Section A - Sep 6mhasweb.org/Resources/DOCUMENTS/2003/Proxy_Questionnaire... · 2020. 7. 6. ·...
67
CONFIDENTIALITY OF INFORMATION This survey is authorized by the Law of Statistical and Geographical Inforamtion, Chapter V, Article 38. All information provided will be kept strictly CONFIDENTIAL. NATIONAL MEXICAN HEALTH AND AGING STUDY 2003 MODELO 1-2003 CONTROL NUM. OF SELECTED HOUSEHOLD PROXY INTERVIEW NAME AND CODE OF THE SUPERVISOR NAME AND CODE OF INTERVIEWER NAME AND CODE OF THE CODER UNIQUE HOUSEHOLD ID-2001 RESULT OF INTERVIEW 2003 COORDINATES UPDATED HOUSEHOLD 2003 LATITUDE N LONGITUDE W (STREET, AVENUE, ALLEY, ROAD, HIGHWAY, BOULEVARD, KM) EXTERIOR NUMBER INTERIOR NUMBER (NEIGHBOORHOOD, UNIT) MUNICIPALITY/ DELEGATION STATE INDICATE IF INTERVIEW TAKES PLACE AT SAME ADDRESS AS MHAS 2001 1 SAME ADDRESS 2 OTHER ADDRESS UPDATE ADDRESS GO TO INTERVIEW
Transcript of Section A - Sep 6mhasweb.org/Resources/DOCUMENTS/2003/Proxy_Questionnaire... · 2020. 7. 6. ·...
-
CONFIDENTIALITY OF INFORMATION
This survey is authorized by the Law of Statistical andGeographical Inforamtion, Chapter V, Article 38. Allinformation provided will be kept strictly CONFIDENTIAL.
NATIONAL MEXICAN HEALTH ANDAGING STUDY
2003
MODELO 1-2003
CONTROLNUM. OF
SELECTEDHOUSEHOLD
PROXY INTERVIEW
NAME AND CODE OF THESUPERVISOR
NAME AND CODE OFINTERVIEWER
NAME AND CODE OF THECODER
UNIQUE HOUSEHOLDID-2001
RESULT OFINTERVIEW 2003
COORDINATES
UPDATEDHOUSEHOLD 2003
LATITUDE N LONGITUDE W
(STREET, AVENUE, ALLEY, ROAD, HIGHWAY, BOULEVARD, KM)
EXTERIOR NUMBER INTERIOR NUMBER (NEIGHBOORHOOD, UNIT)
MUNICIPALITY/DELEGATION
STATE
INDICATE IF INTERVIEW TAKES PLACE AT SAME ADDRESS AS MHAS 2001
1 SAME ADDRESS
2 OTHER ADDRESS UPDATE ADDRESS
GO TO INTERVIEW
-
PROXY INTERVIEW
NAME(S) PATERNAL SURNAME MATERNAL SURNAME
CODE OF RESPONDENT:
SELECTED PERSON-2001 ............................................................. 1
SPOUSE OF SELECETED PERSON-2001 .................................... 2
NEW SPOUSE OF SELECTED PERSON-2003 ............................. 3
NEW SPOUSE OF SPOUSE OF SELECETED-2003 .................... 4
DATE OF INTERVIEW
NUMBER OF VISITS TOATTAIN INTERVIEW ................................. |____||____|
DAY ........................................ |____||____|
MONTH................................... |____||____|
RESULT OF INTERVIEW
COMPLETE ................................... 01
INCOMPLETE ............................... 20
LAST SECTION COMPLETED ............ |_____|
NAME OF INFORMANTE SUSTITUTO:
RELATIONSHIP:
FOLLOW-UP INTERVIEW ......................................... 1
INTERVIEW OF NEW PERSON ............................... 2
REASON FOR USING PROXY:
FOR HEALTH REASONS ............. 1
FOR LANGUAGE REASONS ....... 2
OTHER .......................................... 3
1
2 3
54
6
7
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IEW
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: IN
DIC
AT
E IF
(N
AM
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LIV
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WIT
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G
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NA
ME
46
4.a
Now
I’m
goi
ng t
o m
entio
n to
you
the
nam
es o
f al
l the
peo
ple
that
live
d in
this
hou
seho
ld t
he la
st t
ime
that
we
talk
ed w
ith y
ou (
or y
our
spou
se).
Ple
ase
indi
cate
if t
hey
still
live
her
ean
d fin
ally
if a
nyon
e el
se p
rese
ntly
lives
her
e.
4.b
Cur
rent
ly d
o yo
u re
side
alo
ne (
and/
or
with
you
r sp
ouse
)?
Reg
is-
tra-
tion
NA
ME
FO
R H
OU
SE
HO
LD
RE
SID
EN
TS
AN
D N
EW
3
No
te:
circ
le t
he
re
gis
tra
tion
nu
mb
er
of
the
ch
ildre
n o
f th
e s
ele
cte
d a
nd
th
ose
of
the
sp
ou
se
Reg
istr
atio
nN
um
ber
(MH
AS
200
1)
NU
MB
ER
1.
NO
TE
TH
E C
OD
E O
F T
HE
RE
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ON
DE
NT
SE
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TE
D P
ER
SO
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R S
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US
E-2
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1-00
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EW
SP
OU
SE
OF
SE
LEC
TE
D P
ER
SO
N O
R O
F S
PO
US
E
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
CO
DE
Cu
rren
tly,
wh
at is
the
situ
atio
n o
f(N
AM
E)?
5
RE
SID
EN
CE
Stil
l liv
es h
ere
orte
mpo
raril
y ab
sent
......
1
Per
man
ently
abse
nt...
......
......
......
....2
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ease
d....
......
......
...3
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ed b
y m
ista
ke...
.....4
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res
iden
t.....
......
....5
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to
Go
to
Go
to
Pas
stoG
o to
Not
in li
sts
YE
S...
......
......
....1
NO
......
......
......
..2
Ski
p t
o In
terv
iew
Tell
me
the
nam
eso
f al
l th
e p
eop
leth
at h
abilt
ual
ly l
ive
wit
h y
ou
(an
d y
ou
rsp
ou
se)
HO
US
EH
OL
D R
OS
TE
R
NU
MB
ER
OR
66
6
2a. I
NT
ER
VIE
WE
R:
IND
ICA
TE
TO
TA
LN
UM
BE
R O
F P
ER
SO
NS
-
Regis-tra-tion
Num-ber
CODE
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
19
In the last two years(since the last time wespoke with (NAME), hasthis person lived orworked in the US?
YES .................. 1NO ................... 2
RF ......................... 8DK ......................... 9
NUMBER
17 18
Are any of his/herchildren under age18?
How many children does (NAME) have?
