Supplementary Materials: Study Tools
Transcript of Supplementary Materials: Study Tools
INSPIRE STUDY TOOLS
Cohort profile: Indian Network of Population-Based Surveillance Platforms for Influenza
and Other Respiratory Viruses among the Elderly (INSPIRE)
Anand Krishnan 1 , Lalit Dar 1 , Ritvik Amarchand 1 , Aslesh O Prabhakaran 2 , Rakesh Kumar 1 , Prabu
Rajkumar 3 , Suman Kanungo 4 , Sumit Dutt Bhardwaj 5 , Avinash Choudekar 1 , Varsha Potdar 5 , Alok
Kumar Chakrabarty 4 , Girish Kumar CP 3 , Giridara Gopal P 1 , Shivram Dhakad 1 , Byomkesh
Manna 4 , Ashish Choudhary 1 , Kathryn E Lafond 6 , Eduardo Azziz-Baumgartner 6 , Siddhartha Saha 2
1. All India Institute of Medical Sciences, New Delhi
2. Influenza Division, Centers for Disease Control and Prevention-India Office, New Delhi
3. National Institute of Epidemiology, Chennai
4. National Institute of Cholera and Enteric Diseases, Kolkata
5. National Institute of Virology, Pune
6. Centers for Disease Control and Prevention, Atlanta
Supplementary Materials: Study Tools
For more information contact: [email protected]
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INSPIRE STUDY TOOLS
1. Enrolment form
2. Date form filled
3. Form filled by *(Drop down or login id)
4. Name of the village/ ward (drop down list)
5. Allocated household number
6. Address – house number or, landmark
7. Capture the GIS Location Latitude:_________________
Longitude:__________________
8. How many adults aged 60 or more residing for
more than 6 months
(Adminster PIS to each and seek written informed
consent)
9. Total number of elderly individuals consented
10. Phone Numbers of person (non participant)
Landline:
Mobile__Number_
______
(name of the
person)
11. Total number of persons living in the household:
(include everyone from a one day old child onwards)
12. List of individuals in the household ( Age in completed years as on Date of Interview)
Sn
o
Name Age Gende
r
(M/F)
Sn
o
Name Age Gender
(M/F)
1 8
2 9
3 10
4 11
5 12
6 13
7 14
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2. Community Surveillance questionnaire
This is weekly surveillance form to be filled by nurses
Q1 Please select the day
Monday-M
Tuesday-T
Wednesday-W
Thursday-H
Friday-F
Q2 Please select nurse code 1, 2, 3, 4, 5
Q2.1 Please select serial no. as per the day’s route 1 2 3….so on (as per nurses route map)
Does the system date dd/mm/yyyy and csv date dd/mm/yyyy match? If yes tick the check box. If not please check
whether you have selected the correct day and inform programmer- data cannot be collected if the dates do not match.
Q3 Please check name, age and gender displayed
below with that of the participant in this house. If
correct, go to next screen else go to the previous
screen and select the correct house serial no.
Name (DISPLAY FROM csv file )
H.No. (DISPLAY FROM csv file)
Age (DISPLAY FROM csv file)
Gender (DISPLAY FROM csv file)
Q4 Is the Participant available? If not is he/she likely
to return in next 2-3 hours or is the house locked?
Yes at home =1
Not at home but likely to return by 1 pm=2
Participant not available and unlikely to return
today=3
House locked at first visit=4
House locked on second visit=5
Yes at home but refused to provide information=6
If 1 go to Q11
If 2 or 4 return
after 3 hours or
time suggested
by informer
and go for at
least 2 visit
AND FILL
FROM THIS
POINT ON
, if unavailable
go to Q5 and
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after second visit
fill 3 and proceed
If 3 go to Q6
If 5 go to Q86
If 6 note in
logbook and
inform
supervisor and
go to Q86
Q5 Select no: of visit Visit 1
Visit 2
If still
unavailable after
visit 1 and visit 2
,go to Q86
Q6 Ask the participants whereabouts
Participant has died=1
Participant has migrated out/ shifted won’t return =3
Participant is away for last 3 or more days =4
Participant is away for last 1 or 2 days =5
If 1 go to 7
If 3 go to Q8
If 4 and 5 go to
Q9
Q7 Details related
to death
Date of death(Select date from
calendar)
d d m m y y y y
Note this your
logbook and
inform
supervisor and
go to Q86 Place of death In Hospital
Outside Hospital
Do not know
Q8 Details related
to Migration
Date migrated (select date from
calendar)
d d m m y y y y
Note this in your
logbook and
inform
Supervisor and
go to go to Q86 Place migrated to
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INSPIRE STUDY TOOLS
Q9 Can the participant be reached on phone? if yes call
and inform purpose of calling
No=1; Yes =2
If 2 go to Q11
Q10 The participant could not be contacted, can you or
someone else present in the house answer questions
about his health in last seven days.
