Islander, American Indian/Alaskan Native, or another race?)

WHITE/CAUCASIAN ............................................1

BLACK/AFRICAN AMERICAN ...........................2

ASIAN .....................................................................3

NATIVE HAWAIIAN/PACIFIC ISLANDER........4

AMERICAN INDIAN/ALASKAN NATIVE.........5

BIRACIAL...............................................................6

OTHER ....................................................................7

DONT KNOW....................................................... 8

RACE Frequency Percent Cum Freq Cum Percent

1 2028 72.38 2028 72.38
2 728 25.98 2756 98.36
3 7 0.25 2763 98.61
5 4 0.14 2767 98.75
6 9 0.32 2776 99.07
7 26 0.93 2802 100.00

IF SUBJECT IS UNABLE TO ANSWER B7, PROBE: Which race do you most identify with or
consider yourself to be?

B7a. Are you Hispanic or Latino?

YES..........1 NO..........2

HISPANIC Frequency Percent Cum Freq Cum Percent

-9 2 0.07 2 0.07
-8 1 0.04 3 0.11
1 15 0.54 18 0.64
2 2784 99.36 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 7

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B8. The next questions are about your vision. Do you wear glasses or contact lenses to read?

YES..........1 (B8a) NO..........2 (B8b)

GLASES Frequency Percent Cum Freq Cum Percent

1 2637 94.11 2637 94.11
2 165 5.89 2802 100.00

B8a. How much difficulty do you have reading ordinary print in the newspaper with your
glasses or contact lenses? Would you say...

no difficulty.............................................................. 1 (B9)

a little or some difficulty.......................................... 2 (B9)

extreme difficulty.................................................................3 = INELIGIBLE (B9)

you stopped reading because of your eyesight ....................4 = INELIGIBLE (B9)

you stopped reading for other reasons or you are not

interested in reading................................................. 5 (B9)

VISION Frequency Percent Cum Freq Cum Percent

-1 165 5.89 165 5.89
1 2053 73.27 2218 79.16
2 576 20.56 2794 99.71
5 8 0.29 2802 100.00

B8b. How much difficulty do you have reading ordinary print in the newspaper? Would you
say...

no difficulty..........................................................................1

a little or some difficulty......................................................2

extreme difficulty.................................................................3 = INELIGIBLE

you stopped reading because of your eyesight ....................4 = INELIGIBLE

you stopped reading for other reasons or you are not

interested in reading.............................................................5

DIFREAD Frequency Percent Cum Freq Cum Percent

-9 4 0.14 4 0.14
-1 2637 94.11 2641 94.25
1 134 4.78 2775 99.04
2 27 0.96 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 8

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B9. Now I would like to ask you about your hearing. Do you feel you have a hearing loss?

YES..........1 NO..........2 (B10)

HEARLOST Frequency Percent Cum Freq Cum Percent

-8 1 0.04 1 0.04
-7 1 0.04 2 0.07
1 1205 43.00 1207 43.08
2 1595 56.92 2802 100.00

B9a. Do you wear a hearing aid?

YES..........1 NO..........2 (B10)

HEARAID Frequency Percent Cum Freq Cum Percent

-9 1 0.04 1 0.04
-1 1595 56.92 1596 56.96
1 281 10.03 1877 66.99
2 925 33.01 2802 100.00

B9b. Do you feel you have a hearing loss when wearing your hearing aid?

YES..........1 NO..........2 (B10)

HLOSHAID Frequency Percent Cum Freq Cum Percent

-9 2 0.07 2 0.07
-8 1 0.04 3 0.11
-7 1 0.04 4 0.14
-1 2520 89.94 2524 90.08
1 136 4.85 2660 94.93
2 142 5.07 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 9

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These next few questions are about some daily activities that we all do such as dressing, personal
hygiene, and bathing.

DRESSING:

B10. First I am going to ask you about dressing. By dressing I mean getting clothes from closet
and drawers and putting clothes on, including shoes and socks. Thinking back over the last 7
days, including the last 24 hours, how much dressing did you do on your own?

