{"help": "https://midas.hsl.harvard.edu/gl_ES/api/3/action/help_show?name=datastore_search", "success": true, "result": {"include_total": true, "limit": 100, "records_format": "objects", "resource_id": "f6cb9d8f-59bd-4a4a-a3e0-2abc531ceb10", "total_estimation_threshold": null, "records": [{"_id":1,"Variable / Field Name":"study_id","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"text","Field Label":"Study ID","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":1,"Text Validation Max":10,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":2,"Variable / Field Name":"f0r_doi","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"text","Field Label":"Resident Screening Date","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"date_mdy","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":3,"Variable / Field Name":"f0r_ra_id","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"dropdown","Field Label":"Research Assistant ID","Choices, Calculations, OR Slider Labels":"1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":4,"Variable / Field Name":"f0r_prim_ra","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"radio","Field Label":"Primary Research Nurse","Choices, Calculations, OR Slider Labels":"1, M (1) | 2, H (2)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0r_ra_id] = '3' or [f0r_ra_id] = '4' or [f0r_ra_id] = '5'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":5,"Variable / Field Name":"f0r_facility_name","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"text","Field Label":"Facility Name","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":6,"Variable / Field Name":"f0r_facility_id","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"sql","Field Label":"Facility ID","Choices, Calculations, OR Slider Labels":"SELECT master.value value, concat(site_name.value, ' (', master.value, ')') label FROM redcap_data master INNER JOIN redcap_data site_name ON site_name.project_id = master.project_id AND site_name.record = master.record AND site_name.event_id = master.event_id AND site_name.field_name = 'fs_site_name' WHERE master.project_id = 41 AND master.field_name = 'fs_facility_id' order by convert(master.value, unsigned integer)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":7,"Variable / Field Name":"f0r_scrng_unit_id","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"text","Field Label":"Unit ID","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":8,"Variable / Field Name":"f0r_scrn_res_rm","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"text","Field Label":"Room number","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":9,"Variable / Field Name":"f0r_res_l_name","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"text","Field Label":"Resident Last Name","Choices, Calculations, OR Slider Labels":"","Field Note":"Last name","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":10,"Variable / Field Name":"f0r_res_f_name","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"text","Field Label":"Resident First Name","Choices, Calculations, OR Slider Labels":"","Field Note":"First name","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":11,"Variable / Field Name":"f0r_res_gender","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"radio","Field Label":"Resident gender","Choices, Calculations, OR Slider Labels":"1, Male (0) | 2, Female (1)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":12,"Variable / Field Name":"f0r_res_age","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"calc","Field Label":"Resident age","Choices, Calculations, OR Slider Labels":"round(datediff([f0r_doi],[f0r_res_dob],\"y\",\"mdy\"))","Field Note":"calculated age of resident at interview","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":13,"Variable / Field Name":"f0r_gds7_d","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\nGlobal Deterioration = 7 if:\n1. Verbal skills: All meaningful verbal abilities are lost. Frequently no speech at all. There may be only grunting, meaningless repetitive sounds or occasional words or phrases which do not make sense.\n2. Function: Incontinent of urine and require considerable assistance for eating and toileting\n3. Psychomotor skills: Unable to walk or require considerable assistance to ambulate or transfer. \"The brain appears to no longer be able to tell the body what to do.","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0r_res_age] >= 65","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":14,"Variable / Field Name":"f0r_gds7","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"radio","Field Label":"Global deterioration scale=7?","Choices, Calculations, OR Slider Labels":"0, No (ineligible) (0) | 1, Yes (1)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0r_res_age] >= 65","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":15,"Variable / Field Name":"f0r_doa","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"text","Field Label":"Date of Resident's nursing home admission","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"date_mdy","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0r_res_age] >= 65 and [f0r_gds7] = '1'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":16,"Variable / Field Name":"f0r_lngth_stay","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"calc","Field Label":"Length of nursing home stay","Choices, Calculations, OR Slider Labels":"round(datediff([f0r_doi],[f0r_doa],\"d\",\"mdy\"),2)","Field Note":"calculated based on date of admission and date of screening","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0r_res_age] >= 65 and [f0r_gds7] = '1'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":17,"Variable / Field Name":"f0r_prim_caus_cog_imp","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"radio","Field Label":"Primary cause of cognitive impairment","Choices, Calculations, OR Slider Labels":"0, Dementia (Any cause) (0) | 1, Acute stroke (ineligible) (1) | 2, Head trauma (ineligible) (2) | 3, Psychiatric illness (ineligible) (3) | 4, Brain tumor or other malignancy (ineligible) (4) | 5, Other (ineligible) (5)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0r_gds7] = '1' and [f0r_lngth_stay] >= 30","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":18,"Variable / Field Name":"f0r_other_descrip","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"text","Field Label":"\"Other\" primary cause of cognitive impairment","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0r_prim_caus_cog_imp] = '5'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":19,"Variable / Field Name":"f0r_res_coma","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"radio","Field Label":"Resident in coma?","Choices, Calculations, OR Slider Labels":"0, No (0) | 1, Yes (1)","Field Note":"Is resident in a coma?","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0r_prim_caus_cog_imp] = '0'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":20,"Variable / Field Name":"f0r_proxy","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"radio","Field Label":"Proxy appointed?","Choices, Calculations, OR Slider Labels":"0, No (0) | 1, Yes (1)","Field Note":"Has a proxy been appointed?","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0r_prim_caus_cog_imp] = '0' and [f0r_res_coma] = '0'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":21,"Variable / Field Name":"f0r_res_eligible_y_d","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\nResident IS ELIGIBLE to participate in the EVINCE study.\n\nPlease continue to collect proxy information in the following form (form0c).","Choices, Calculations, OR Slider Labels":"","Field Note":"Click yest to indicate that resident IS eligible","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0r_res_age] >= 65.0 and [f0r_gds7] = '1' and [f0r_lngth_stay] >= 30.0 and [f0r_prim_caus_cog_imp] = '0' and [f0r_res_coma] = '0' and [f0r_proxy] = '1'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":22,"Variable / Field Name":"f0r_res_eligible_n_d","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\nResident IS NOT ELIGIBLE to participate in the EVINCE study.