United States Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation

Office of Disability, Aging and Long-Term Care Policy (DALTCP): LIST OF INSTRUMENTS

This page alphabetically lists instruments, questionnaires, and other survey/project development forms produced through DALTCP-funded research. (Some projects were funded when DALTCP was known as the Office of Social Services Policy or the Office of Family, Community and Long-Term Care Policy.) The instruments are in the HTML and Portable Document Format (PDF). [You will need a copy of the Acrobat Reader in order to view PDF versions.] The project the instrument was developed for is listed after the title.

We will continue working towards putting ALL versions of Full Reports and Instruments online.

Instrumentss are Listed in This Section Alphabetically (by Title):
A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

A

All Repondents Questionnaire ( ) -- National Board and Care Survey Design

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/AllResp.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/AllResp.pdf (4 PDF pages)

Applicant Screen (December 1981) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/1981/AppSc.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/1981/AppSc.pdf (27 PDF pages)

Assisted Living Discharged Resident Proxy Respondent Telephone Interview -- National Study of Assisted Living for the Frail Elderly

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/ALDRPRTI.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/ALDRPRTI.pdf (11 PDF pages)

Assisted Living Discharged Resident Telephone Interview -- National Study of Assisted Living for the Frail Elderly

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/ALDRTI.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/ALDRTI.pdf (15 PDF pages)

B

None at this time.

C

Client Contact Log ( ) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/ClConLog.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/ClConLog.pdf (8 PDF pages)

Client Tracking Form (March 1982) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/1982/ClTracFm.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/1982/ClTracFm.pdf (9 PDF pages)

Clinical Assessment and Research Baseline Instrument: Community Version (January 1982) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/1982/carbicv.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/1982/carbicv.pdf (98 PDF pages)

Clinical Baseline Assessment Instrument: Community Version (June 1983) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/1983/cbaicv.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/1983/cbaicv.pdf (46 PDF pages)

Clinical Baseline Assessment Instrument: Institutional Version (July 1983) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/1983/cbaiiv.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/1983/cbaiiv.pdf (50 PDF pages)

D

None at this time.

E

Exit Proxy Questionnaire (February 1996) -- National Survey Development: Asset and Health Dynamics of the Oldest Old

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/1996/ExProxQ.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/1996/ExProxQ.pdf (161 PDF pages)

F

Facility Screening Questionnaire (1998) -- National Study of Assisted Living for the Frail Elderly

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/FacScQ.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/FacScQ.pdf (11 PDF pages)

G

None at this time.

H

• Health Information Technology Round Two Screener [http://aspe.hhs.gov/daltcp/instruments/HITscreener.pdf] -- Electronic Health Information Technology Systems: Costs and Benefits

I

Interagency Councils Questionnaire ( ) -- National Board and Care Survey Design

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/IntCoun.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/IntCoun.pdf (5 PDF pages)

J

None at this time.

K

None at this time.

L

Licensure Questionnaire ( ) -- National Board and Care Survey Design

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/Licensure.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/Licensure.pdf (19 PDF pages)

Local Agency Questionnaire ( ) -- National Board and Care Survey Design

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/LocalAg.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/LocalAg.pdf (18 PDF pages)

Local Ombudsman Questionnaire ( ) -- National Board and Care Survey Design

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/LocalOm.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/LocalOm.pdf (4 PDF pages)

M

None at this time.

N

None at this time.

O

None at this time.

P

Participation Questionnaire ( ) -- Personal Assistance Services "Cash and Counseling" Demonstration/Evaluation

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/DecideFm.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/DecideFm.pdf (9 PDF pages)

Payment/Eligibility Questionnaire ( ) -- National Board and Care Survey Design

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/PayElig.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/PayElig.pdf (10 PDF pages)

Public Voucher for Purchases and Services Other Than Personal ( ) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/scheduleC.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/scheduleC.pdf (9 PDF pages)

Q

None at this time.

R

None at this time.

S

Screening Identification Sheet (March 1982) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/1982/ScrIDSh.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/1982/ScrIDSh.pdf (9 PDF pages)

Site Monthly Caseload Report ( ) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/smcr.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/smcr.pdf (9 PDF pages)

Statement of Funds Applied ( ) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/scheduleA.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/scheduleA.pdf (8 PDF pages)

Statement of Project Expenses ( ) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/scheduleB.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/scheduleB.pdf (10 PDF pages)

Statement of Research Activity ( ) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/scheduleD.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/scheduleD.pdf (8 PDF pages)

[A] Study of the Roles and Use of Licensed Social Workers in the United States (2004) -- Report to Congress on Supply and Demand of Social Workers in Long-Term Care: Listening Sessions

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/2004/rulsw.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/2004/rulsw.pdf (10 PDF pages)

T

Time Sheet ( ) -- National Long-Term Care Channeling Demonstration

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/TimeSh.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/TimeSh.pdf (8 PDF pages)

U

None at this time.

V

VISTA Recruitment: A Survey of Recent Applicants ( ) -- Analyses of VISTA Marketing and Recruitment Activities

Full HTML Version: http://aspe.hhs.gov/daltcp/instruments/VISTArec.htm

Full PDF Version: http://aspe.hhs.gov/daltcp/instruments/VISTArec.pdf (10 PDF pages)

W

None at this time.

X

None at this time.

Y

None at this time.

Z

None at this time.

Last revised: June 26, 2012

BACK TO: DALTCP Home