DID NOT RECEIVE HELP ............1 (B10c)

RECEIVED HELP...........................2

DID NOT DO .................................8 (B10c)

DRESSACT Frequency Percent Cum Freq Cum Percent

1 2781 99.25 2781 99.25
2 21 0.75 2802 100.00

B10b. How many times in the last 7 days did you receive this help? ___ ___ # TIMES

DRESHELT Frequency Percent Cum Freq Cum Percent

-8 1 0.04 1 0.04
-1 2781 99.25 2782 99.29
1 1 0.04 2783 99.32
2 7 0.25 2790 99.57
3 3 0.11 2793 99.68
7 6 0.21 2799 99.89
14 3 0.11 2802 100.00

USE SCORING CRITERIA IN BOX ON OPPOSITE PAGE TO SCORE B10c.

B10c. DRESSING SCORE: _____

DRESSSCO Frequency Percent Cum Freq Cum Percent

1 2788 99.50 2788 99.50
2 5 0.18 2793 99.68
3 9 0.32 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 10

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 PERSONAL HYGIENE:

B11. The next questions are about personal hygiene. By personal hygiene I mean activities such
as combing hair, brushing teeth, shaving, applying makeup, washing and drying face and
hands. It does not include bathing and showering. Thinking back over the last 7 days,
including the last 24 hours, how much personal hygiene did you do on your own?

DID NOT RECEIVE HELP ............1 (B11c)

RECEIVED HELP...........................2

DID NOT DO ..................................8 (B11c)

PERHYACT Frequency Percent Cum Freq Cum Percent

1 2799 99.89 2799 99.89
2 3 0.11 2802 100.00

B11b. How many times in the last 7 days did you receive this help? ___ ___ # TIMES

PERHHELT Frequency Percent Cum Freq Cum Percent

-1 2799 99.89 2799 99.89
1 1 0.04 2800 99.93
2 1 0.04 2801 99.96
7 1 0.04 2802 100.00

USE SCORING CRITERIA IN BOX ON OPPOSITE PAGE TO SCORE B11c.

B11c. PERSONAL HYGIENE SCORE: ____

PERHYSCO Frequency Percent Cum Freq Cum Percent

1 2800 99.93 2800 99.93
2 1 0.04 2801 99.96
3 1 0.04 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 11

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 DRESSING & PERSONAL HYGIENE SCORING
1 = Independent: No help or caregiver oversight -OR- Caregiver help/oversight provided
only one or two times during the last seven days.
2 = Supervision: Oversight, encouragement, or cueing provided three or more times during
last seven days -OR- Supervision (3 or more times) plus physical
assistance provided only one or two times during last seven days.
3 = Limited Assistance: Subject highly involved in activity, received physical help in guided
maneuvering of limbs or other non-weight-bearing assistance on three or
more occasions -OR- limited assistance (3 or more times) plus more help
provided only one or two times during last seven days.
4 = Extensive Assistance: While the subject performed part of activity over last seven days, help of
following type(s) was provided three or more times:
Weight-bearing support provided three or more times
Full caregiver performance of activity (three or more times) during
part (but not all) of last seven days.
5 = Total Dependence: Full caregiver performance of the activity during entire seven-day period.
Complete non-participation by the subject in all aspects of the ADL
definition.
8 = Activity did not Over the last seven days, the ADL activity was not performed by the
occur during the elder or caregiver. In other words, the particular activity did not occur at
entire 7-day period: all.

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 12

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 BATHING:

BATHING SCORING
1= Independent: Did on own.
2= Supervision: Oversight help only
3= Limited Assistance: Received assistance in transfer only
4= Assistance: Received assistance in part of bathing self.
Do not include help with washing ones back.
5 = Total Dependence: Total dependence
8 = Activity did not occur Activity did not occur at all.

B12. Now I am going to ask you about bathing. By bathing I mean getting soap and water and
washing and drying the whole body. This includes getting in and out of the tub or shower.
Thinking back over the last 7 days, including the last 24 hours, how much bathing did you do
on your own?