NUMBER
CHILDREN
None ............. 00
RF ...................... 88DK ...................... 99
Go to19
Number of children
Pass to 18
YES .................. 1NO ................... 2
RF ......................... 8DK ......................... 9
MIGRATIONHEALTH
16
Currently, doesthis person haveany serioushealth problemsor any physicallimitations?
YES .............. 1
NO ............... 2
RF ................ 8DK ................ 9
CODE NUMBER
ACTIVITY
Currently this person...
Read the optionsuntil you get ananswer
Works ............................................. 1Does not work, but had a job ......... 2Is looking for work .......................... 3Is a student .................................... 4Is dedicated self to household chores5Does not work ................................ 6
RF .................................................. 8DK .................................................. 9
IF (NAME) IS NOT ACHILD GO TO NEXTRECORD OR TOINTERVIEWCONTROL
15
RESIDENT CHILDREN 12 YEARS OR OLDER
IF THIS PERSON IS NOTPERMANENTLY ABSENTGO TO NEXT RECORDOR TO INTERVIEWCONTROL
FINANCIAL SITUATION
Would you say thatthis person’s financialsituation is...
CODE
Excellent .................... 1Very good .................. 2Good .......................... 3Fair ............................ 4Poor ........................... 5
RF .............................. 8DK .............................. 9
14
-
MONTH YEAR
20 22
Regis-tra-tion
Num-ber
CODE
(This child) lives… The community where (thischild) lives is… Approximately when did
(this child) move?
TIMES
23
FOR PERMANENTLY ABSENT CHILDREN 12 YEARS OR OLDER
21
in the same community ................ 1
in a different community ................ 2
RF .............................. 8DK .............................. 9
Passto 21
...larger than this oneand in Mexico. ................................ 1
...smaller than this oneand in Mexico ................................. 2
..same size as this oneand in Mexico. ................................ 3
...in the US. ..................................... 4
... in another place other than the US.5
RF .................................................. 8DK .................................................. 9
With what frequency do you oryour spouse contact (thischild) in person, by mail or bytelephone?
PER PERIOD:
week ........................................... 1
month ......................................... 2
year ............................................. 3
2 years ....................................... 4
RF ....................................................... 88/8DK ....................................................... 99/9
NEVER..........................00/0
PERIOD
MIGRATION CONTACT
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
NOTE MONTH AND YEAR
RF ............................................... 88/2008
DK ............................................... 99/2009
Go to 22
Go to 22
GO TO NEXTRECORD ORTO INTERVIEWCONTROL
2 0 0
2 0 02 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
-
25
Regis-tra-tion
Num-ber
CODE
Approximately when did(this child) passaway?(month/year)
Where did (this person) passaway?
In the same community. ........................... 1
In a different community .......................... 2
In the US .................................................. 3
OtheR ...................................................... 4
RF ........................................................... 8DK ........................................................... 9
CODE
26
MONTH YEAR
What was the main cause ofhis/her death?
Diabetes. ................................................. 1
Cancer. .................................................... 2
Heart. ....................................................... 3
Stroke. ..................................................... 4
Other disease .......................................... 5
Accident or violence. ............................... 6
Other cause ............................................. 7
RF ........................................................... 8DK ........................................................... 9
24
DECEASED
NOTE MONTH AND YEAR
RF ............................................... 88/2008
DK ............................................... 99/2009
INFORMATION ON THE DEATH
GO TO NEXTRECORD OR TOINTERVIEWCONTROL
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
2 0 0
2 0 02 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
FINISHING TIME |_____|_____|:|_____|_____|
PASS TO INTERVIEWCONTROL
-
PASS TO SECTION AFOLLOW UP ....................................... 1
NEW PERSON .................................... 2 GO TO SECTION AA
CE.1 INDICATE WHETHER IT IS A FOLLOW UP OR NEW PERSON INTERVIEW
INTERVIEW CONTROL
-
SECTION A - DEMOGRAPHICS
A.3 Currently (NAME) is ...
single? ........................................ 1
married? ...................................... 2
in a consensual union? .............. 3
divorced? .................................... 4
separated?from a union? ................... 5from a marriage? .............. 6
widowedfrom a union? ................... 7from a marriage? .............. 8
Go to A.7
Pass to A.4
Go to A.5
A.5 Did the last marriage (union) end within thelast two years (since we last talked to him/her)?
YES ...................................... 1NO ........................................ 2
RF ......................................... 8DK ......................................... 9
A.8 How many years has (NAME) lived in thiscommunity?
YEARS ..................... |____|____|
LESS THAN 6 MONTHS .......... 006-11 MONTHS.......................... 01
HAS ALWAYS LIVED HERE .... 97
RF ............................................ 88DK ............................................ 99
A.4 Has (name) stayed in a marriage (union) withthe same person for two years (since welast talked to him/her)?
YES ...................................... 1NO ........................................ 2
RF ......................................... 8DK ......................................... 9
MIGRATION HISTORY
Go to A.7Go to A.6
A.1 INTERVIEWER INDICATE IF (NAME) IS A…
MALE .................................... 1
FEMALE ................................ 2
A.2 How old is (NAME)?
MARITAL STATUS
A.7 INDICATE IF IT IS IN THE SAME DWELLING AS2001 (VERIFY THE ROSTER)
Pass to A.8
Go to A.12YES ...................................... 1
NO ........................................ 2
YES ...................................... 1NO ........................................ 2
RF ......................................... 8DK ......................................... 9
A.6 Did the marriage (union) begin in the lasttwo years (since we last talked to him/her)?
YES ...................................... 1NO ........................................ 2
RF ......................................... 8DK ......................................... 9
Go to A.40
Pass to A.13
A.12 Not counting vacations, has (NAME) everworked/lived in the US?
YES ...................................... 1NO ........................................ 2
He/she is in the U.S. ............ 3
Go to A.22
A.14 In the last two years (since we last spoke tohim/her), not counting vacations or short vis-its, has (name) worked or lived in the US?
YES ...................................... 1NO ........................................ 2 Go to A.22
Pass to A.21
A.15 Was this the first time going to the US to workor live?
... moved to a rural community in Mexico .. 1
... moved to an urban communityin Mexico .................................................... 2... has always lived in the placehe/she was born ....................................... 3
RF ............................................................... 8DK ............................................................... 9
A.13 Before going to the US, (NAME)…
MIGRATION TO THE UNITED STATES
GO TO A.12
GO TO A.21
Pass to A.15
Pass to A.15
YEARS ........ |____|____|____|
RF ..................................... 888DK ..................................... 999
Go to A.7
-
FINISH TIME: |_____|_____|:|_____|_____|
GO TO INTERVIEW CONTROL
A.40 INTERVIEWER:WITH WHAT FREQUENCY DID THE RESPONDENTNEED HELP TO ANSWER SECTION A. DEMOGRAPH-ICS?