Yes someone who can tell is available=1
No, none of the persons present can provide any
info=2
If 1 go to Q11
and if 2 mark
visit 1 or 2 and
go to Q86
Q11 Informant
Self in person=1
Self (on phone)=2
Another adult=3
If self (1 or 2)
go to Q14
Q12 Name of the adult informant ___________________
Q13 Relationship with participant
Spouse=1; Son=2 ; Daughter=3
Daughter in law=4 ; Adult grandchild =5
Others=6
Go to Q14
Q14 Were you (the participant) hospitalized in last
seven days? Yes=1, No=2
If 2 go to 18
Q15 HOSPITALIZATION
DETAILS
Name of hospital (Note
this in your logbook)
Inform
Supervisor
Address of hospital(Note
this in your logbook)
Date of admission Note
this in your logbook)
d d m m y y y y
Reason for admission
(Note in your logbook)
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Q16 Status of Hospitalized Patient(Note this in your
logbook)
Still in Hospital=1,Discharged=2 If 1 inform
supervisor and
go to Q86
Q17 Date of discharge (Select date from calendar)(note
this in your logbook)
d d m m y y y y
Now I am going to ask you about respiratory systems in last seven days
Q18 Last week when I visited you had informed that
cough was “Present /Absent” (will be automatically displayed )
(this will be prefilled and
“PRESENT ” will display When participant was visited last week and
he/ she had cough)
if displays
Absent, go to Q
21
Q19 Has that cough ended?
Yes=1, No=2
If 2 go to Q25
Q20 Date of end of cough (Select date from calendar) d d m m y y y y
Write date and
Go to Q55
Q21 Did you (the participant) have cough in last seven
days? Yes=1, No=2
If 2 Go to Q55
Q22 Date of start of cough d d m m y y y y
Q23 Has cough ended?
Yes=1, No=2
If 2 go to Q28
Q24 Date of end of cough d d m m y y y y
Go to Q55
Q 25 Last week when I visited you had informed that
sputum was “Present /Absent” (will be automatically displayed )
(this will be prefilled and
“PRESENT ” will display When participant was visited last week he/
she had sputum associated with
cough)
If Absent go to Q
30
Q26 Has that sputum ended? Yes=1 No=2
If 2 go to Q32
Q27 Date of end of sputum (select date from calendar) d d m m y y y y
Write the date
and Go to Q55
Q28
Did you (the participant) have sputum in last seven
days?
Yes=1; No=2
If 2 go to Q55
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Q29 Date of start of sputum (select date from calendar) d d m m y y y y
Q30 Has the sputum ended? Yes=1 No=2
If 2 go to Q37
Q31 Date of end of sputum (select date from calendar) d d m m y y y y
Write the date
and Go to Q55
Q32 Last week when I visited you had informed that an
increased volume of sputum was “Present /Absent” (will be automatically displayed )
(this will be prefilled and
“PRESENT ” will display When participant was visited last week he/
she had an increased volume of
sputum was)
If Absent go to
Q35
Q33 Has that increased volume of sputum come back to
usual level? Yes=1 No=2
If 2 go to Q39
Q34 Date the volume of sputum associated with cough
came back to usual level (select date from
calendar)
d d m m y y y y
go to Q39
Q35 Has the volume of sputum increased in last seven
days level? Yes=1 No=2
If 2 go to Q39 or
Q42
Q36 Date on which the volume of sputum increased
over its usual level (select date from calendar)
d d m m y y y y
Q37 Has the volume of sputum come back to usual
level? Yes=1 No=2
If 2 go to Q39 or
Q42
Q38 Date the increased volume of sputum associated
with cough came back to usual level (select date
from calendar)
d d m m y y y y
Go to Q42
Q39
Last week when I visited you had informed that an
change in color of sputum was “Present /Absent” (will be automatically displayed )
(this will be prefilled and
“PRESENT ” will display When participant was visited last week he/
she had an change in color of
sputum)
If Absent go to
Q42
Q40
Has the sputum color returned to its usual color?