DID NOT RECEIVE HELP ............1 (B12b)

RECEIVED HELP...........................2

DID NOT DO ..................................8 (B12b)

BATHACT Frequency Percent Cum Freq Cum Percent

1 2785 99.39 2785 99.39
2 14 0.50 2799 99.89
8 3 0.11 2802 100.00

USE SCORING CRITERIA IN BOX ABOVE TO SCORE B12b.

B12b. BATHING SCORE: ____

BATHSCO Frequency Percent Cum Freq Cum Percent

1 2786 99.43 2786 99.43
2 5 0.18 2791 99.61
3 8 0.29 2799 99.89
8 3 0.11 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 13

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B13. DID SUBJECT RECEIVE A SCORE OF 4 OR 5 IN ANY ONE OR MORE DAILY
ACTIVITIES (B10c, B11c, B12b)?
OR
DID SUBJECT SCORE AN (8) IN ALL THREE DAILY ACTIVITIES (B10c, B11c, B12b)?

YES ..............................................................1 = INELIGIBLE

NO................................................................2

ACTSCORE Frequency Percent Cum Freq Cum Percent

2 2802 100.00 2802 100.00

The next few questions are about medical conditions you might have.

B14. Has a doctor or a nurse ever told you that you have:

YES NO DK

a. arthritis .................................... 1 2 8

ARTHRIT Frequency Percent Cum Freq Cum Percent

1 1592 56.82 1592 56.82
2 1198 42.76 2790 99.57
8 12 0.43 2802 100.00

b. diabetes ................................... 1 2 8

DIABETES Frequency Percent Cum Freq Cum Percent

1 358 12.78 358 12.78
2 2441 87.12 2799 99.89
8 3 0.11 2802 100.00

c. heart attack or
myocardial infarction ............. 1 2 8

HEARTDIS Frequency Percent Cum Freq Cum Percent

1 309 11.03 309 11.03
2 2477 88.40 2786 99.43
8 16 0.57 2802 100.00

d. Alzheimers Disease ................ 1 = INELIGIBLE 2 8

ALZHEIME Frequency Percent Cum Freq Cum Percent

2 2802 100.00 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 14

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e. a stroke within the past year ... 1 = INELIGIBLE 2 8

STROKE Frequency Percent Cum Freq Cum Percent

2 2800 99.93 2800 99.93
8 2 0.07 2802 100.00

f. cancer, other than

skin cancer, within the
past 5 years............................... 1 2 (C1) 8 (C1)

CANCER Frequency Percent Cum Freq Cum Percent

1 158 5.64 158 5.64
2 2644 94.36 2802 100.00

B14g. What kind of cancer (site of the cancer) is it?

CODE ALL SUBJECT MENTIONS.

LUNG ..........................................................1 = INELIGIBLE

LUNGCA
N Frequency Percent Cum Freq Cum Percent
-1 2644 94.36 2644 94.36
0 158 5.64 2802 100.00

STOMACH ..................................................2 = INELIGIBLE

STOMAC
H Frequency Percent Cum Freq Cum Percent
-1 2644 94.36 2644 94.36
0 158 5.64 2802 100.00

LIVER..........................................................3 = INELIGIBLE

LIVER Frequency Percent Cum Freq Cum Percent

-1 2644 94.36 2644 94.36
0 158 5.64 2802 100.00

PANCREAS.................................................4 = INELIGIBLE

PANCREAS Frequency Percent Cum Freq Cum Percent

-1 2644 94.36 2644 94.36
0 158 5.64 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 15

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 ESOPHAGUS ..............................................5 = INELIGIBLE

ESOPHAG Frequency Percent Cum Freq Cum Percent

-1 2644 94.36 2644 94.36
0 158 5.64 2802 100.00

OTHER ........................................................6

OTHERCAN Frequency Percent Cum Freq Cum Percent

-1 2644 94.36 2644 94.36
6 158 5.64 2802 100.00

B14h. Are you currently receiving chemotherapy or radiation treatment for this (these)
cancer(s)?

YES ..............................................................1 = INELIGIBLE

NO................................................................2

CHEMOTHR Frequency Percent Cum Freq Cum Percent

-1 2644 94.36 2644 94.36
2 158 5.64 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 16

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SECTION C: AVAILABILITY AND OTHER STUDIES

C1. Are you planning to move out of the area (county) in the next year or so?