NEVER ......................................................... 1A FEW TIMES ............................................... 2MOST OF THE TIME ..................................... 3
A.21 Is (NAME) currently a permanent resident orcitizen of the United States?
PERMANENT RESIDENT ................................... 1CITIZEN ............................................................ 2NO; NEITHER OF THE TWO ............................ 3
RF ..................................................................... 8DK .................................................................... 9
A.22 In total, how many years has (NAME) workedor lived in the US?
YEARS ................................................ |____|____|
12 MONTHSN OR LESS ..... 01
RF ....................................... 88DK ....................................... 99
GO TO A.40
-
SECTION AA - DEMOGRAPHICS FOR NEW PERSON START TIME: |_____|_____|:|_____|_____|
AA.4b Does (NAME) know how to read and write amessage?
YES ...................................... 1NO ........................................ 2
RF ......................................... 8DK ......................................... 9
AA.3 In what State/Country was (NAME) born?
STATE/COUNTRY
GENERAL DATA
AA.4a What is the last year or grade that (NAME)completed in school?
None ........................................... 0Primary ....................................... 1Secondary ................................. 2Technical or Commercial ........... 3Preparatory or High School ....... 4Basic teaching school ............... 5College ....................................... 6Graduate .................................... 7
RF ..................................................... 8DK ..................................................... 9
GRADE ............................................... |____|
LEVEL:
Pass toAA.4b
Go toAA.10
Go toAA.4b
DK ..................................................................... 99
AA.5 Can (NAME) count from 1 to 10?
YES ...................................... 1NO ........................................ 2
RF ......................................... 8DK ......................................... 9
MARITAL STATUS
AA.11In what year or what age was (NAME) whenhis/her last marriage (union) ended?
YEAR ............................... |____|____||____|____|
RF ................................... 8888DK ................................... 9999
ORAGE ..................................................... |____|____|
AA.12In what year or what age was (NAME)when thatmarriage (union) began?
YEAR ............................... |____|____||____|____|
RF ................................... 8888DK ................................... 9999
AA.13a Before his/her (current marriage/ lastmarriage/current union/last union) was(NAME) married or in a union?
YES ...................................... 1NO ........................................ 2
RF ......................................... 8DK ......................................... 9
Go toAA.19
Pass toAA.13b
ORAGE..................................................... |____|____|
AA.10 Currently is (NAME) ...
single? ........................................ 1
married? ...................................... 2
in a consensual union? .............. 3
divorced? .................................... 4
separated?from a union? ................... 5from a marriage? .............. 6
widowedfrom a union? ................... 7from a marriage? .............. 8
Go toAA.19
Go toAA.12
Pass toAA.11
JUMP TO AA.1 0
AA.2 On what day, month, and year was (NAME) born?
DAY ..................................................... |____|____|
MONTH ................................................ |____|____|
YEAR ............................... |____|____||____|____|
DK ............................................................ 99/9999
AA.1 INDICATE IF (NAME) IS A…
MALE .................................... 1
FEMALE ................................ 2
-
AA.34 While in the US, did (name) contribute tosocial security through working?
YES ...................................... 1NO ........................................ 2
RF ......................................... 8DK ......................................... 9
YES ...................................... 1NO ........................................ 2
RF ......................................... 8DK ......................................... 9
Go to AA.35
Pass toAA.26a
AA.25 Not counting vacations and short visits, has(NAME) ever worked or lived in the U.S.?
MIGRATION TO THE UNITED STATES
AA.26a In total, about how many years has (NAME)worked or lived in the U.S.?
12 MONTHS OR LESS ........ 01
RF ....................................... 88DK ....................................... 99
YEARS ................................................ |____|____|
MIGRATION HISTORY
AA.21 About how many years has (NAME) lived inthis community or has (NAME) always livedhere?
YEARS ................................................ |____|____|
LESS THAN 6 MONTHS .......... 006-11 MONTHS.......................... 01
HAS ALWAYS LIVED HERE .... 97
RF ............................................ 88DK ............................................ 99
AA.19 How many live births has (NAME) had?
NONE .................................. 00RF ....................................... 88DK ....................................... 99
AA.20 Of those live births, how many of them arestill alive?
ALL ..................................... 96RF ....................................... 88DK ....................................... 99
Go toAA.21
NUMBER .............................................. |____|____|
NUMBER .............................................. |____|____|
FERTILITY
AA.14 Excluding the current union, how manytimes has (NAME) been married or in aconsensual union?
RF ....................................... 88DK ....................................... 99
NUMBER OF UNIONS .......................... |____|____|
AA.13c How did marriage (union) end?
Separation .................................. 1
Divorce .......................................2
Widowhood ................................3
RF ..........................................8DK ..........................................9
AA.13b What was the marital status of (NAME) be-fore this current union?
Single? ........................................ 1
Married? ......................................2
In concesual union? ................... 3
Divorced? ...................................4
Separated ...................................5
Widowed .................................... 6
RF .......................................... 8
DK .......................................... 9
Go toAA.19
Pass toAA.13c
Go toAA.14
AA.33 Is (NAME) currently a permanent resident orcitizen of the United States?
PERMANENT RESIDENT ................................... 1CITIZEN ............................................................ 2NO; NEITHER OF THE TWO ............................ 3
RF ..................................................................... 8DK .................................................................... 9
JUMP TO AA.19
JUMP TO AA.25
JUMP TO AA.33
-
AA.35 Was there a time when (NAME) raised his/heryoung children without having a spouse or apartner there with him/her?
YES .......................................... 1[VOL] YES, BUT OTHERSWERE THERE WITH ME ............ 2NO ............................................ 3
RF ............................................. 8DK ............................................ 9
Go toAA.37
Pass toAA.36
IF RESPONDENT IS MALE, GO TO AA.3 7
AA.36 In total, for about how many years did (NAME)raise his/her children alone without his/herspouse?
YEARS ................................................ |____|____|
12 MONTHS OR LESS........ 01ALWAYS ............................ 77
RF ....................................... 88DK ....................................... 99
AA.37 Does (NAME) speak English?
YES ...................................... 1YES, SOME .......................... 2NO ........................................ 3
RF ......................................... 8DK ......................................... 9
LANGUAGE AND RELIGION
AA.43 INTERVIEWER:WITH WHAT FREQUENCY DID THE RESPONDENTNEED HELP TO ANSWER SECTION AA. DEMO-GRAPHICS?