Yes=1 , No=2
If 2 go to Q46
Q41
DATE on which the sputum returned to its usual
color? (select date from calendar)
d d m m y y y y
Go to Q46
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Q42 Did you (the participant) notice a change from
usual in color of sputum in last seven days?
Yes=1 No=2
If 2 go to Q46 or
Q49
Q43 Date the change in sputum color was noticed? d d m m y y y y
Q44 Has the sputum returned to its usual color?
Yes=1; No=2
If 2 go to Q45 or
Q49
Q45 Date the sputum color came back to its usual color d d m m y y y y
Go to Q49
Q46
Last week when I visited you had informed that
blood was “Present /Absent” (will be automatically displayed )
(this will be prefilled and
“PRESENT” will display When participant was visited last week he/
she had blood in sputum)
If Absent go to
Q49
Q47
Has the blood cleared from sputum? Yes=1 No=2
If 2 go to Q 53
Q48 Date blood cleared from sputum (select date from
calendar)
d d m m y y y y
Go to Q 53
Q49 Did you (the participant) notice blood in sputum in
last seven days? Yes=1, No=2
If 2 go to Q53
Q50 Date from which blood was noticed in sputum d d m m y y y y
Q51 Has the blood cleared from sputum?
Yes=1, No=2
If 2 go to Q53
Q52 Date blood cleared from sputum d d m m y y y y
Q53 Last week when I visited you had informed that
difficulty in Breathing was “Present /Absent” (will be automatically displayed )
(this will be prefilled and PRESENT
will display when participant was
visited last week he/ she had
difficulty in breathing
If Absent skip to
Q 56
Q54 Has that difficulty in breathing ended?
Yes=1, No=2
If 2 go to Q60
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Q55 Date of end of difficulty in breathing d d m m y y y y
Write date and
Go to Q 62
Q56 Did you have difficulty in breathing in the last
seven days? Yes =1; No= 2
If 2 Go to Q 62
Q57 Date of start of difficulty in breathing select date
from calendar)
d d m m y y y y
Q58 Has difficulty in breathing ended?
Yes=1, No=2
If 2 go to Q60
Q59 Date of end of difficulty in breathing d d m m y y y y
Q60 Is there chest pain associated with difficulty in
breathing?
Yes=1, No=2
If 2 Go to Q62
Q61 Does the chest pain increase with respiration?
Yes=1, No=2
If 2 Go to Q62
Q62
Last week when I visited you had informed that
fever was “Present /Absent” (will be automatically
displayed )
(this will be prefilled and PRESENT
will display when participant was
visited last week he/ she had fever
If Absent go to
Q65
Q63 Has that fever ended? Yes=1, No=2
If 2 got to Q70
Q64 Date of end of fever (select date from calendar) d d m m y y y y
Write date and
go to Q70
Q65 Did you have fever in last seven days?
Yes =1; No= 2
If 2go to Q70
Q66 Date of start of fever d d m m y y y y
Q67 Has that fever ended? Yes=1, No=2
If 2go to Q70
Q68 Date of end of fever (select date from calendar) d d m m y y y y
Q69 Did you have chill and Rigor in last seven days ?
Yes = 1 ; No = 2
Q71 Did you have malaise in last seven days?
Yes =1; No= 2
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Q72 Did you have headache in last seven days?
Yes =1; No= 2
Q73 Did you have muscle pain in last seven days?
Yes =1; No= 2
If participant reports respiratory symptoms in last seven days proceed for clinical assessment
IF any of these are reported afresh in last seven days ( cough/ difficulty in breathing / sore throat or, nasal
discharge ) or persistent cough ( continued from last week) with ( sputum with cough/ increase in volume of
sputum/ change in color of sputum/ blood in sputum) or persistent cough ( continued from last week) with
fever in last seven days or, persistent difficulty in breathing ( continued from last seven days) with (fever in
last seven days or, chest pain associated with difficulty in breathing )
Clinical Assessment
Q 74 Temperature (Axillary) (In Fahrenheit) .
Q75
Pulse rate (per minute – count for one minute)
Q76 Respiratory Rate (count for a minute)
Q77 Oxygen Saturation
(Read after 1 minute )
Q 78 Auscultation Findings
a) Crepitation
Yes =1; No= 2
b) Rhonchi
Yes =1; No= 2
c) Reduced air entry
Yes =1; No= 2
Others ______(specify)_________
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INSPIRE STUDY TOOLS
Q79 If patient is classified as ALRI(will be automatically displayed )
(Presence of symptoms of an acute lower respiratory tract illness i.e. cough and at least one other lower
respiratory tract symptom (dyspnea, chest pain) AND at least one systemic feature (sweating, fevers, shivers,
aches and pains and/or temperature of 38° C or more) AND tachypnea (respiratory rate> 20).