\n\nStop data collection here.","Choices, Calculations, OR Slider Labels":"","Field Note":"Resident IS eligible","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0r_res_age] < 65.0 or [f0r_gds7] = '0' or [f0r_lngth_stay] < 30.0 or [f0r_prim_caus_cog_imp] = '1' or [f0r_prim_caus_cog_imp] = '2' or [f0r_prim_caus_cog_imp] = '3' or [f0r_prim_caus_cog_imp] = '4' or [f0r_prim_caus_cog_imp] = '5' or [f0r_res_coma] = '1' or [f0r_proxy] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":23,"Variable / Field Name":"f0r_res_eligibility","Form Name":"form_0r_resident_screening","Section Header":"","Field Type":"yesno","Field Label":"Is Resident eligible to participate in the EVINCE study?","Choices, Calculations, OR Slider Labels":"","Field Note":"Click yest to indicate that resident IS eligible","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":24,"Variable / Field Name":"f0c_ra_id","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"dropdown","Field Label":"RA ID","Choices, Calculations, OR Slider Labels":"1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":25,"Variable / Field Name":"f0c_contact_inf_date","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"text","Field Label":"Contact info date","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"date_mdy","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":26,"Variable / Field Name":"f0c_prxy_name","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"text","Field Label":"Proxy name","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":27,"Variable / Field Name":"f0c_prxy_strt_adrs","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"text","Field Label":"Proxy street address","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":28,"Variable / Field Name":"f0c_prxy_city","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"text","Field Label":"Proxy city","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":29,"Variable / Field Name":"f0c_prxy_state","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"text","Field Label":"Proxy State","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":30,"Variable / Field Name":"f0c_prxy_zipcode","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"text","Field Label":"Proxy Zipcode","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"zipcode","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":31,"Variable / Field Name":"f0c_prxy_homephone","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"text","Field Label":"Proxy home phone","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"phone","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":32,"Variable / Field Name":"f0c_prxy_workphone","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"text","Field Label":"Proxy work phone","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"phone","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":33,"Variable / Field Name":"f0c_prxy_cellphone","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"text","Field Label":"Proxy cell phone","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"phone","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":34,"Variable / Field Name":"f0c_prxy_email","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"text","Field Label":"Proxy email","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"email","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":35,"Variable / Field Name":"f0c_prxy_relationship","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"radio","Field Label":"Proxy's relationship to resident","Choices, Calculations, OR Slider Labels":"1, Spouse (1) | 2, Son or daughter (2) | 3, Grandson or granddaughter (3) | 4, Sibling (4) | 5, Niece or nephew (5) | 6, Legal guardian (6) | 7, Other (7)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":36,"Variable / Field Name":"f0c_prxy_other","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"text","Field Label":"Proxy relationship other","Choices, Calculations, OR Slider Labels":"","Field Note":"Define the proxy's relationship to resident","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0c_prxy_relationship] = '7'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":37,"Variable / Field Name":"f0c_prxy_cntc_notes","Form Name":"form_0c_proxycontact_information","Section Header":"","Field Type":"text","Field Label":"Contact Field Notes","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":38,"Variable / Field Name":"f0p_study_assign","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"calc","Field Label":"<div style=\"font-size:12pt\">Study assignment","Choices, Calculations, OR Slider Labels":"( function(){ $(document).data(\"url\",\"https://ifar-edc.hsl.harvard.edu/redcap/api/\"); $(document).data(\"params\", { format : \"xml\", type : \"flat\", content : \"record\", token : \"13ECC561A5932D67B9D0F660624213E1\", fields: \"fs_site_r_assign\", records: [resident_eligibili_arm_1][f0r_facility_id] }); $(document).data(\"response\", $.ajax( { type: \"POST\", url: $(document).data(\"url\"), async: false, data: $(document).data(\"params\"), dataType: \"xml\" } ).responseXML); return $($(document).data(\"response\")).find(\"fs_site_r_assign\").text() } )();","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":39,"Variable / Field Name":"f0p_re_consent","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF78;font-size:12pt\">Previously consented then changed to Ineligible. \n\nPlease be aware that you have spoken with this proxy before and received consent for their participation in the study, but as the eligibility status changed, the dyad was removed from study and is now being re-screened/recruited.","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[proxy_eligibility_arm_1][f0p_prxy_consent] = '1' and [resident_eligibili_arm_1][f99_dyad_status] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":40,"Variable / Field Name":"f0p_doi","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"text","Field Label":"<div style=\"font-size:12pt\">Proxy Screening date","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"date_mdy","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":41,"Variable / Field Name":"f0p_researcher","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"dropdown","Field Label":"<div style=\"font-size:12pt\">RA ID","Choices, Calculations, OR Slider Labels":"1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5) | 6, Angelo (6)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":42,"Variable / Field Name":"f0p_prxy_cntcted","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">\nProxy Contacted?","Choices, Calculations, OR Slider Labels":"0, No (0) | 1, Yes (1) | 2, Yes but resident no longer eligible (2)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":43,"Variable / Field Name":"f0p_prxy_res_inelig","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">\nReason resident no longer eligible","Choices, Calculations, OR Slider Labels":"1, Resident is dead or actively dying (1) | 2, Resident is not longer in the facility (2) | 3, Resident is in coma (3)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cntcted] = '2'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":44,"Variable / Field Name":"f0p_prxy_refuses","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">\nProxy Refuses prior to eligibility conversation","Choices, Calculations, OR Slider Labels":"0, No (0) | 1, Yes (1)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cntcted] = '1'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":45,"Variable / Field Name":"f0p_proxy_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"font-size:12pt\">\nPerson named in the chart as proxy is the health care proxy/decision maker for the resident?","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_refuses] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":46,"Variable / Field Name":"f0p_prxy_validation","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">\nIs Person the Proxy?","Choices, Calculations, OR Slider Labels":"0, No (0) | 1, Yes (1)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_refuses] = '0'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":47,"Variable / Field Name":"f0p_wrong_contact_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\"> \nAsk person for contact information on actual proxy. Update/correct contact information on form0c, and follow-up with new proxy/contact. DO NOT SAVE THIS RECORD","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_validation] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":48,"Variable / Field Name":"f0p_prxy_english","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">\nProxy speaks english?","Choices, Calculations, OR Slider Labels":"0, No (0) | 1, Yes (1)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_validation] = '1'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":49,"Variable / Field Name":"f0p_d1_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\"> \nWe would like to include you and (resident) in the EVINCE study. Participating in this study will involve one year of quarterly phone calls, and one initial face to face visit. Our research staff can drive to meet with you within a 60 mile radius of Boston. Would this be possible given your residence or practice of visiting with (resident)?