FINISH TIME: |_____|_____|:|_____|_____|
NEVER ......................................................... 1A FEW TIMES ............................................... 2MOST OF THE TIME ..................................... 3
PASS TO INTERVIEW CONTROL
JUMP TO AA.43
-
GO TO SECTION BSINGLE INTERVIEW ............................. 1
COUPLE INTERVIEW ............................ 2 PASS TO CE.2
CE.1 INDICATE WHETHER IT IS A SINGLE OR COUPLE INTERVIEW
PROXY INTERVIEW CONTROL
PASS TO CE.3FIRST ................................................... 1
SECOND ............................................... 2 GO TO CE.4
CE.2 INDICATE WHETHER FIRST OR SECOND INTERVIEW
GO TO SECTION CYES ...................................................... 1
NO ........................................................ 2 PASS TOSECTION B
CE.4 INDICATE WHETHER SECTION G HAS BEEN ANSWERED IN THE FIRST INTERVIEW
YES ...................................................... 1
NO ........................................................ 2 PASS TO SECTION B
CE.3 INDICATE WHETHER SECTION B WILL BE ANSWERED IN THE SECOND INTERVIEW
CONDUCT THE OTHER INTERVIEW ANDCOME BACK TO THIS ONE AFTERWARDS
-
FOR NON-RESIDENT CHILDREN 12 Y EARS OLD OR MORE
CODE
Currently, what is thesituation of (NAME)?
Still lives here ortemporarily absent......1
Permanentlyabsent.........................2
Deceased...................3
Listed by mistake........4
New resident...............5
B7 B9
SCHOOLING
What is the last yearor grade that this
None.............................0Elementary....................1Secondary.....................2Technical orCommercial.................3Prepatory orHigh School..................4Basic TeachingSchool...........................5College..........................6Graduate School...........7
RF...................................8DK..................................9
LEVEL:
LEVEL GRADE CODE
B11
What is this child’smarital status?
Read the options until
S i n g l e . . . . . . . . . . . . . . . . . . 1M a r r i e d . . . . . . . . . . . . . . . 2ConsensualU n i o n . . . . . . . . . . . . . . . . . . . 3Divorced .............4S e p a r r a t e d . . . . . . . . . . . 5W i d o w e d . . . . . . . . . . . . . . 6
R F. . . . . . . . . . . . . . . . . . . . . . . . .8D K . . . . . . . . . . . . . . . . . . . . . . . 9
MARITAL
Would you saythat this childeconomicsituation is......
Excellent .............. 1Very Good ............ 2Good ..................... 3Fair ....................... 4Poor ...................... 5
B12
CODE
FINANCIAL
TIMES
B10
CONTACT
In the last two years, howoften has (NAME) (orspouse) been in contact
PERIOD:week .................................1month
RF............................88/8
NEVER...........00/ Go to
PERIOD
RESIDENCE STATUS
Go
Go
Go tonext
recordor to
INTERVIEWER: INDICATE IF IN MHAS-2001 THE
Registrationnumber
NUMBER
Not in lists
B8
Pass
YES.............................................................1 GO TO B.4aNO.................................................2
START TIME |____|____|:|____|____|
NAME
B4 B6
Regis-tra-tion
NAME
FOR ALL NON-RESIDENT CHILDREN
B3
B1 . WRITE RESPONDENT CODE
201
202
203
204
205
206207
208
209210
211
212
213214
215
216
217218219
CODE
B5
Is the personmale orfemale?
SEX
Male.......................1Female...................2
AGE
How old ishe/she?LLESS THAN1YEAR............0098 or more......98DK.................99
IF (NAME) ISLESS THAN 12YEARS OLDGO TO NEXT
Y EARS
B4 .a Now I’m going to mention to youthe names of all the people thatlived in this household the lasttime that we talked with you (or yourspouse). Please indicate if they stilllive here and finally if anyone elsepresently lives here.
4 .b Currently do you reside alone (and/or with your spouse)?
YES...................1 Skip to InterviewNO....................2 T ell me the names
of all the people thathabiltually live with
you (and your spouse)
Note: circle the registration number of thechildren of the selected and those of the
spouse
SECTION B - NON-RESIDENT CHILDREN
RESPONDENT OR SPOUSE-2001 ......................................................... 001-B2a. INTERVIEWER:
INDICATE TOTALNUMBER OF PERSONS
-
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
B17
CODECODE
MIGRATIONHEALTH
B14
Currently, does thischild have any serioushealth problems or anyphysical limitations?
YES .......................... 1
NO ............................. 2
RF ............................. 8DK ............................. 9
B15 B16
Are any of his/herchildren under age18?
How many children doesthis child have?
NUMBER
CHILDREN
NONE ......... 00
RF ................... 88DK ................... 99
Go toB17
Number ofchildren
Pass toB1 6
YES ................. 1NO .................... 2
RF .................... 8DK .................... 9
CODE
B13
CODE
ACTIVITY
Currently this child...?
Read options until youget an answer Same house or building ................1
Same locality or neighborhood ..... 2
Different locality or neighborhoodbut same city ...............................3
Other city in Mexico ..................... 4
U.S. .............................................. 5
Other country ............................... 6
RF ................................................8DK ................................................9
Where does this childlive?
NON RESIDENT CHILDREN 12 YEARS OR OLDER
Works .......................................... 1Is looking for a job ...................... 2Is a student ................................. 3Dedicates self to householdchores ......................................... 4Doesn’t work ............................... 5
RF ............................................... 8DK ............................................... 9
-
Regis-tra-tion
Num-ber
CODE CODE
When did this child passaway? (month/year)
Where did this child passaway?
In this community. ......................... 1
In another community in Mexico. .. 2
In the US. ...................................... 3
Other .............................................. 4
RF .................................................. 8DK .................................................. 9
CODEMONTH Y EAR
What did this child die of?
Diabetes. ........................................ 1
Cancer. .......................................... 2
Heart. ............................................. 3
Stroke. ........................................... 4
Other dicease ................................. 5
Violence .......................................... 6
Other cause ................................... 7
RF .................................................. 8DK .................................................. 9
Yes .................... 1
No ..................... 2
RF ..................... 8DK ..................... 9
NON RESIDENT DECEASED CHILDREN 1 2 Y EARS OR OLDER
INDICATE MONTH AND YEAR
RF ............................... 88/2008DK .............................. 99/2009
GO TO NEXTRECORD ORTO SECTION C
DECEASE DATA
B18 B20 B21B19
In the last two years (since welast talked with (name)), hasthis child lived or worked inthe US??
MIGRATION
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
GO TO NEXTRECORD ORTO SECTION C
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 02 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0
2 0 0PASS TO SECTION C
-
START TIME |_____|_____|:|_____|_____|SECTION C - HEALTH
HY PERTENSION
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.4 (During the last two years/ever) has a doctor ormedical personnel told (name) that he/she hadhypertension or high blood pressure?
Go to C.6
Pass to C.5
C.5 Is (NAME) currently taking any medication to lowerhis/her blood pressure?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
DIABETES
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.6 (During the last two years/ever) has (name) beendiagnosed with diabetes?
Go to C.12
Pass to C.7
C.11 With what frequency does (NAME) measure his/her blood-sugar level or urine-sugar level?