YES ..............................................................1 = INELIGIBLE

NO................................................................2

PLANMOVE Frequency Percent Cum Freq Cum Percent

-8 1 0.04 1 0.04
2 2801 99.96 2802 100.00

C2. In the next year or so, do you plan to be away for an extended period of time, such as one
or more months at a time? (PROBE: For example, do you regularly go (south in the
winter / north in the summer) for several months?)

YES ............................................................. 1 (C2a)

NO................................................................2 (C2b)

PLANAWAY Frequency Percent Cum Freq Cum Percent

-8 2 0.07 2 0.07
1 183 6.53 185 6.60
2 2617 93.40 2802 100.00

C2b. Are you planning any short trips for several days or a week in the next 3 months?

YES ...................................................1 (C2c)

NO.................................................... 2 (C2d)

TRIPS Frequency Percent Cum Freq Cum Percent

-9 4 0.14 4 0.14
-8 3 0.11 7 0.25
1 923 32.94 930 33.19
2 1872 66.81 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 17

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 C2d. BASED ON SUBJECTS REPLIES TO C2 - C2c AND SITES TESTING AND
TRAINING SCHEDULE, CODE BELOW.

NO CONFLICT ...............................1

CONFLICT - WORKABLE ............2 RECONTACT

CONFLICT - NOT WORKABLE...3 = INELIGIBLE

CONFLICT Frequency Percent Cum Freq Cum Percent

-9 2 0.07 2 0.07
-1 415 14.81 417 14.88
1 2375 84.76 2792 99.64
2 10 0.36 2802 100.00

C3. This study offers a program on 2 to 3 mornings or afternoons a week for 5 weeks.
Do you have any commitments such as employment, caregiving or volunteering that
could not be rearranged and thus would affect your availability to participate in this
study?

NO CONFLICT ...............................1

CONFLICT - WORKABLE ............2 RECONTACT

CONFLICT - NOT WORKABLE...3 = INELIGIBLE

COMMIT Frequency Percent Cum Freq Cum Percent

-7 1 0.04 1 0.04
1 2788 99.50 2789 99.54
2 13 0.46 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 18

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C4. In the past 2 years, have you participated in any research study or educational training
program for older adults to improve thinking, memory or problem solving?
YES ..............................................................1

NO................................................................2 (C5)

PARTSTUD Frequency Percent Cum Freq Cum Percent

-9 1 0.04 1 0.04
1 67 2.39 68 2.43
2 2734 97.57 2802 100.00

C4b. Who ran this study or training program?

DO NOT READ CHOICES BELOW. IF NEEDED, USE SITE SPECIFIC PROGRAM

NAME AS A PROBE.

Johns Hopkins Memory Research Center....1 = INELIGIBLE (C5)

Penn State ADEPT Program........................2 = INELIGIBLE (C5)

OTHER ........................................................3

WHORAN Frequency Percent Cum Freq Cum Percent

-1 2735 97.61 2735 97.61
3 67 2.39 2802 100.00

C4d. BASED ON C4a-c, CODE:

STUDY/PROGRAM IS NOT SIMILAR TO ACTIVE ......1

STUDY/PROGRAM IS SIMILAR TO ACTIVE ...............2 = INELIGIBLE

ASIMILAR Frequency Percent Cum Freq Cum Percent

-9 1 0.04 1 0.04
-1 2735 97.61 2736 97.64
1 66 2.36 2802 100.00

C5. In the past 2 years, have you participated in a research study to help you handle everyday
activities like paying the bills, using the telephone, or taking your medications?

YES. .............................................................1

NO................................................................2 (D1)

PASTEVAC Frequency Percent Cum Freq Cum Percent

1 3 0.11 3 0.11
2 2799 99.89 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 19

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SECTION D: INTERVIEWER ASSESSMENT OF SUBJECT COMMUNICATION

USING THE SCORING CRITERIA ON THE NEXT PAGE, CODE YOUR ASSESSMENT OF
SUBJECTS ABILITY TO MAKE SELF UNDERSTOOD AND TO UNDERSTAND OTHERS.