\n\nCan you meet with someone from our research team in person within 2 weeks of this phone call? ","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_validation] = '1' and [f0p_prxy_english] = '1'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":50,"Variable / Field Name":"f0p_prxy_can_meet","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">\nProxy can meet","Choices, Calculations, OR Slider Labels":"0, No (0) | 1, Yes (1)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_validation] = '1' and [f0p_prxy_english] = '1'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":51,"Variable / Field Name":"f0p_prxy_eligible_y_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\nProxy IS ELIGIBLE to particpate in EVINCE","Choices, Calculations, OR Slider Labels":"","Field Note":"Click on YES to indicate that proxy IS eligible to participate","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_validation] = '1' and [f0p_prxy_english] = '1' and [f0p_prxy_can_meet] = '1'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":52,"Variable / Field Name":"f0p_prxy_eligible_n_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\n Proxy is NOT ELIGIBLE to participate in EVINCE. ","Choices, Calculations, OR Slider Labels":"","Field Note":"Click on no to indicate that proxy is NOT eligible to participate","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_validation] = '1' and [f0p_prxy_english] = '0' or [f0p_prxy_can_meet] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":53,"Variable / Field Name":"f0p_prxy_eligible","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">\nIs proxy eligible?","Choices, Calculations, OR Slider Labels":"0, No (0) | 1, Yes (1)","Field Note":"Fill in to trigger appropriate follow-up","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_validation] = '1'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":54,"Variable / Field Name":"f0p_not_elig_end_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"font-size:12pt\">\nPlease save this record and end data collection here.","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_eligible] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":55,"Variable / Field Name":"f0p_consent_2_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\n\n CONSENT FORM FOR RESEARCH PARTICIPATION\n\n Study title:  Improving Nursing home Care in End-stage dementia \nPrincipal Investigator:  Susan L. Mitchell MD, MPH/Angelo Volandes MD, MPH\nPrimary Affiliation: Hebrew SeniorLife/Massachusetts General Hospital\nCo-Investigators: Michele Shaffer, PhD; Laura Hanson MD, MPH\n\n\nAbout this Consent Form\nPlease read this form carefully. This form provides important information about participating in a research study. As a research participant, you have the right to take your time in making decisions about participating in this research and you are encouraged to discuss your decision with your family and your doctor.  If you have any questions about the research or any part of this form, please ask us. If you decide to take part in this research, you will be asked to provide your consent over the phone.   The research team member will record your decision on his/her form. You may want to sign and date your own copy of this consent form to keep for your records.  \n\nWhat you should know about a Research Study\nParticipation in research is voluntary, which means that it is something for which you volunteer. It is your choice to participate in the study, or to decline participation. If you choose to participate now, you may change your mind and stop participating at a later date. Refusal to participate or withdrawal of participation will not result in any penalty or loss of benefits to which you are otherwise entitled. \n\n\nSTUDY PURPOSE  \nYou are being asked to participate in a research study entitled Improving Nursing home Care in End-stage dementia which is being conducted by Drs. Susan Mitchell and Angelo Volandes. Making sure that patients with late-stage dementia get the type of medical treatments that they would want to receive is an important health care concern. The purpose of this study is to learn the best way to help decision-makers for these patients, such as yourself, make these decisions. These are common decisions made by decisions-makers for people with advanced dementia that can influence the resident's quality and length of life. The nursing home where [RESIDENT] lives has already been assigned to use the usual practices provided in the facility to understand and determine your choices for his/her care.   We anticipate that about 400 nursing home residents with advanced dementia and their health care proxies will participate in this study.\n\nSPONSORSHIP\nThis study is being funded or sponsored by the National Institutes of Health.\n\nPROCEDURES: \nThe study will take place over the next 12 months. If you agree to participate, the following procedures will be performed: \n\n1.  At the beginning of the study and every 3 months, we will review [RESIDENT's] nursing home medical record to collect information about his/her health and the care he/she has received. While we hope [RESIDENT's] stays well during the study, if he/she passes away, the chart will also be reviewed within 14 days of death. Basic demographic data will be collected at the beginning of the study, such as age, gender, and the date of the nursing home admission. At each follow-up assessment, the chart will be reviewed to learn about the [RESIDENT]'s health status, care he or she has received, and decisions made about that care.\n\n2. At the beginning of the study only, we will spend a few minutes asking [RESIDENT's] nurse about his/her cognitive and self-care abilities.\n\n3. At the beginning of the study only, we will spend five minutes asking [RESIDENT] some questions to evaluate his/her thinking abilities.\n\n4. Within the next two weeks, a member of our research team will meet with you in-person for about 20 minutes or less. You can choose to have this meeting at a time of your convenience either in a quiet room at the [RESIDENT's] nursing home or in your home. At the interview we will ask questions about decisions you may have made about the type of care you think [RESIDENT] should receive and discussions you have had with nursing home care providers about these decisions. \n\n5. We would also like to interview you on the telephone every 3 months after the start of the study for a maximum of 12 months. These interviews will take about 20 minutes or less. We will ask questions about decisions you may have made about [RESIDENT]'s care and discussions you have had with nursing home care providers about these decisions.  All interviews will be conducted at your convenience.\n\nRISKS\nThere are minimal risks associated with this study. The majority of the patient's information will be obtained from the medical record and the nurse. In our experience, it is unlikely he or she will become bothered during the one-time 5-minute testing of his or her thinking, however if he or she is bothered, the testing will stop. While unlikely, you may experience discomfort from answering some of the questions during the interviews. You can refuse answering the questions at any time. You may become fatigued from the length of the interview, in which case we can reschedule another session. \n\nIN CASE OF INJURY\nWhile injury is unlikely in this research, if injury does occur while participating in the research, we will offer you or [Resident] the care needed to treat any injury that directly results from taking part in this research study.  If you think you or [Resident] have been injured or have experienced a medical problem as a result of taking part in this research study, tell the person in charge of the study as soon as possible. The researcher's name and phone number are listed at the end of this consent form You will be informed of any significant new findings developed during the course of this research, which may relate to your willingness to continue participation.