NUMBER OF TIMES .............................. |____|____|
RF ...................................................... 88DK ...................................................... 99
PER PERIOD:
week ........................... 1month ......................... 2year ............................. 3NEVER ........................ 5
CANCER
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.12 (During the last two years/ever) has a doctor ormedical personnel diagnosed (NAME) with can-cer?
Go to C.19
Pass to C.13
C.7 Is (NAME) currently taking any oral medication inorder to control his/her diabetes?
C.8 Is (NAME) currently using insulin shots?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.13 In total, how many cancers in different places ororgans has (NAME) ever had?
NUMBER OF CANCERS ........... |___|___|
RF ............................................... 88DK ............................................... 99
C.15 In the last two years, has (NAME) consulted a doc-tor or a medical personnel about his/her cancer?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
RF DKORGAN/BODY PART
88 99
C.14 In which organs or parts of his/her body has(NAME) had cancer(s)?
88 99
88 99
88 99
JUMP TO C.4
JUMP TO C.1 1
-
RESPIRATORY PROBLEMS
C.17 Is (NAME) currently receiving treatment for his/her cancer?
C.16 In the last two years, what type of treatments has(NAME) received for his/her cancer?
MARK ALL THAT APPLY
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.18 About in what year or at what age was his/her(most recent) cancer diagnosed?
Chemotherapy/ Medication ........................................ 1Surgery or Biopsy ...................................................... 2Radiation or X-Ray .................................................... 3Medication or Treatment for Symptoms
(Pain, Nausea, Rash) ............................................. 4NONE ........................................................................ 5
OTHER __________________________________ 7 SPECIFYRF ............................................................................. 8DK ............................................................................. 9
YEAR .................... |___|___|___|___|
RF................................... 8888DK .................................. 9999
ORAGE ..................................................... |____|____|
HEART PROBLEMS
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.22a (During the last two years/ever) has a doctor ormedical personnel told (NAME) that he/she hashad a heart attack?
Go to C.26
Pass toC.22b
C.23 Is (NAME) currently taking medication for his/herheart condition?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.24 Does (NAME) carry any medicine with him/her forchest pain?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.22b About in what year or at what age did (NAME) hashis/her (most recent) heart attack?
RF................................... 8888DK .................................. 9999
YEAR .................... |___|___|___|___|
ORAGE ..................................................... |____|____|
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.19 (During the last two years/ever) has a doctor ormedical personnel diagnosed (NAME) with a res-piratory illness such as asthma or emphysema?
Go toC.22a
Pass to C.20
C.20 Is (NAME) currently taking medication or usinganother treatment for his/her respiratory illness?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
[VOL] POSSIBLE STROKE OR TIA (TRANSIENTISCHEMIC ATTACK)
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.26 (During the last two years/ever) has a doctor ormedical personnel told (name) that he/she has hada stroke?
Go to C.32
Pass to C.27
STROKE
JUMP TO C.22a
JUMP TO C.26
-
OTHER CONDITIONS
YES NO RF DK
1 2 8 9Liver or kidney infection?
Tuberculosis?
Pneumonia?
1 2 8 9
1 2 8 9
C.36 In the last 2 years, has a doctor or medical per-sonnel told (NAME) that he/she has...
YES NO RF DK
1 2 8 9
...any weakness in his/herarms or legs or has his/hercapacity to move them or usethem been diminished?
...difficulty speaking or eat-ing?
...difficulty with his/hervision?
...difficulty thinking or sayingwhat he/she wants?
1 2 8 9
1 2 8 9
1 2 8 9
C.27 Because of his/her stroke does (NAME) have...?
C.28 Is (NAME) currently taking any medications be-cause of his/her stroke or for complications dueto the stroke?
C.29 Is (NAME) doing physical therapy or rehabilita-tion because of the stroke or the complicationsthat resulted from the stroke?
C.30 About in what year or at what age did (NAME) havehis/her (most recent) stroke?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
RF................................... 8888DK .................................. 9999
YEAR .................... |___|___|___|___|
ORAGE ..................................................... |____|____|
C.34 Is (NAME) taking medication or is he/she receiv-ing other treatment for his/her arthritis or rheuma-tism?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.33 Does (name) have pain, stiffness or swelling in thejoints?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
ARTHRITIS
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.32 (During the last two years/ever) has a doctor ormedical personnel told (name) that he/she hasarthritis or rheumatism?
Go to C.36
Pass to C.33
FALL
C.37 Has (NAME) fallen down in the last two years?
C.40 Since his/her fiftieth birthday, has (NAME) fracturedany bone including his/her hip?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
YES ........................................... 1NO ............................................. 2IS YOUNGER THAN 50 YEARS OLD
3
RF.............................................. 8DK ............................................. 9
Go to C.40
Pass to C.38
C.39 Has (NAME) hurt him/her-self in these falls badlyenough to need medical treatment?
C.38 Approximately how many times has this hap-pened?
RF....................................... 88DK ...................................... 99
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
NUMBER OF TIMES .................. |___|___|
JUMP TO C.32
JUMP TO C.36
-
SIGHT
C.41 Does (NAME) usually wear glasses?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
HEARING
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.43 Does (NAME) usually use a hearing aid or audi-tory device?
C.56 About how many cigarettes or packs does (NAME)usually smoke in a day?
CIGARETTES/DAY ................ |____|____| ORPACKS/DAY ............................ |____|____|
87 OR MORE CIGARETTES ............. 87RF ....................................................... 88DK ....................................................... 99
ASK FOR AN AVERAGE
SMOKING
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.54 Does (NAME) smoke cigarettes now?
Go to C.59a
Pass to C.55
daily ...................................... 1not every day ....................... 2
RF......................................... 8DK ........................................ 9
C.55 How often does (name) smoke?
Go to C.59a
Pass to C.56
C.51 Has (NAME) ever smoked cigarettes?
INCLUDE MORE THAN 100 CIGARETTES OR 5PACKS IN (NAME'S) LIFETIME. DO NOT IN-CLUDE PIPES OR CIGARS.
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
Y ES ............................................. 1
NO ............................................... 2
[VOL] NEVER HAVEUSED ALCOHOL ........................ 3
RF ............................................... 8DK ............................................... 9
C.59a Does (NAME) ever drink any alcoholic beveragessuch as beer, wine, liquor, or pulque?
Pass to C.59b
Go to C.64
C.59b In the last three months, about how many days aweek has (NAME) had any alcohol to drink?
NONE, OR LESS THAN ONE PER WEEK MARK "0 "AND GO TO C.64
NUMBER OF DAYS ...................... |____|
RF .............................................8DK .............................................9
C.59c On the days (NAME) drank alcoholic bever-ages in the last three months, about how manydrinks did he/she have per day?