Proceed and collect a nasal and a throat swab. Go to Q.95 and Q 96
Q80 If patient is classified as AURI (for those not classified as ALRI, will be automatically displayed )
and today is your designated day to collect samples take a nasal and a throat swab
Q 81 Was Nasal swab collected?
This was not the designated day =1
Yes =2; No= 3 Refused to provide swab=8
If 1 go to go to
Q85
If 2 , 3 or 8 go to
Q85
Q82 Was throat swab collected?
This was not the designated day =1
Yes =2; No= 3 Refused to provide swab =8
If either nasal or
throat swab is
taken go to 83
Else go to 85
Q83 Scan the barcode used for the samples
Get Barcode
Q84 SAMPLE ID ALLOCATED
(Bar Code Number)
Q85 For the ongoing /previous ARI episode did you
(the participant) visit any : 1 PUBLIC HEALTH SECTOR
(modern system)
2) PRIVATE HEALTH SECTOR
(modern system)
3 OTHER (specify)
Q86
Outcome
Select either a or b and save the
form
a)Form completed
b)Need to return to fill the form
If algorithm suggests use of antibiotics/ PCM/ Referral please follow the directions
Handheld screen will display the directions as per the algorithm
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INSPIRE STUDY TOOLS
3. Baseline Household form
1 Date form filled (automatically generated by system)
2 ID of the person filling the form (interviewer code) -2 digits
3 Please select city code (select one –radio button)
4 Please select area code (Two digit)
(Ward/ village code)
5
Please enter the allocated structure number (4 Digits followed by 1 alphabet) in three centers the
alphabet is fixed as A as the mapping has happened for the first time
6 Please enter the allocated household number (as per list of households in each structure) (Two
digit)
If for any question respondent refuses to answer / let the worker observe write 8/88
7 What is the MAIN source of drinking water for
your household most of the time of the year?
Piped water in own house =01 ,
Piped water from community pipe =02
Hand pump=03, Tube well= 04,
Dug well =05,Bottled water=06 ,
Tanker truck=07Surface Water=11,
Others=12Specify_________
8 Do you treat water before drinking in all seasons? Yes= 1, No=2
9 If Yes, mention how does your household mostly
treat your drinking water?
Boiling =01, Filtering by cloth =02, Using
candle filter =03, Adding Chlorine
Solution/tablet =04, Aquaguard=05,
Reverse Osmosis =06, Others =07Specify
10 What is the MAIN source of water used by your
household for purposes other than drinking such
as cooking most of the time of the year?
Piped water in own house =01,
Piped water from community pipe =02
Hand pump=03, Tube well= 04,
Dug well =05, Bottled water = 06,
Tanker truck =07, Surface Water=11,
Others=12Specify ___________
11 What kind of toilet facility do members of your
family usually use
Water Seal latrine =01; Pit Latrine =02, Dry
Latrine =03,
No facility/uses open space or field =4
If choice =4 go to Q7
12 Do you share this toilet facility with other
households
Open Fire =01, Chullah=2 , Improved
Stove=3,=4 ,Induction plate/ Electric Heater
=5,
Gas Stove =6 ; Kerosene stove=7, OthersSpecify=11_________
13 What type of stove is usually used for cooking? Open Fire=01, Chullah=2 , Improved
Stove=4 ,Induction plate/ Electric Heater
=5,
Gas Stove=6 ; Kerosene stove=7, OthersSpecify=11_________
14 Does your household have a hand washing
facility?
Yes= 1, No=2
15 If yes then is water available there? Yes= 1, No=2
16 If yes then is soap available there? Yes= 1, No=2
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Record your observation regarding the built of the floor, roof and walls of the household.
17 MAIN material of the floor Mud/clay/earth/cow dung=1, Unburnt
brick/stone=2
Bricks/Concrete/tiles/marble=3,
Others = 04(specify) _________________
18 MAIN material of the roof Thatched/Leaves/Mud/polythene sheet =1,
Unburnt brick/stone slab/ wooden planks/
Bamboo =2, Cement/Concrete/Asbestos
sheet/ tiles/Burnt brick, Others =
04(specify)_________________
19 MAIN material of exterior walls Thatched/Leaves/Mud/polythene sheet=1,
Stone with mud/mud brick/ wooden
planks=2, Concrete/Burnt brick/Asbestos
sheets =3 Others =
04(specify)_________________
Ask and note the detail about rooms and their ventilation
20 What is the total number of rooms in the house
used by your household?