\n\nBENEFITS \nThere are no direct benefits to you or [RESIDENT] from participation in this study, however others may benefit from the knowledge gained in connection with your participation.\n \nALTERNATIVE TREATMENTS \nThere are no treatments in this study. The alternative to participating in this study is not to participate.\n\nCONFIDENTIALITY\nAll personal information obtained in the study, will be kept confidential, and this information will only be available to the research staff and the HSL Institutional Review Board.  The records identifying your name and the [RESIDENT's] will be kept confidential and, to the extent permitted by the applicable laws and/or regulations, will not be made publicly available. The results of the study will only be published or presented as group data.  No individual participants will be identified.  Data forms will be identified with a unique study number and kept locked in the study office. \n\nCOMPENSATION\nFor your participation in this study, you will be given a $10 gift card to CVS at the time of your in-person interview.  \n\nCOSTS\nThere are no costs to you for participating in this study.\n\nSTUDY WITHDRAWAL\nYour and [RESIDENT's] participation in this research is completely voluntary.  If you chose not to participate or withdraw from the study, you or [RESIDENT] will incur no penalty or loss of usual benefits.  You may withdraw your consent and discontinue participation at any time without affecting you or the [RESIDENT'S] health care or other services you or [RESIDENT] may be receiving.  If you choose to take part in the study, you have the right to stop at any time. Your or [RESIDENT's] participation in this research project may be terminated if the study is determined to be inappropriate or potentially harmful for you or him/her.\n\nAUTHORIZATION FOR USE AND DISCLOSURE OF [RESIDENT'S] PROTECTED HEALTH INFORMATION\nAs part of this study, we will be collecting and sharing information about you and [Resident] with others.  Please review this section carefully as it contains information about the federal privacy rules and the use of Protected Health Information.\n\nProtected Health Information (PHI)\nBy agreeing to this informed consent document, you are allowing the investigators and other authorized personnel to use (internally at HSL) and disclose (to people and organizations outside the HSL workforce identified in this consent) health information about [RESIDENT].  This may include information about you and [RESIDENT] that already exists such as: the [RESIDENT's] medical record, your demographic information (gender and age) as well as any new information generated as part of this study through nurse interviews and  telephone interviews that we may ask you or [RESIDENT] to undergo.  This is the [RESIDENT's] Protected Health Information.\n\nPeople/Groups at HSL Who Will Use Protected Health Information\n\n[RESIDENT's] Protected Health Information may be shared with the investigators listed on this consent form as well as the supporting research team (i.e. research assistants, statisticians, data managers, laboratory personnel, administrative assistants). [RESIDENT's] Protected Health Information may also be shared with the Institutional Review Board of Hebrew SeniorLife as it is responsible for reviewing studies for the protection of the research subjects.\n\nPeople/Groups Outside of HSL with Whom [RESIDENT'S] Protected Health Information Will Be Shared\n\nWe will take care to maintain confidentiality and privacy about you and [RESIDENT's] Protected Health Information. We may share [RESIDENT's] Protected Health Information with the following groups so that they may carry out their duties related to this study: \n\n• The sponsor of this study, the National Institutes of Health, and their clinical research organizations\n\n• The other hospitals and medical centers taking part in this study including:  Massachusetts General Hospital and Seattle Children's Research Institute and research collaborators at those institutions\n\n• Statisticians and other data monitors not affiliated with HSL:  Seattle Children's Research Institute, Data Safety and Monitoring Board \n\n• Your or [RESIDENT's] health insurance company\n\n• The Food and Drug Administration (FDA), the Department of Health and Human Services (DHHS), the National Institutes of Health (NIH), and the Office for Human Research Protections (OHRP) \n\nThose who receive [RESIDENT's] Protected Health Information may make further disclosures to others.  If they do, your information may no longer be covered by the federal privacy regulations.\n\nWhy We Are Using and Sharing [RESIDENT'S] Protected Health Information:\n\nThe main reason for using and sharing [RESIDENT's] Protected Health Information is to conduct and oversee the research as described in this Informed Consent Document.  We also shall use and share [RESIDENT's] Protected Health Information to ensure that the research meets legal, and institutional requirements and to conduct public health activities.  \n\nNo Expiration Date - Right to Withdraw Authorization\nYour authorization for the use and disclosure of [RESIDENT's] Protected Health Information in this Study shall never expire.  However, you may withdraw your authorization for the use and disclosure of [RESIDENT's] Protected Health Information at any time by notifying the Principal Investigator in writing.  If you would like to take back your authorization so that [RESIDENT's] Protected Health Information can no longer be used in this study, please send a letter notifying the Principal Investigator of your withdrawal of your authorization to Susan L. Mitchell MD, MPH at 1200 Centre Street, Boston, MA 02131.  Please be aware that the investigators in this study will not be required to destroy or retrieve any of [Resident's] Protected Health Information that has already been used or disclosed before the Principal Investigator receives your letter.\n\nRight to Access and Copy Your PHI\nIf you wish to review or copy [RESIDENT's] Protected Health Information, you may do so after the completion or termination of the study by sending a letter to the Principal Investigator requesting a copy of it.  You may not be allowed to inspect or copy [RESIDENT's] Protected Health Information until this Study is completed or terminated.\n\nNotice of Privacy Practices\nIn addition to agreeing to participate in this study, you may also be asked to sign an HSL Acknowledgement Received Notice of Privacy Practices form to acknowledge that you have received the HSL Notice of Privacy Practices. \n\nQUESTIONS\nIf you have any questions regarding this research or your or [RESIDENT's] participation in it, either now or at any time in the future, please feel free to ask. \n\n•  You may obtain further information about your and [RESIDENT's] rights as a research participant or if you have any research concerns, please contact Madhuri Reddy, MD, MSc, Chair, HSL Institutional Review Board (IRB) at (617) 678-7592. \n\n•  If you have any questions about your or [RESIDENT's] role in the research study, or if any; problems arise as a result of your or [RESIDENT's] participation in this study, including research-related injuries, please contact the principal investigator, Susan L. Mitchell MD, MPH at Hebrew SeniorLife, 1200 Centre Street, Boston, at (617) 971-5326 immediately.\n\nDo you have any additional questions?\n\nSIGNATURE\nI attest that I have fully explained the above information to  [RESIDENT's HEALTH CARE PROXY name], answered any questions to his/her satisfaction, and sent him/her a copy of this form.  I attest that the health care proxy gave consent to participate and to allow ______________________________ [RESIDENT] to participate in this research study.\n\n________________________________ Signature of Research Associate\n________________________________ Printed Name \n________________________________ Date\n","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_study_assign] = '2' and [f0p_prxy_eligible] = '1'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":56,"Variable / Field Name":"f0p_consent_1_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\n\nCONSENT FORM FOR RESEARCH PARTICIPATION\n\nStudy title: Educational Video to Improve Nursing home Care in End-stage dementia (EVINCE)\nPrincipal Investigator:  Susan L. Mitchell MD, MPH/Angelo Volandes MD, MPH\nPrimary Affiliation: Hebrew SeniorLife/Massachusetts General Hospital\nCo-Investigators: Michele Shaffer, PhD; Laura Hanson MD, MPH\n\nAbout this Consent Form\nPlease read this form carefully. This form provides important information about participating in a research study. As a research participant, you have the right to take your time in making decisions about participating in this research and you are encouraged to discuss your decision with your family and your doctor.  