NUMBER OF DRINKS .......... |____|____|
RF ....................................................... 88DK ....................................................... 99
ALCOHOL
C.64 Compared to two years ago, does (NAME) weigh...
5 more kilos .............................. 15 less kilos ................................ 2About the same ......................... 3
RF.............................................. 8DK ............................................. 9
WEIGHT AND HEIGHT
C.59d In the last three months, on how many days has(NAME) had four or more drinks on one occasion?
NUMBER OF DAYS .............. |____|____|
NONE.................................................. 0087 OR MORE DAYS ........................... 87RF ....................................................... 88DK ....................................................... 99
C.65 In the last two years, has (NAME) changed his/herdiet or his/her exercise habits in order to gain orlose weight?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
JUMP TO C.43
JUMP TO C.51
JUMP TO C.54
JUMP TO C.59a
JUMP TO C.64
Go to C.59a
Pass to C.54
-
C.72 NTERVIEWER:WITH WHAT FREQUENCY DID THE RESPONDENTNEED HELP TO ANSWER SECTION C. HEALTH?
NEVER ........................................................ 1A FEW TIMES ............................................. 2MOST OF THE TIME .................................. 3
FINISH TIME: |____|____|:|____|____|
SYMPTOMS
C.67 About how tall is (NAME) without shoes?
METERS AND CENTIMETERS ......... |____|.|____|____|
RF.......................................... 8.88DK ......................................... 9.99
PASS TO SECTION D
C.71 In the last 12 months, because of an illness orinjury, about how many days did (NAME) have tostay in bed more than half a day?
NUMBER OF DAYS ................ |____|____|____|
RF ............................................................... 888DK ............................................................... 999
INCLUDE DAYS WHEN YOU WERE IN HOSPITAL
C.66 About how much does (NAME) weigh now?
KILOS ......................... |____|____|____|
RF ......................................... 888DK ......................................... 999
C.69b In the last two years, has (NAME) lost a limb orpart of his/her body due to an accident or illness?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
C.69a Is (NAME) missing any limb or part of his/her legsor arms due to an accident or illness?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
JUMP TO C.69a
Go to C.70
Pass to C.69b
C.70 (During the last two years/ever), has a doctor ormedical personnel told (name) that he/she has anyhealth problem caused by his/her work?
YES ......................................... 1NO ........................................... 2DOES NOT WORK .................. 3
RF ............................................ 8DK ............................................ 9
INCLUDE WORK ACCIDENTS
-
YES ...................... 1NO ........................ 2
RF ........................ 8DK ........................ 9
D.8 Does (NAME) have the rightto medical attention in...?
D.9 Does (NAME) have theright to these medical ser-vices because he/she is...?
A worker ................................... 1Affiliated on his/her own ........... 2Retired ...................................... 3Spouse of insured ..................... 4Mother or father of insured ........ 5Other ........................................ 7RF ..................................................... 8DK ..................................................... 9
Go to thenext optionor to D.10
Pass to D.9
IF MARKED NO=2 IN ALL OPTIONS OF D.1 , ASK TO VERIFY :
YES, HE/SHE HAS .............. 1NO, HE/SHEDOESN'T HAVE ................... 2RF......................................... 8DK ........................................ 9
D.10 Then, (NAME) does not have the right to medical services in any institu-tion?
Pass to D.11
CORRECT ABOVE AND PASS TO D.11
D.11 Including all of your hospital stays of the pastyear, about how many nights did (NAME) stay in ahospital overnight?
NONE ............................... 000RF ..................................... 888DK .................................... 999
NUMBER OF NIGHTS ................ |____|____|____|
Go to D.15
D.12 Where did (NAME) receive the service(s)?
IMSS ................................................. 1ISSSTE .............................................2Department of Health ........................3IMSS Solidaridad ..............................4Private clinic or hospital ................... 5Red Cross, Green Cross .................6OTHER .............................................. 7
RF......................................................8DK .....................................................9
READ ALL OPTIONS AND CIRCLE ALL THATAPPLY
D.13 Altogether, about how much did (NAME) pay forthese hospitalizations?
NOTHING................... 000000
RF............................... 888888
DK .............................. 999999Pass to D.14
IF RESP SPECIFIES AN AMOUNT, GO TO D.15
D.14 Would you say that it was ...
YES .................. 1
No .................... 2
DK .................... 9
Pass to D.14b
Go to D.14c
Go to D.15
YES .................. 1
No .................... 2
DK .................... 9
Go to D.15
D.14b ...more than $2,000 pesos?
D.14c ...more than $16,000 pesos?
D.14a ...more than $4,000 pesos?
YES .................. 1
No .................... 2
DK .................... 9
AMOUNT ................. |__|__|__|__|__|__|
Go to D.15
(MARK ALL THAT APPLY )
Pass to D.12
Social Security (IMSS)
ISSSTE
Pemex, Defense or Navy
Private medical insurance
Other
|___||___||___||___||___||___||___|
SECTION D. HEALTH CARE SERVICES
JUMP TO D.8
-
D.15 During the last year, how manytimes…
NONE ................ 000
RF ..................... 888DK ..................... 999
Pass to D.16
Go to next columnor to D.18
D.16 Altogether, about how much did(NAME) pay for these consultations, ordid he/she pay in-kind?
SPECIFIES AMOUNT
NOTHING .................... 000000
PAID IN-KIND .............. 777777
RF ............................... 888888
DK ............................... 999999Pass to D.17
Go to nextcolumn or to D.18
D.17 Would you say that it was ...
YES .................. 1
No .................... 2
DK .................... 9
Pass to D.17b
Go to D.17c
Go to nextcolumn or to
D.18
YES .................. 1
No .................... 2
DK .................... 9
D.17b more than $200 pesos?
D.17c more than $8,000 pesos?
D.17a more than $1,000 pesos?
YES .................. 1
No .................... 2
DK .................... 9
Go to nextcolumn or to
D.18
DENTISTFOLKHEALER
Go to nextcolumn or to
D.18
MEDICAL VISITSOUTPATIENTPROCEDURES
|___|____|____|
|___|
|___|
|___|
|___|____|____|
|___|
|___|
|___|
|___|____|____|
|___|
|___|
|___|
|___|____|____|
|___|
|___|
|___|
has (NAME) seena dentist?
has (NAME) seena folk healer orhomeopath?
...has (NAME)visited or con-sulted a doctor ormedical person-nel?
has (NAME) hadoutpatientprocedures, notincluding staysin the hospital?
UTILIZATION OF SERVICES
IF RESP SPECIFIES AN AMOUNT D.16
-
D.18 In the last year, has (NAME) consulted a pharma-cist about his/her health?
YES ...................................... 1NO ........................................ 2
RF......................................... 8DK ........................................ 9
D.20 In the last year, who paid most of the out-of-pocketmedical costs?