Room
21 Do you use a separate kitchen for cooking, or do
you use part of another room for cooking food or
do you cook in open space outside the house?
Cook in a separate kitchen =1
Use part of another room for cooking =2
Cook in open space outside the house=3
22 Is there proper ventilation most of the time in
rooms used for sleeping and living room (observe
possibility of cross ventilation/ ask if need be)
Yes= 1, No=2
23 How is the ventilation at the place used for
cooking ?
Room/ Kitchen with eave spaces affording
some ventilation=2
Room/ Kitchen with open Windows/door
affording good ventilation=3
Veranda/ Partially open space=4
Outdoors=5If choice is 4 or 5 go to Q20
Ask for the ownership of immovable and movable assets of the family
24 Does this household own this or any other house? Yes= 1, No=2
25 Does this household own any land? Yes= 1, No=2
26 If yes, how much? Specify (Acres or another size/unit) ________
27 What is the type of your electricity connection? Metered=01, Unmetered=02, No
connection=03
28 Ownership of animals or Birds? Yes= 1, No=2
29 If yes, which of these animals or birds Yes= 1, No=2
Cows/ Buffalo
Horse/donkey/mule/ Bull
Goats/Sheep
Pig
Poultry(Hen/Fowl/Duck/Pigeon/Parrot)
Others (specify) अन्य(बताय)े_________________
30 Do you have the following items in your household? Yes owns = 1, No does not own =2
Desert cooler Pressure cooker
Air conditioner Mattress
Computer Chair
Refrigerator Cot/bed
Radio/transistor Table
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INSPIRE STUDY TOOLS
B & W television Mobile telephone
Colour television Any other telephone
Watch/clock Animal-drawn cart
Sewing machine Car
Bicycle Water pump
Motorcycle/scooter Thresher
Electric fan Tractor
31 Does any member has a bank account/post office
account?
Yes= 1, No=2, Don’t know=3
32 What is the type of ration card that this household
has?
APL=1 , BPL=2, Antodaya =3, None
=4 DNK=7
No response/ do not want to tell =8
33 What all type of fuel does your household use for cooking tell all the fuels that are used? (multiple
option)( fill Yes= 1, No=2 for each option)
Charcoal Electricity
Straw/ Shrubs/ Grass/Crop waste LPG Gas
Coal Biogas
Dung Cakes Kerosene
Wood Othersअन्यspecify___________
35 Which is the main fuel used for cooking? 1. Charcoal
2. Straw/ Shrubs/ Grass/Crop waste
3. Coal
4. Dung Cakes
5. Wood
6. Electricity
7. LPG Gas
8. Biogas
9. Kerosene
36 What all type of fuels does your family use for heating water or heating room in winters?
(multiple option)( fill Yes= 1, No=2 for each option)
Charcoal Electricity
Straw/ Shrubs/ Grass/Crop waste LPG Gas
Coal Biogas
Dung Cakes Kerosene
Wood Othersअन्यspecify___________
37 Does anyone living in this household regularly
smoke cigarette, bidis, hukkahs or other tobacco
products inside the home?
Yes =1 , No =2 , Do Not Know=7
No response/ do not want to tell =8
38 Number of children aged less than 5 years living
in the house?
39 Number children aged less than 18 years living in
the house who go to school?
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4. Baseline Individual form
Individual ID
Data Collected By: (drop down)
Date Form Filled: (dd/mm/yyyy) ___ ___ / ___ ___ / ___ ___ ___ ___
1. Name of the participant gender and age
would be displayed
2. Please tell me your current marital
Status
Never married=1Married =2Widow/widower= 3 Divorced or separated =4 Do not want to tell = 8
3. Please tell the number of years you
spent attaining education
Years
4. Currently employed in any income
generating activities Yes=1 No=2
5. If yes, what is your current occupation
6. If No, what was your last occupation
7. Are you receiving any pension? None=1 Old age=2 Post retirement =3
8. Do you currently have any have health
insurance?
Yes=1 No=2
8.1 If yes for 8, specify
1. ESI
2. CGHS
3. Community Health insurance
4. Reimbursement from employer
5. Private Purchased
6. Insurance through employer
7. RSBY
8. Others (Specify)----------
9. Aadhar No (Write 7777-7777-7777 if
do not have Aadhar card, Write 8888-
8888-8888 if do not want to share
Aadhar details
10. Contact Number
(Note the number of the elderly individual)
Pre-existing Health Conditions and treatment
Now I will ask you about some chronic health conditions please let me know if you suffer from them.