D1. MAKING SELF UNDERSTOOD

UNDERSTOOD..........................................................................................0

USUALLY UNDERSTOOD.......................................................................1
(DIFFICULTY FINDING WORDS OR FINISHING THOUGHTS.)

SOMETIMES UNDERSTOOD..................................................................2
(ABILITY IS LIMITED TO MAKING CONCRETE REQUESTS.)

RARELY/NEVER UNDERSTOOD...........................................................3

SELFUNDE Frequency Percent Cum Freq Cum Percent

0 2771 98.89 2771 98.89
1 28 1.00 2799 99.89
9 3 0.11 2802 100.00

D2. ABILITY TO UNDERSTAND OTHERS

UNDERSTANDS........................................................................................0

USUALLY
UNDERSTANDS.....................................................................1
(MAY MISS SOME PART/INTENT OF MESSAGE.)

SOMETIMES UNDERSTANDS................................................................2
(RESPONDS ADEQUATELY ONLY TO SIMPLE, DIRECT
COMMUNICATION)

RARELY/NEVER UNDERSTANDS.........................................................3

OTHEUNDE Frequency Percent Cum Freq Cum Percent

0 2712 96.79 2712 96.79
1 90 3.21 2802 100.00

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D3. DID SUBJECT RECEIVE A SCORE OF A 2 OR 3 IN EITHER ITEM (D1 OR D2)?

YES ..............................................................1 = INELIGIBLE

NO................................................................2

UNDERSCO Frequency Percent Cum Freq Cum Percent

2 2802 100.00 2802 100.00

MAKING SELF UNDERSTOOD SCORING

0 = Understood: The subject expresses ideas clearly.
The subject has difficulty finding the right words or finishing thoughts,
1 = Usually Understood: resulting in delayed responses; or requires some prompting to make self
understood.
2 = Sometimes The subject has limited ability, but is able to express concrete request
Understood: regarding at least basic needs (e.g., food, drink, sleep, toilet).
3 = Rarely/Never At best, understanding is limited to interpretation of highly individual,
Understood: person-specific sounds (e.g. indicated presence of pain or need to toilet).

ABILITY TO UNDERSTAND OTHERS SCORING

0 = Understands: Clearly comprehends the interviewers message(s) and demonstrates
comprehension by words or questions.
May miss some part of intent of the message but comprehends most of it.
1 = Usually Understands: The subject may have periodic difficulties integrating information but
generally demonstrates comprehension by responding to words or
questions.
2 = Sometimes Demonstrates frequent difficulties integrating information, and responds
Understands: adequately only to simple and direct questions or directions. When the
message is rephrased or simplified, the subjects comprehension is
enhanced.
3 = Rarely/Never Demonstrates very limited ability to understand communication. Or,
Understands: interviewer has difficulty determining whether the subject comprehends
messages, based on verbal responses. Or, the subject can hear sounds but
does not understand messages.

DETERMINE SUBJECT ELIGIBILITY AND GO TO

APPROPRIATE SCRIPT ON NEXT PAGE.

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 21

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SECTION E: FINAL DISPOSITION

FOR ELIGIBLE SUBJECTS

Thank you for answering the questions. We would like to continue with you in the program and
meet you in person and have you meet us. At this in-person meeting, we will test your vision, ask
you some more questions and have you complete some activities involving words and memory, to
determine if you are eligible for participation in the program. This meeting will take from 5 minutes
to two hours depending on how much information is needed from you. It will be held at (SITE). We
would like to offer you $XX for your time, and transportation expenses.

Do you have any questions for me at this time?

E1. Would you be willing to meet with us?

YES............................1 (ELIGIBLE/NOT REFUSED SCRIPT)

NO.............................2 (ELIGIBLE/REFUSED SCRIPT)

AGRPERSC Frequency Percent Cum Freq Cum Percent

1 2802 100.00 2802 100.00

ACTIVE FORM #2 - TELEPHONE SCREENER - VERSION 12/17/98 - Page 22

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