Go to D.34
Pass to D.21
ALL .................................................. 781RF ............................................................ 888DK ............................................................ 999
MEDICAL EXPENSES
SON/DAUGHTER ................ 01SON/DAUGHTER-IN-LAW .. 02GRANDCHILD ..................... 03FATHER/MOTHER .............. 04OTHER RELATIVE .............. 05OTHER PERSON ................ 06RESPONDENT AND/ORSPOUSE .............................. 07DID NOT HAVE EXPENSES08
RF ........................................ 88DK ........................................ 99
[IF IT IS SON/DAUGHTER-IN-LAW, NOTE THE REGISTRATIONNUMBER OF THE CHILD HE/SHE IS RELATED TO]
REGISTRATIONNUMBER
|____|____|____|
NAME
D.21 Which child paid most?
|__|__|
PASS TO SECTION PC
FINISH TIME: |_____|_____|:|_____|_____|
D.34 INTERVIEWER:WITH WHAT FREQUENCY DID THE RESPONDENTNEED HELP TO ANSWER SECTION D. HEALTHSERVICES?
NEVER ........................................................ 1A FEW TIMES ............................................. 2MOST OF THE TIME .................................. 3
JUMP TO D.20
JUMP TO D.34
-
29
START TIME: |_____|_____|:|_____|_____|SECTION PROXY COGNITIVE
PC.2 Compared to two years ago, would you say(NAME's) memory is...?
PC.1 Part of this study is concerned with people'smemory, and ability to think about things.
First, how would you rate (NAME's) memory atthe present time? Would you say it is....
Excellent ................................... 1Very Good ................................. 2Good ......................................... 3Fair ............................................ 4Poor .......................................... 5
RF ............................................. 8DK ............................................. 9
Better ........................................ 1Same ........................................ 2Worse ....................................... 3
RF ............................................. 8DK ............................................. 9
PC.3 How would you rate (NAME'S) ability to makejudgements and decisions? Would you say his/her abilities are...?
PC.4 How would you rate (NAME'S) ability to organizehis/her daily activities? Would you say his/herabilities are...?
Now we want you to remember how (NAME) was two years ago and tocompare it with how he/she is like now. Two years ago was in2 0 0 1 . I will read situations where (NAME) has to use his/hermemory or intelligence. We would like you to indicate whetherthis has improved, stayed the same, or gotten worse in that situ-ation over the past two years. Note the importance of comparinghis/her present performance with two years ago. So if two yearsago (NAME) always forgot where he/she had left things, and he/she still does, then this would be considered «not much change».
PC.5 Compared to two years ago, how is (NAME) at rememberingthings about family and friends, such as occupations,birthdays, and addresses? Has this...
Go to PC.8
Excellent ................................... 1Very Good ................................. 2Good ......................................... 3Fair ............................................ 4Poor .......................................... 5
RF ............................................. 8DK ............................................. 9
Excellent ................................... 1Very Good ................................. 2Good ......................................... 3Fair ............................................ 4Poor .......................................... 5
RF ............................................. 8DK ............................................. 9
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.6Go to PC.8Go to PC.7
PC.6 Is it much improved or a bit improved?
PC.7 Is it much worse or a bit worse?
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
Go to PC.8
PC.8 Compared with two years ago, how is (NAME) at rememberingthings that have happened recently? Has this...?
Go to PC.11
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.9Go to PC.11Go to PC.10
PC.9 Is it much improved or a bit improved?
PC.10 Is it much worse or a bit worse?
Go to PC.11
PC.11 Compared with two years ago, how is (NAME) at recallingconversations a few days later? Has this...?
Go to PC.14
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.12Go to PC.14Go to PC.13
PC.12 Is it much improved or a bit improved?
PC.13 Is it much worse or a bit worse?
Go to PC.14
READ THE OPTIONS
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
-
30
Go to PC.17
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.15Go to PC.17Go to PC.16
PC.14 Compared to two years ago, how is (NAME) at rememberinghis/her address and telephone number? Has this...?
PC.17 Compared to two years ago, how is (NAME) at rememberingwhat day and month it is? Has this...?
Go to PC.20
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.18Go to PC.20Go to PC.19
PC.18 Is it much improved or a bit improved?
PC.19 Is it much worse or a bit worse?
Go to PC.20
PC.20 Compared to two years ago, how is (NAME) at rememberingwhere things are usually kept? Has this...?
Go to PC.23
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.21Go to PC.23Go to PC.22
PC.21 Is it much improved or a bit improved?
PC.22 Is it much worse or a bit worse?
Go to PC.23
PC.23 Compared to two years ago, how is (NAME) at rememberingwhere to find things which have been put in a different placethan usual? Has this...?
Go to PC.26
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.24Go to PC.26Go to PC.25
PC.15 Is it much improved or a bit improved?
PC.16 Is it much worse or a bit worse?
Go to PC.17
PC.24 Is it much improved or a bit improved?
PC.25 Is it much worse or a bit worse?
Go to PC.26
PC.26 Compared to two years ago, how is (NAME) at knowing how towork familiar machines around the house? Has this...?
Go to PC.29
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.27Go to PC.29Go to PC.28
PC.27 Is it much improved or a bit improved?
Go to PC.29
PC.28 Is it much worse or a bit worse?
PC.29 Compared to two years ago, how is (NAME) at learning to use anew gadget or machine around the house? Has this...?
Go to PC.32
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.30Go to PC.32Go to PC.31
PC.30 Is it much improved or a bit improved?
Go to PC.32
PC.31 Is it much worse or a bit worse?
READ THE OPTIONS
READ THE OPTIONS
READ THE OPTIONS
READ THE OPTIONS
READ THE OPTIONS
READ THE OPTIONS
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
-
31
Go to PC.35
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.33Go to PC.35Go to PC.34
PC.33 Is it much improved or a bit improved?
PC.34 Is it much worse or a bit worse?
Go to PC.35
PC.32 Compared to two years ago, how is (NAME) at learning newthings in general? Has this...?
Go to PC.38
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.36Go to PC.38Go to PC.37
PC.36 Is it much improved or a bit improved?
PC.37 Is it much worse or a bit worse?
Go to PC.38
PC.35 Compared to two years ago, how is (NAME) at following a storyin a book or on TV? Has this...?
PC.38 Compared to two years ago, how is (NAME) at making decisionson everyday matters, like what to cook or to wear? Has this...?
Go to PC.41
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.39Go to PC.41Go to PC.40
PC.39 Is it much improved or a bit improved?
Go to PC.41
PC.40 Is it much worse or a bit worse?
PC.41 Compared to two years ago, how is (NAME) at handling moneyfor shopping? Has this...?
Go to PC.44
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.42Go to PC.44Go to PC.43
PC.42 Is it much improved or a bit improved?