( For each health problem that the participant responds as yes ask whether he/ she is on treatment for the same )
11.Have you ever been told by a healthcare
provider that they you suffer from :
Options
Yes=1 No=2
Do not Know=7
For each of the condition
for which participant says
yes he/ she is suffering
from this askes, are you
currently receiving
Options
Yes=1 No=2
Do not Know=7
11.1 Diabetes
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11.2 High Blood Pressure treatment or taking
medication for this
condition?
11.3 Heart Condition
11.4 Chronic Liver disease
11.5 Stroke/CVA
11.6 HIV/AIDS
11.7 Chronic Kidney disease
11.8 Tuberculosis
11.9 Chronic respiratory disease
11.10 Malignancy
11.11 Arthritis
11.12 Anemia
11.13 Depression
11.14 Other conditions lasting for more than
6 months (specify below):
________________
11.15 Do you have any problems related to
vision ?( distant/ near )Yes=1 No =2
11.16 Do you find any difficulty in hearing?
Yes=1 No=2
11.17 Is your physical movement restricted ?
Yes=1 No=2
12 Are you currently under treatment for chronic treatment?
Yes=1 No=2
12.1 If yes to 12, are you taking oral or systemic steroids for
treatment?
Yes=1 No=2
13 Have you received any vaccine in last one year? Yes=1 No=2 If yes go to 13.1
If no goto 14
13.1 If yes to 13, list the vaccines 1.__________
2.__________
14 Lifestyle factors
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14.1 Do you currently smoke tobacco on daily basis? Yes=1 No=2
14.2Have you smoked tobacco daily in past? Yes=1 No=2
14.3 Do you currently use smokeless tobacco on a daily
basis?
Yes=1 No=2
14.4Have you used smokeless tobacco daily in past? Yes=1 No=2
14.5 Do you usually drink alcohol more than once a week? Yes=1 No=2
14.5 Have you worked in place where you were exposed to
dust, smoke or fumes for prolonged period of time in last 10
years
Yes=1 No=2
14.7 Have you been exposed to household smoke in last 10
years
Yes=1 No=2
14.8 How often do you wash your hand with soap in a day
1. 2-3 times
2. At least once in a dayl
3. Never
Social Capital
Q How frequently do you socialize with family or friends
who are not living with you in this house? 1-once in a week or more
0-otherwise
Q How frequently do you socialize with neighbours? 1-once in a week or more
0-otherwise
Q How frequently do you attend religious or social events? 1-once in a week or more
0-otherwise
Q In past 3 months, did you lose any close family member or
friends?
या हैं ?
1 - Yes
2 – No
Q When you need help can you count on someone from the
following who is willing and able to help you :
1 Spouse
0-Never
1-sometimes
2-yes always
3-Not Applicable
2 Family member
2-yes always
1-sometimes
0-Never
3 Friends/Neighbours
2-yes always
1-sometimes
0-Never
Q How often do you open up to the following about your
personal problems:
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1 Spouse
0-hardly ever
1-Sometimes
2-Often
3-Not Applicable
2 Family member
0-hardly ever
1-Sometimes
2-Often
3 Friends/Neighbours
0-hardly ever
1-Sometimes
2-Often
Social Capital
Q How frequently do you socialize with family or friends
who are not living with you in this house? 1-once in a week or more
0-otherwise
Q How frequently do you socialize with neighbours? 1-once in a week or more
0-otherwise
Q How frequently do you attend religious or social events? 1-once in a week or more
0-otherwise
Q In past 3 months, did you lose any close family member or
friends?
या हैं ?
1 - Yes
2 – No
Q When you need help can you count on someone from the
following who is willing and able to help you :
1 Spouse
0-Never
1-sometimes
2-yes always
3-Not Applicable
2 Family member
2-yes always
1-sometimes
0-Never
Physical measurements
16.Anthropometry
Now we want to measure your weight - could you please keep your shoes off and step on this scale.
15.1Weight (in kilograms)
I would now like to measure how tall you are. To measure your height I need you to please take off your shoes. Put your
feet and heels close together, stand straight and look forward standing with your back, head and heels touching the wall.
Look straight ahead.
15.2 Height (in centimetres)
15.3 Arm span (in centimetres)
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16. Grip strength
16.1 Have you had any surgery on your left arm, hand or
wrist in the last 3 months OR arthritis or pain in your left
hand or wrist?