If you have any questions about the research or any part of this form, please ask us. If you decide to take part in this research, you will be asked to provide your consent over the phone.  The research team member will record your decision on his/her form. You may want to sign and date your own copy of this consent form to keep for your records.  \n\nWhat you should know about a Research Study\nParticipation in research is voluntary, which means that it is something for which you volunteer. It is your choice to participate in the study, or to decline participation. If you choose to participate now, you may change your mind and stop participating at a later date. Refusal to participate or withdrawal of participation will not result in any penalty or loss of benefits to which you are otherwise entitled. \n\nSTUDY PURPOSE  \nYou are being asked to participate in a research study entitled Educational Video to Improve Nursing home Care in End-stage dementia (EVINCE) which is being conducted by Drs. Susan Mitchell and Angelo Volandes. Making sure that patients with late-stage dementia get the type of medical treatments that their family and health care providers feel they would want to receive is an important health care concern. The purpose of this study is to learn the best way to help decision-makers, such as yourself, make these decisions.  These are common decisions made by decisions-makers for people with advanced dementia that can influence the resident's quality and length of life.\n\nThe nursing home where [RESIDENT] lives has already been assigned to use the video to help you understand and determine your choices for his/her care. We anticipate that about 400 nursing home residents with advanced dementia and their health care proxies will participate in this study.\n\n\nSTUDY FUNDING AND DISCLOSURE OF ANY SPECIAL INTERESTS OF THE RESEARCHERS\nThis study is being funded or sponsored by the National Institutes of Health.  Dr. Volandes, along with other medical professionals, developed the video used in this research. Dr. Volandes is the President of the Nous Foundation, a not-for-profit organization that aims to improve patient communication with video support tools.  Dr. Volandes does not receive a salary or have any equity or financial arrangements with the nonprofit.  Dr. Volandes' wife is the Executive Director and receives a salary from the Foundation.\n\nPROCEDURES: \nThe study will take place over the next 12 months. If you agree to participate, the following procedures will be performed: \n\n1. At the beginning of the study and every 3 months, we will review [RESIDENT's] nursing home medical record to collect information about his/her health and the care he/she has received. While we hope [RESIDENT's] stays well during the study, if he/she passes away, the chart will also be reviewed within 14 days of death. Basic demographic data will be collected at the beginning of the study, such as age, gender, and the date of the nursing home admission. At each follow-up assessment, the chart will be reviewed to learn about the [RESIDENT]'s health status, care he or she has received, and decisions made about that care.\n\n2. At the beginning of the study only, we will spend a few minutes asking [RESIDENT's] nurse about his/her cognitive and self-care abilities. \n\n3. At the beginning of the study only, we will spend five minutes asking [RESIDENT] some questions to evaluate his/her thinking abilities.\n\n4. Within the next two weeks, a member of our research team will meet with you in-person for about 40 minutes or less. You can choose to have this meeting at a time of your convenience either in a quiet room at the [RESIDENT's] nursing home or in your home. The following steps will occur at this meeting:\n\na. For about 20 minutes or less, we will ask questions about decisions you may have made about the type of care you wish [RESIDENT] to receive and discussions you have had with nursing home care providers about these decisions. \n\nb. We will show you a 12-minute video on a laptop computer that describes different types of care options available to patients with late-stage dementia. \n\nc. After viewing the video, for about 10 minutes or less, we will ask you questions about the type of care you wish [RESIDENT] to receive, similar to the questions you were asked before viewing the video. \n\nd. After the in-person interview, we will place a paper in [RESIDENT'S] chart and/or email this document to his/her primary care team that describes the type of care you wish him/her to receive as you stated to us during our interview. This document is only meant as information for the [RESIDENT'S] nursing home providers. We will NOT write any medical orders in [RESIDENT'S] chart. If want your wishes to be part of [RESIDENT'S] care, you would need to speak directly with his/her doctor.\n\n5. We would also like to interview you on the telephone every 3 months after the start of the study for a maximum of 12 months. These interviews will take about 20 minutes or less. We will ask questions about decisions you may have made about [RESIDENT]'s care and discussions you have had with nursing home care providers about these decisions.  All interviews will be conducted at your convenience.\n\nRISKS\nThere are minimal risks associated with this study. The majority of the patient's information will be obtained from the medical record and the nurse. In our experience, it is unlikely he or she will become bothered during the one-time 5-minute testing of his or her thinking, however if he or she is bothered, the testing will stop.  While unlikely, you may experience discomfort from viewing the video or answering some of the questions during the interviews. You can refuse to continue watching the video or answering the questions at any time. You may become fatigued from the length of the interview, in which case we can reschedule another session. \n\nIN CASE OF INJURY\nWhile injury is unlikely in this research, if injury does occur while participating in the research, we will offer you or [Resident] the care needed to treat any injury that directly results from taking part in this research study.  If you think you or [Resident] have been injured or have experienced a medical problem as a result of taking part in this research study, tell the person in charge of the study as soon as possible. The researcher's name and phone number are listed at the end of this consent form.   You will be informed of any significant new findings developed during the course of this research, which may relate to your willingness to continue participation.\n\nBENEFITS \nThere are no direct benefits to you or [RESIDENT] from participation in this study, however others may benefit from the knowledge gained in connection with your participation.\n \nALTERNATIVE TREATMENTS \nThere are no treatments in this study. The alternative to participating in this study is not to participate.\n\nCONFIDENTIALITY\nAll personal information obtained in the study, will be kept confidential, and this information will only be available to the research staff and the HSL Institutional Review Board.  The records identifying your name and the [RESIDENT's] will be kept confidential and, to the extent permitted by the applicable laws and/or regulations, will not be made publicly available. The results of the study will only be published or presented as group data.  No individual participants will be identified.  Data forms will be identified with a unique study number and kept locked in the study office. \n\nCOMPENSATION\nFor your participation in this study, you will be given a $10 gift card to CVS at the time of your in-person interview.  \n\nCOSTS\nThere are no costs to you for participating in this study.\n\nSTUDY WITHDRAWAL\nYour and [RESIDENT's] participation in this research is completely voluntary.  If you chose not to participate or withdraw from the study, you or [RESIDENT] will incur no penalty or loss of usual benefits.  