PC.43 Is it much worse or a bit worse?
Go to PC.44
PC.44 Compared to two years ago, how is (NAME) at handling financialmatters, that is, the pension or dealing with the bank? Hasthis...?
Go to PC.47
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.45Go to PC.47Go to PC.46
PC.45 Is it much improved or a bit improved?
Go to PC.47
PC.46 Is it much worse or a bit worse?
PC.47 Compared to two years ago, how is (NAME) at handling othereveryday arithmetic problems, such as, knowing how much foodto buy, knowing how long between visits from family or friends?Has this...?
Go to PC.50
Improved ................................... 1Not much changed ................... 2Gotten worse ............................ 3
RF ............................................. 8DK ............................................. 9
Pass to PC.48Go to PC.50Go to PC.49
PC.48 Is it much improved or a bit improved?
Go to PC.50
PC.49 Is it much worse or a bit worse?
READ THE OPTIONS READ THE OPTIONS
READ THE OPTIONSREAD THE OPTIONS
READ THE OPTIONS
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
-
32
PC.50 Compared to two years ago, how is (NAME) at using his/herintelligence to understand what's going on and to reason thingsthrough? Has this...?
Go to PC.53
Improved ...................................... 1Not much changed ...................... 2Gotten worse ............................... 3
RF ................................................ 8DK ................................................ 9
Pass to PC.51Go to PC.53Go to PC.52
PC.51 Is it much improved or a bit improved?
Go to PC.53
PC.52 Is it much worse or a bit worse?
PASS TO F.3
PC.53 Now, thinking about some currentbehaviors, does he/she ever get lost ina familiar environment?
PC.56 Does (NAME) ever see or hear thingsthat are not really there?
PC.55 Can he/she be left alone for an hour orso?
PC.54. Does he/she ever wander off and notreturn by himself/herself?
YES .......................................... 1NO .................................. 2RF ................................... 8DK .................................. 9
PC.58 During the past week, how often has(NAME) had difficulties falling asleep or wakes up frequently during the night?Has it been...?
PC.60 During the past week, how often has(NAME) paced around or madeunexplained rocking movements whilesitting? Has it been...?
PC.59 During the past week, how often has(NAME) done things that are dangerousto himself/herself or others? Has itbeen...?
PC.61 During the past week, how often has(NAME) mentioned that people areplotting against or trying to harm him/her? Has it been...?
PC.57 During the past week, how often hashe/she become angry or hostile? Has itbeen...?
PC.62 During the past week, how often has(NAME) drunk too much alcohol? Hasit been...?
MOST OF TIME ............. 1
SOME OF TIME ...................... 2
NEVER ........................ 3
RF ............................... 8
DK ............................... 9
FINISH TIME: |____|____|:|____|____|
YES .......................................... 1NO .................................. 2RF ................................... 8DK .................................. 9
YES .......................................... 1NO .................................. 2RF ................................... 8DK .................................. 9
YES .................................. 1NO .................................. 2RF ................................... 8DK .................................. 9
PC.6 3 INTERVIEWER:WITH WHAT FREQUENCY DID THEPROXY RESPONDENT NEED HELP TOANSWER SECTION PC. PROXY COG-NITIVE?
READ THE OPTIONS
PAST WEEK
MUCH IMPROVED ...................1A BIT IMPROVED .....................2
RF .............................................8DK .............................................9
MUCH WORSE ........................1A BIT WORSE ..........................2
RF .............................................8DK .............................................9
MOST OF TIME ............. 1
SOME OF TIME ...................... 2
NEVER ........................ 3
RF ............................... 8
DK ............................... 9
MOST OF TIME ............. 1
SOME OF TIME .................... 2
NEVER ........................ 3
RF ............................... 8
DK ............................... 9
MOST OF TIME ............. 1
SOME OF TIME .................... 2
NEVER ........................ 3
RF ............................... 8
DK ............................... 9
MOST OF TIME ............. 1
SOME OF TIME .................... 2
NEVER ........................ 3
RF ............................... 8
DK ............................... 9
MOST OF TIME ............. 1
SOME OF TIME .................... 2
NEVER ........................ 3
RF ............................... 8
DK ............................... 9
NEVER ......................................... 1A FEW TIMES .............................. 2MOST OF THE TIME ................... 3
-
HORA AL INICIAR |_____|_____|:|_____|_____|
MOTHER
F.5 Because of a health problem does (NAME's)mother need any help with basic personal needslike dressing, eating or bathing?
YES ........................... 1NO ............................. 2
RF ............................. 8DK ............................. 9
F.6 Can (NAME's) mother be left alone for an hour ormore?
YES ........................... 1NO ............................. 2
RF ............................. 8DK ............................. 9
Go to F.9
SECTION F. PARENTS AND HELP TOPARENTS
F.12 Is (NAME's) father alive now?
F.3 Is (NAME's) mother alive now?
YES ........................... 1NO ............................. 2
RF ............................. 8DK ............................. 9 Go to F.9
Pass to F.4
Go to F.7
MOTHER ALIVE
YES ........................... 1NO ............................. 2
RF ............................. 8DK ............................. 9 Go to F.18
Pass to F.13Go to F.16
F.7 Did (NAME's) mother die within the last twoyears (since the last time we talked with him/her)?
AGE ...................... |____|____|____|
RF ........................................... 888DK ........................................... 999
DECEASED MOTHER
YES ........................... 1NO ............................. 2
RF ............................. 8DK ............................. 9 Go to F.9
F.8 How old was (NAME's) mother when she died?
Pass to F.8
F.9 Did a doctor or medical personnel ever tell(NAME's) mother that she had diabetes or highblood sugar?
YES ........................... 1NO ............................. 2
RF ............................. 8DK ............................. 9
F.4 How old is (NAME's) mother?
AGE ...................... |____|____|____|
RF ........................................... 888DK ........................................... 999
FATHER
GO TO F.3
JUMP TO F.12
-
F.19 INTERVIEWER - LOOK AT F.3 AND F.12 ANDMARK WITHOUT ASKING
BOTH PARENTS LIVING .................................... 1
ONLY MOTHER LIVING ..................................... 2
ONLY FATHER LIVING ....................................... 3
BOTH PARENTS REPORTED DEAD OR ITIS NOT KNOWN IF THEY ARE ALIVE ................ 4
ONLY MOTHER LIVING
F.20 Is (NAME's) mother currently married or in aunion?
YES ........................... 1NO ............................. 2
RF ............................. 8DK ............................. 9
ONLY FATHER LIVING
YES ........................... 1NO ............................. 2
RF ............................. 8DK ............................. 9
Pass to F.23
BOTH PARENTS LIVING
F.22 Are (NAME's) parents married to each other?
F.23 Do (NAME's) parents live together?
YES ........................... 1NO .........