1 YES -> DO NOT TEST LEFT HAND
2 NO
16.2 Have you had any surgery on your right arm, hand or
wrist in the last 3 months OR arthritis or pain in your right
hand or wrist?
1 YES -> DO NOT TEST RIGHT HAND
2 NO
16.3 Which hand do you consider your dominant hand?
Dominant Hand - Check one answer. If a respondent is
ambidextrous, the hand that is used for signing/writing is
considered the dominant hand.
1 LEFT
2 RIGHT
3 USE BOTH THE SAME
Remain sitting and let your hand drop to your side. Keep your upper arm against your body and bend your elbow to 90
degrees with palm facing in (like shaking hands). Keep your elbow pressed against your side.( DEMONSTRATE.)
Then grab the two pieces of metal together like this. (DEMONSTRATE).
I will ask you to do this two times in each hand. Let’s start with your left hand, please take this in your left hand. If you
feel any pain or discomfort, tell me and we will stop. When I say "squeeze", squeeze as hard as you can.
(INTERVIEWER: Check positioning and grip to make sure it is correct. WHEN HE OR SHE BEGINS, SAY: SQUEEZE,
SQUEEZE,)
Ready? Squeeze, squeeze, squeeze!
16.4 Grip strength-First test left hand (in Kg)
16.5 Grip strength-Second test left hand (in Kg)
16.6 Grip strength-First test right hand (in Kg)
16.7 Grip strength-Second test right hand(in Kg)
17 Frailty assessment
17.1 Please imagine that this pre-drawn circle is a clock.
I would like you to place the numbers in the correct positions
then place the hands to indicate a time of ‘ten after eleven’
0-No error
1-Minor spacing error
2. Other error
17.2 In the past year, how many times have you been
admitted to a hospital? 0-Zero
1-one to two
2. More than two
17.3 In general, how would you describe your health? 0-Excellent, very good, good
1-fair
2. Poor
17.4 How many of the following activity do you need help? 0-No, 1-Yes
17.4.1 Meal preparation
0-No, 1-Yes
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17.4.2 Shopping,
0-No, 1-Yes
17.4.3 Transportation
0-No, 1-Yes
17.4.4 Telephone
0-No, 1-Yes
17.4.5 Housekeeping
0-No, 1-Yes
17.4.6 Laundry
0-No, 1-Yes
17.4.7 Managing money 0-No, 1-Yes
17.4.8 Taking medications 0-No, 1-Yes
17.5 When you need help, can you count on someone
who is willing and able to meet your needs? 0-Always
1-Sometimes
2. Never
17.6 Do you use five or more different prescription
medications on a regular basis?
0-No, 1-Yes
17.7 At times, do you forget to take your prescription
medications?
0-No, 1-Yes
17.8 Have you recently lost weight such that your clothing
has become looser? 0-No, 1-Yes
17.9 Do you often feel sad or depressed? 0-No, 1-Yes
17.10 Do you have a problem with losing control of urine
when you don’t want to? 0-No, 1-Yes
17.11 I would like you to sit in this chair with your back and
arms resting. Then, when I say ‘GO’, please stand up and walk at a safe and comfortable pace
to the mark on the floor (approximately 3 m away), return to
the chair and sit down’
0- Zero to 10 sec
1- 11 to 20 sec
2- >20 sec or unwilling or require assistance
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5. Frailty follow-up assessment questionnaire
Individual ID
Data Collected By: (drop down)
Date Form Filled: (dd/mm/yyyy) ___ ___ / ___ ___ / ___ ___ ___ ___
11. Name of the participant gender and age
would be displayed
2.1 In past 3 months did you suffer from or had been diagnosed with any acute
illness (1- Yes, 2-No)
2.2 If yes,
duration of
illness
(in days)
2.3 Were you
hospitalized
(1- Yes, 2-No)
2.1.1 Acute respiratory illness (upper or lower respiratory infections,
exacerbation of asthma or COPD, pneumothorax etc)
2.1.2 Acute gastro intestinal illness (diarrheal disease, typhoid,
gastritis, hepatitis, pancreatitis, appendicitis
2.1.3 Acute Uro-genital illness (urinary tract infections)
2.1.4 Acute musculo-skeletal illness (
2.1.5 Acute cardiac vascular diseases (Myocardial infarction, stroke
etc)
2.1.6 Others (specify)
2.1.7 In past 3 months did you suffer from any injury, accidents or fall
3 In past 3 months did you undergo any elective or emergency
surgical procedure 1- Yes, 2-No
4 In past 3 months, did you lose any close family member or friends? 1- Yes, 2-No
5. In past 3 months had been diagnosed with any Chronic conditions
(1- Yes, 2-No)