You may withdraw your consent and discontinue participation at any time without affecting you or the [RESIDENT'S] health care or other services you or [RESIDENT] may be receiving.  If you choose to take part in the study, you have the right to stop at any time. Your or [RESIDENT's] participation in this research project may be terminated if the study is determined to be inappropriate or potentially harmful for you or him/her.\n\nAUTHORIZATION FOR USE AND DISCLOSURE OF [RESIDENT'S] PROTECTED HEALTH INFORMATION\nAs part of this study, we will be collecting and sharing information about you and [Resident] with others.  Please review this section carefully as it contains information about the federal privacy rules and the use of Protected Health Information.\n\nPROTECTED HEALTH INFORMATION (PHI)\nBy agreeing to this informed consent document, you are allowing the investigators and other authorized personnel to use (internally at HSL) and disclose (to people and organizations outside the HSL workforce identified in this consent) health information about [RESIDENT].  This may include information that already exists such as: the [RESIDENT's] medical record, your demographic information (gender and age) as well as any new information generated as part of this study through nurse interviews and your interviews that we may ask you or [RESIDENT] to undergo.  This is [RESIDENT's] Protected Health Information.\n\nPeople/Groups at HSL Who Will Use Protected Health Information\n\n[RESIDENT's] Protected Health Information may be shared with the investigators listed on this consent form as well as the supporting research team (i.e. research assistants, statisticians, data managers, laboratory personnel, administrative assistants). [RESIDENT's] Protected Health Information may also be shared with the Institutional Review Board of Hebrew SeniorLife as it is responsible for reviewing studies for the protection of the research subjects.\n\nPeople/Groups Outside of HSL with Whom Protected Health Information Will Be Shared\n\nWe will take care to maintain confidentiality and privacy about you and [RESIDENT's] Protected Health Information. We may share [RESIDENT's] Protected Health Information with the following groups so that they may carry out their duties related to this study:\n\n• The sponsor of this study, the National Institutes of Health, and their clinical research organizations\n\n• The other hospitals and medical centers taking part in this study including:  Massachusetts General Hospital and Seattle Children's Research Institute and research collaborators at those institutions\n\n• Statisticians and other data monitors not affiliated with HSL: Seattle Children's Research Institute, Data Safety and Monitoring Board. \n\n• Your or [RESIDENT's] health insurance company\n\n• The Food and Drug Administration (FDA), the Department of Health and Human Services (DHHS), the National Institutes of Health (NIH), and the Office for Human Research Protections (OHRP) \n\nThose who receive [RESIDENT's] Protected Health Information may make further disclosures to others.  If they do, this information may no longer be covered by the federal privacy regulations.\n\nWhy We Are Using and Sharing [Resident's] Protected Health Information\n\nThe main reason for using and sharing [RESIDENT's] Protected Health Information is to conduct and oversee the research as described in this Informed Consent Document.  We also shall use and share [RESIDENT's] Protected Health Information to ensure that the research meets legal, and institutional requirements and to conduct public health activities.  \n\nNo Expiration Date - Right to Withdraw Authorization\nYour authorization for the use and disclosure of [RESIDENT's] Protected Health Information in this Study shall never expire.  However, you may withdraw your authorization for the use and disclosure of [RESIDENT's] Protected Health Information at any time by notifying the Principal Investigator in writing.  If you would like to take back your authorization so that [RESIDENT's] Protected Health Information can no longer be used in this study, please send a letter notifying the Principal Investigator of your withdrawal of your authorization to Susan L. Mitchell MD, MPH at 1200 Centre Street, Boston, MA 02131.  Please be aware that the investigators in this study will not be required to destroy or retrieve any of [RESIDENT's] Protected Health Information that has already been used or disclosed before the Principal Investigator receives your letter.\n\nRight to Access and Copy Your PHI\nIf you wish to review or copy [RESIDENT's] Protected Health Information, you may do so after the completion or termination of the study by sending a letter to the Principal Investigator requesting a copy of it.  You may not be allowed to inspect or copy [RESIDENT's] Protected Health Information until this Study is completed or terminated.\n\nNotice of Privacy Practices\nIn addition to agreeing to participate in this study, you may also be asked to sign an HSL Acknowledgement Received Notice of Privacy Practices form to acknowledge that you have received the HSL Notice of Privacy Practices. \n\nQUESTIONS\nIf you have any questions regarding this research or your or [RESIDENT's] participation in it, either now or at any time in the future, please feel free to ask. \n\n• You may obtain further information about your and [RESIDENT's] rights as a research participant or if you have any research concerns, please contact Madhuri Reddy, MD, MSc, Chair, HSL Institutional Review Board (IRB) at (617) 678-7592. \n\n• If you have any questions about your or [RESIDENT's] role in the research study, or if any; problems arise as a result of your or [RESIDENT's] participation in this study, including research-related injuries, please contact the principal investigator, Susan L. Mitchell MD, MPH at Hebrew SeniorLife, 1200 Centre Street, Boston) at (617)971-5326 immediately.\n\n \nDo you have any additional questions?\n\nSIGNATURE\nI attest that I have fully explained the above information to  [RESIDENT's HEALTH CARE PROXY name], answered any questions to his/her satisfaction, and sent him/her a copy of this form.  I attest that the health care proxy gave consent to participate and to allow ______________________________ [RESIDENT] to participate in this research study.\n\n________________________________ Signature of Research Associate\n\n________________________________ Printed Name \n\n________________________________ Date\n","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_study_assign] = '1' and [f0p_prxy_eligible] = '1'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":57,"Variable / Field Name":"f0p_cnsnt_rd","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">\nConsent Read?","Choices, Calculations, OR Slider Labels":"0, No (0) | 1, Yes (1)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_eligible] = '1'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":58,"Variable / Field Name":"f0p_date","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"text","Field Label":"<div style=\"font-size:12pt\">\nDate Consent Read","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"date_mdy","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_cnsnt_rd] = '1'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":59,"Variable / Field Name":"f0p_prxy_consent","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">\nProxy consent to participate","Choices, Calculations, OR Slider Labels":"0, No (0) | 1, Yes (1)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_cnsnt_rd] = '1'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":60,"Variable / Field Name":"f0p_cnsnt_date","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"text","Field Label":"<div style=\"font-size:12pt\">\nConsent Date","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"date_mdy","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_consent] = '1'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":61,"Variable / Field Name":"f0p_descript_n_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\nIf Proxy REFUSES to participate, continue with \"non-participation\" questions that follow","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_refuses] = '1' or [f0p_prxy_consent] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":62,"Variable / Field Name":"f0p_descript_y_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\n\"Thank you\" for your time and cooperation with this study. \n\nL Klein, one of our research assistants, will be contacting