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XT104
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IWER:note sex of decedent (ask if unsure) |
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XT001
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[{Name of the deceased}] has participated in the SHARE study before [his/her] death. [His/Her] contribution was very valuable. We would find it extremely helpful to havesome information about the final year of [{Name of the deceased}]'s life. All the information collected is strictly confidential, and will be held anonymously. |
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XT006
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IWER:Code proxy respondent's sex. |
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XT002
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Before we start ask ing questions about the last year of life of [{Name of the deceased}], would you please tell me what was your relationship to the deceased? |
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XT003
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IWER:Specify other relative |
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XT004
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IWER:Specify other non-relative |
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XT005
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During the last twelve months of [his/her] life, how often did you have contact with [{Name of the deceased}], either personally, by phone, mail, email, or any other electronicmeans? |
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XT007
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Can you tell me your year of birth? |
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XT101
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Let us now talk about the deceased. Just to mak e sure that we have the correct information about [{Name of the deceased}], can I just confirm that [he/she] was born in[{Month and Year birth of deceased}]? |
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XT102
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In which month and year was [{Name of the deceased}] born?MONTH:YEAR: |
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XT103
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In which month and year were [{Name of the deceased}] born?MONTH: ^XT102_DecMonthBirthYEAR: |
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XT008
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We would lik e to k now more about the circumstances of [{Name of the deceased}] 's death. In what month and year did [he/she] pass away?MONTH:YEAR: |
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XT009
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In what month and YEAR did [he/she] pass away?MONTH: ^XT008_MonthDiedYEAR: |
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XT010
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How old was [{Name of the deceased}] when [he/she] passed away? |
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XT109
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Was [{Name of the deceased}] married at the time of [his/her] death? |
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XT039
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How many children did [{Name of the deceased}] have that were still alive at the time of [his/her] death? Please include foster and adopted children. |
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XT011
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What was the main cause of [his/her] death? |
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XT012
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IWER:Specify other cause of death |
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XT013
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How long had [{Name of the deceased}] been ill before [he/she] died? |
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XT014
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Did [he/she] die ... |
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XT045
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IWER:Specify other place of death |
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XT015
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In the last year before [he/she] died, on how many different occasions did [{Name of the deceased}] stay in a hospital, hospice or nursing home? |
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XT016
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During the last year of [his/her] life, for how long altogether did [{Name of the deceased}] stay at hospitals, hospices or nursing homes? |
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XT017
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We would now lik e to ask you some questions about any expenses which [{Name of the deceased}] incurred as a result of the medical care [he/she] received in the last 12months before [he/she] died. For each of the types of care I will now read out, please indicate whether the deceased received the care and, if so, give your best estimate ofthe costs incurred from that care. Please include only costs not paid or reimbursed by the health insurance or the employer. |
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XT018
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Has [{Name of the deceased}] had any [care from a general practitioner/care from specialist physicians/hospital stays/care in a nursing home/hospicestays/medication/aids and appliances/home care or home help due to disability] (in the last 12 months of [his/her] life)? |
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XT019
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About how much did [his/her] [care from a general practitioner/care from specialist physicians/hospital stays/care in a nursing home/hospice stays/medication/aidsand appliances/home care or home help due to disability] cost (in the last 12 months of [his/her] life)? |
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XT105
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We would lik e to k now more about the difficulties people have in their last year of life because of a physical, mental, emotional or memory problems. During the last year of[his/her] life, did [{Name of the deceased}] have any difficulty remembering where [he/she] was? Please name only difficulties that lasted at least three months? |
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XT106
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During the last year of [his/her] life, did [{Name of the deceased}] have any difficulty rememberingwhat year it was? (Please name only difficulties that lasted at least three months?) |
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XT107
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During the last year of [his/her] life, did [{Name of the deceased}] have any difficulty recognizingfamily members or good friends? (Please name only difficulties that lasted at least three months?) |
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XT020
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Because of a physical, mental, emotional or memory problem, did [{Name of the deceased}] have difficulty doing any of the following activities during the last twelve monthsof [his/her] life? Please name only difficulties that lasted at least three months. |
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XT022
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Think ing about the activities that the deceased had problems with during the last twelve months of [his/her] life, has anyone helped regularly with these activities? |
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XT023
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Who, including yourself, has helped mainly with these activities? Please name at most three persons. |
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XT024
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Overall, during the last twelve months of [his/her] life, for how long did the deceased receive help? |
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XT025
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And about how many hours of help were necessary during a typical day? |
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XT026a
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The next questions are about the assets and life insurance policies the deceased may have owned and what happened to those assets after [{Name of the deceased}] died.I appreciate that this may upset or distress you, but we would find it very helpful to have some information about the financial issues surrounding death. Before I continue,though, I'd lik e to assure you again that everything you have already told me and anything else you tell me will be k ept completely confidential. |
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XT026b
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Some people mak e a will to determine who receives what parts of the estate.Did [{Name of the deceased}] have a will? |
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XT027
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Who were the beneficiaries of the estate, including yourself? |
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XT028
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IWER:Specify other relative |
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XT029
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IWER:Specify other non-relative |
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XT030
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Did the deceased own [his/her] home or apartment - either in total or a share of it? |
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XT031
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After any outstanding mortgages, what was the value of the home or apartment or the share of it owned by the deceased? |
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XT051
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IWER:Specify other relative |
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XT052
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IWER:Specify other non-relative |
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XT053
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IWER:First names of children who inherited home |
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XT033
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Did the deceased own any life insurance policies? |
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XT034
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In total, about what was the value of all life insurance policies owned by the deceased? |
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XT035
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Who were the beneficiaries of the life insurance polices, including yourself. |
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XT054
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IWER:Specify other relative |
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XT055
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IWER:Specify other non-relative |
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XT056
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IWER:First names of children who were beneficiaries |
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XT036
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I will now read out a few types of assets people may have. For each item, please tell me whether the deceased owned them at the time of [his/her] death and, if so, pleasegive your best estimate of their value after any outstanding debts. |
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XT037
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Did [he/she] own any [businesses, including land or premises/other real estate/cars/financial assets, e.g. cash, bonds or stock s/jewelry or antiquities]? |
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XT038
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About what was the value of the [businesses, including land or premises/other real estate/cars/financial assets, e.g. cash, bonds or stock s/jewelry or antiquities] ownedby [{Name of the deceased}] at the time of [his/her] death? |
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XT040b
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Would you say that some children received more than others to mak e up for previous gifts? |
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XT040c
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Would you say that some children received more than others to give them financial support? |
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XT040d
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Would you say that some children received more than others because they helped or cared for the deceased towards the end of [his/her] life? |
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XT040e
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Would you say that some children received more than others because of other reasons? |
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XT040f
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What other reasons do you mean? |
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XT041
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Finally, we would lik e to k now about the deceased's funeral. Was the funeral accompanied by a religious ceremony? |
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XT108
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We have ask ed you many questions about numerous aspects of [{Name of the deceased}]'s health and finances, and we want to thank you very much for your assistancewith them. Is there anything else you would lik e to add about the life circumstances of [{Name of the deceased}] in [his/her] last year of life? |
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XT042
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This is the end of the interview. Thank you once again for all the information you have given us. It will prove extremely useful in helping us to understand how people fare atthe end of their lives |
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XT043
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IWER:Please state mode of interview |
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XT044
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IWER:Your interviewer id. |
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XT032
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Who inherited the deceased's home or apartment, including yourself? |