5.1 Diabetes 5.7 Chronic Kidney disease
5.2 High Blood Pressure 5.8 Tuberculosis
5.3 Heart Condition 5.9 Chronic respiratory disease
5.4 Chronic Liver disease 5.10 Malignancy
5.5 HIV/AIDS 11.11 Arthritis
5.6 Depression
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6. Frailty assessment
6.1 Please imagine that this pre-drawn circle is a clock.
I would like you to place the numbers in the correct positions then place the hands
to indicate a time of ‘ten after eleven’
0-No error
1-Minor spacing error
2. Other error
6.2 In the past year, how many times have you been admitted to a hospital? 0-Zero
1-one to two
2. More than two
6.3 In general, how would you describe your health? 0-Excellent, very good, good
1-fair
2. Poor
6.4 How many of the following activity do you need help? 0-No, 1-Yes
6.4.1 Meal preparation
0-No, 1-Yes
6.4.2 Shopping,
0-No, 1-Yes
6.4.3 Transportation
0-No, 1-Yes
6.4.4 Telephone
0-No, 1-Yes
6.4.5 Housekeeping
0-No, 1-Yes
6.4.6 Laundry
0-No, 1-Yes
6.4.7 Managing money 0-No, 1-Yes
6.4.8 Taking medications 0-No, 1-Yes
6.5 When you need help, can you count on someone who is willing and able to
meet your needs?
0-Always
1-Sometimes
2. Never
6.6 Do you use five or more different prescription medications on a regular basis? 0-No, 1-Yes
6.7 At times, do you forget to take your prescription medications? 0-No, 1-Yes
6.8 Have you recently lost weight such that your clothing has become looser? 0-No, 1-Yes
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6.9 Do you often feel sad or depressed? 0-No, 1-Yes
6.10 Do you have a problem with losing control of urine
when you don’t want to? 0-No, 1-Yes
6.11 I would like you to sit in this chair with your back and arms resting. Then,
when I say ‘GO’, please stand up and walk at a safe and comfortable pace
to the mark on the floor (approximately 3 m away), return to the chair and sit
down’
3- Zero to 10 secons
4- 5 to 20 sec
5- >20 sec or unwilling or
require assistance
7. Grip strength
7.1 Have you had any surgery on your left arm, hand or wrist in the last 3 months
OR arthritis or pain in your left hand or wrist?
1 Yes -> do not test left hand
2 No
7.2 Have you had any surgery on your right arm, hand or wrist in the last 3 months
OR arthritis or pain in your right hand or wrist?
1 Yes -> do not test right hand
2 No
7.3 Which hand do you consider your dominant hand? Dominant Hand - Check one
answer. If a respondent is ambidextrous, the hand that is used for signing/writing is
considered the dominant hand.
1 Left
2 Right
3 Use both the same
Remain sitting and let your hand drop to your side. Keep your upper arm against your body and bend your elbow to 90
degrees with palm facing in (like shaking hands). Keep your elbow pressed against your side. ( DEMONSTRATE.)
Then grab the two pieces of metal together like this. (DEMONSTRATE).
I will ask you to do this two times in each hand. Let’s start with your left hand, please take this in your left hand. If you
feel any pain or discomfort, tell me and we will stop. When I say "squeeze", squeeze as hard as you can.
(INTERVIEWER: Check positioning and grip to make sure it is correct. WHEN HE OR SHE BEGINS, SAY: SQUEEZE,
SQUEEZE,)
Ready? Squeeze, squeeze, squeeze!
7.4 Grip strength-First test left hand (in Kg)
7.5 Grip strength-Second test left hand (in Kg)
7.6 Grip strength-First test right hand (in Kg)
7.7 Grip strength-Second test right hand(in Kg)
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6. Cost Data Collection
A
B
C
D
E
F
Onset date of the episode (X)
Type of Care -
Non medically
attended/
Emergency/OPD/
IPD/ICU
Place of
treatment
(Private/Public/
Secondary/
Tertiary)
Direct medical cost Direct non-medical cost Indirect cost
End date of the episode (Y) Medication Consultation Investigation Transport Lodging Food
Care
giver Self
X
-
-
-
-
-
-
-
-
-
-
Y
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