you in the near future to set up a meeting with you. \n\nPlease feel free to call me with any questions or concerns at any time. Thank you","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_consent] = '1'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":63,"Variable / Field Name":"f0p_not_recruited_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"font-size:12pt\">\nWhy was the resident not recruited?","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_refuses] = '1' or [f0p_prxy_consent] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":64,"Variable / Field Name":"f0p_reason_not_recrt","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">Reason resident not recruited","Choices, Calculations, OR Slider Labels":"1, Proxy refuses (1) | 2, Physician refuses (2) | 3, Resident change in med status (3) | 4, Other (4)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_refuses] = '1' or [f0p_prxy_consent] = '0'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":65,"Variable / Field Name":"f0p_prxy_no_reas","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"checkbox","Field Label":"<div style=\"font-size:12pt\">Reasons for proxy's refusal to consent","Choices, Calculations, OR Slider Labels":"1, Proxy concerned about proxy's privacy (1) | 2, Proxy concerned about resident's privacy (2) | 3, Proxy feels it is too burdensome (3) | 4, Proxy not interested (4) | 5, Other (5)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_reason_not_recrt] = '1'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":66,"Variable / Field Name":"f0p_reason_for_no_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"font-size:12pt\">\nDocument other reason for proxy's refusal to participate in the study","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_no_reas(5)] = '1'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":67,"Variable / Field Name":"f0p_prxy_no_reas_oth","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"notes","Field Label":"<div style=\"font-size:12pt\">Other Reasons for proxy refusal to consent","Choices, Calculations, OR Slider Labels":"","Field Note":"Explain other reason for no proxy consent","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_no_reas(5)] = '1'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":68,"Variable / Field Name":"f0p_explain_other_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"font-size:12pt\">\nExplain resident's change in medical status that prohibits participation in study","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_reason_not_recrt] = '3'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":69,"Variable / Field Name":"f0p_res_status_change","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"notes","Field Label":"<div style=\"font-size:12pt\">Change in resident medical status","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_reason_not_recrt] = '3'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":70,"Variable / Field Name":"f0p_no_recrt_oth","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"notes","Field Label":"<div style=\"font-size:12pt\">Other reason for not being recruited","Choices, Calculations, OR Slider Labels":"","Field Note":"Explain other reason for no recruitment","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_reason_not_recrt] = '4'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":71,"Variable / Field Name":"f0p_res_inf_ref_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\nRESIDENT INFORMATION \nThank you. \nI understand that you do not wish to participate in this study, but it would be very helpful to us to know a little more information about the resident. Would you mind if we asked a few questions about him/her? You may refuse to answer any of the questions (Leave blank if HCP refuses all questions)","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_refuses] = '1' or [f0p_prxy_consent] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":72,"Variable / Field Name":"f0p_prxy_cnt1","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">Do you mind a few questions about resident?","Choices, Calculations, OR Slider Labels":"0, No (continue survey) (0) | 1, Yes (end survey there) (1)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_refuses] = '1' or [f0p_prxy_consent] = '0'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":73,"Variable / Field Name":"f0p_prxy_cnt_y_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\nThank you for your time. \nI am now going to ask you a few questions about the resident.\n\nContinue with questions below.","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cnt1] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":74,"Variable / Field Name":"f0p_prxy_cnt_n_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\nI understand. Thank you for your time.\n\nEnd survey here.","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cnt1] = '1'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":75,"Variable / Field Name":"f0p_res_ethnicity","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">Resident Ethnicity","Choices, Calculations, OR Slider Labels":"1, American Indian/Alaskan native (1) | 2, Asian (2) | 3, Native Hawaiian or other Pacific Islander (3) | 4, Black/African American (4) | 5, White (5) | 6, Other (6) | 888, Refused (888)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cnt1] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":76,"Variable / Field Name":"f0p_res_ethnic_other","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"text","Field Label":"<div style=\"font-size:12pt\">\nResident Ethnicity Other","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_res_ethnicity] = '6'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":77,"Variable / Field Name":"f0p_res_race","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">Resident Racial Group","Choices, Calculations, OR Slider Labels":"1, Hispanic/Latino (1) | 2, Not Hispanic/Latino (2) | 888, Refused (888)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cnt1] = '0'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":78,"Variable / Field Name":"f0p_non_part_prxy_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\nPROXY INFORMATION \nWe would like to ask you similar questions about yourself. \nYou may refuse to answer any or the questions. \n(Leave blank if Proxy refuses all questions or if unable to speak with Proxy)","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cnt1] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":79,"Variable / Field Name":"f0p_prxy_cnt2","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">Do you mind a few questions about yourself?","Choices, Calculations, OR Slider Labels":"0, No (continue survey) (0) | 1, Yes (end survey there) (1)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cnt1] = '0'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":80,"Variable / Field Name":"f0p_prxy_cnt2_y_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\nThank you.\n\n(Continue with survey)","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cnt2] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":81,"Variable / Field Name":"f0p_prxy_cnt2_n_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\nThank you for your time.\n\n(End survey)","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cnt2] = '1'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":82,"Variable / Field Name":"f0p_prxy_dob","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"text","Field Label":"<div style=\"font-size:12pt\">\nProxy birthdate","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"date_mdy","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cnt2] = '0'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":83,"Variable / Field Name":"f0p_prxy_gndr","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">Proxy gender","Choices, Calculations, OR Slider Labels":"1, Male | 2, Female","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cnt2] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":84,"Variable / Field Name":"f0p_prxy_eductn","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"radio","Field Label":"<div style=\"font-size:12pt\">Proxy education","Choices, Calculations, OR Slider Labels":"1, No schooling (1) | 2, Less than or equal to 8th grade (2) | 3, Between 9th and 11th grade (3) | 4, Graduated high school (4) | 5, Technical or trade school (5) | 6, Some college (6) | 7, Bachelor's degree (7) | 8, Graduate degree (8) | 888, Refused to answer  (888)","Field Note":"What is the highest grade or year of school you have completed? (Don't read options, just ask question)","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cnt2] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":85,"Variable / Field Name":"f0p_thank_you_d","Form Name":"form_0p_proxy_screening_consent","Section Header":"","Field Type":"descriptive","Field Label":"<div style=\"background:#FFFF99;font-size:12pt\">\nThank you for your time. ","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f0p_prxy_cnt2] = '0'","Required Field?":"","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":86,"Variable / Field Name":"f1_doi","Form Name":"form_1a_baseline_demographics","Section Header":"<div style=\"background:#FFFF99;font-size:12pt\">   BASELINE RESIDENT INTAKE ASSESSMENT","Field Type":"text","Field Label":"Resident Baseline Date","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"date_mdy","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":87,"Variable / Field Name":"f1_ra_id","Form Name":"form_1a_baseline_demographics","Section Header":"","Field Type":"dropdown","Field Label":"RA ID","Choices, Calculations, OR Slider Labels":"1, M (1) | 2, H (2) | 3, R (3) | 4, L (4) | 5, S (5)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":88,"Variable / Field Name":"f1_base_unit_id","Form Name":"form_1a_baseline_demographics","Section Header":"","Field Type":"text","Field Label":"Unit ID","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":89,"Variable / Field Name":"f1_base_res_rm","Form Name":"form_1a_baseline_demographics","Section Header":"","Field Type":"text","Field Label":"Room number","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"y","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":90,"Variable / Field Name":"f1_res_spcl_unt","Form Name":"form_1a_baseline_demographics","Section Header":"","Field Type":"radio","Field Label":"Resident in Certified Alzheimer's Unit?","Choices, Calculations, OR Slider Labels":"0, No (0) | 1, Yes (1)","Field Note":"Is the resident currently being cared for in a special care unit for dementia?","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":91,"Variable / Field Name":"f1_res_race","Form Name":"form_1a_baseline_demographics","Section Header":"<div style=\"background:#FFFF99;font-size:12pt\">   Chart Review: DEMOGRAPHICS","Field Type":"radio","Field Label":"Resident Racial Group","Choices, Calculations, OR Slider Labels":"1, Hispanic/Latino (1) | 2, Not Hispanic/Latino (2) | 999, Not available (999)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":92,"Variable / Field Name":"f1_res_ethnic","Form Name":"form_1a_baseline_demographics","Section Header":"","Field Type":"radio","Field Label":"Resident Ethnicity","Choices, Calculations, OR Slider Labels":"1, American Indian/Alaskan native (1) | 2, Asian (2) | 3, Native Hawaiian or other Pacific Islander (3) | 4, Black/African American (4) | 5, White (5) | 6, Other (6) | 999, Unknown (999)","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":93,"Variable / Field Name":"f1_res_ethnic_oth","Form Name":"form_1a_baseline_demographics","Section Header":"","Field Type":"text","Field Label":"Resident Ethnicity Other","Choices, Calculations, OR Slider Labels":"","Field Note":"","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f1_res_ethnic] = '6'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":94,"Variable / Field Name":"f1_res_edu","Form Name":"form_1a_baseline_demographics","Section Header":"","Field Type":"radio","Field Label":"Resident Highest education","Choices, Calculations, OR Slider Labels":"1, No schooling (1) | 2, Less than or equal to 8th grade (2) | 3, Between 9th and 11th grade (3) | 4, Graduated high school (4) | 5, Technical or trade school (5) | 6, Some college (6) | 7, Bachelor's degree (7) | 8, Graduate degree (8) | 888, Refused to answer (888) | 999, Do not know (999)","Field Note":"What was the highest grade or year of school the resident completed? (from MDS)","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":95,"Variable / Field Name":"f1_res_prim_lang","Form Name":"form_1a_baseline_demographics","Section Header":"","Field Type":"radio","Field Label":"Resident primary language","Choices, Calculations, OR Slider Labels":"1, English (1) | 2, Spanish (2) | 3, French (3) | 4, Russian (4) | 5, Portuguese (5) | 6, Lituanian (6) | 7, Italian (7) | 8, Greek (8) | 9, Other (9) | 10, Chinese (10) | 999, Do not know (999)","Field Note":"What is the resident primary language? (from MDS)","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":96,"Variable / Field Name":"f1_res_prim_lang_oth","Form Name":"form_1a_baseline_demographics","Section Header":"","Field Type":"text","Field Label":"Resident primary language (other)","Choices, Calculations, OR Slider Labels":"","Field Note":"What is the resident primary language? (from MDS)","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f1_res_prim_lang] = '9'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":97,"Variable / Field Name":"f1_res_rel_bkgrnd","Form Name":"form_1a_baseline_demographics","Section Header":"","Field Type":"radio","Field Label":"Resident religious background","Choices, Calculations, OR Slider Labels":"1, Protestant (1) | 2, Catholic (2) | 3, Jewish (3) | 4, Muslim (4) | 5, Other (5) | 999, Unknown (999)","Field Note":"What is the resident's religious background?","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":98,"Variable / Field Name":"f1_res_rel_bkgrnd_oth","Form Name":"form_1a_baseline_demographics","Section Header":"","Field Type":"text","Field Label":"Resident religious background (other)","Choices, Calculations, OR Slider Labels":"","Field Note":"What is the resident religious background, if other?","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"[f1_res_rel_bkgrnd] = '5'","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":99,"Variable / Field Name":"f1_res_mar_stat","Form Name":"form_1a_baseline_demographics","Section Header":"","Field Type":"radio","Field Label":"Resident Marital Status","Choices, Calculations, OR Slider Labels":"1, Married/with Partner (1) | 2, Widowed (not remarried) (2) | 3, Divorced or separated (not remarried) (3) | 4, Never married (4) | 999, Not Available (999)","Field Note":"What is the resident's marital status?","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""},{"_id":100,"Variable / Field Name":"f1_res_dmtia_cause","Form Name":"form_1b_base_chart_review_med_status","Section Header":"<div style=\"background:#FFFF99;font-size:12pt\">   Chart Review: RESIDENT'S MEDICAL STATUS","Field Type":"checkbox","Field Label":"Underlying Cause of Residents Dementia","Choices, Calculations, OR Slider Labels":"1, Alcoholic dementia (1) | 2, Alzheimer's disease (2) | 3, Vascular dementia due to stroke or multiple infarcts (3) | 4, Lewy Body disease (4) | 5, Parkinson's disease (5) | 6, Pick's disease (6) | 7, Other (7)","Field Note":"Please check the underlying cause/causes of resident's dementia","Text Validation Type OR Show Slider Number":"","Text Validation Min":null,"Text Validation Max":null,"Identifier?":"","Branching Logic (Show field only if...)":"","Required Field?":"y","Custom Alignment":"","Question Number (surveys only)":"","Matrix Group Name":"","Matrix Ranking?":"","Field Annotation":""}], "fields": [{"id": "_id", "type": "int"}, {"id": "Variable / Field Name", "type": "text"}, {"id": "Form Name", "type": "text"}, {"id": "Section Header", "type": "text"}, {"id": "Field Type", "type": "text"}, {"id": "Field Label", "type": "text"}, {"id": "Choices, Calculations, OR Slider Labels", "type": "text"}, {"id": "Field Note", "type": "text"}, {"id": "Text Validation Type OR Show Slider Number", "type": "text"}, {"id": "Text Validation Min", "type": "numeric"}, {"id": "Text Validation Max", "type": "numeric"}, {"id": "Identifier?", "type": "text"}, {"id": "Branching Logic (Show field only if...)", "type": "text"}, {"id": "Required Field?", "type": "text"}, {"id": "Custom Alignment", "type": "text"}, {"id": "Question Number (surveys only)", "type": "text"}, {"id": "Matrix Group Name", "type": "text"}, {"id": "Matrix Ranking?", "type": "text"}, {"id": "Field Annotation", "type": "text"}], "_links": {"start": "/api/action/datastore_search?resource_id=f6cb9d8f-59bd-4a4a-a3e0-2abc531ceb10", "next": "/api/action/datastore_search?resource_id=f6cb9d8f-59bd-4a4a-a3e0-2abc531ceb10&offset=100"}, "total": 880, "total_was_estimated": false}}