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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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^CV004_Name has participated in the 50+ in Europe study before [his/her] death. [His/Her] contribution was very valuable. We would find it extremely helpful to have some information about the final year of ^CV004_Name'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 asking questions about the last year of life of ^CV004_Name, 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 ^CV004_Name, either personally, by phone, mail or email? |
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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 make sure that we have the correct information about ^CV004_Name, can I just confirm that [he/she] was born in {FL_XT101_3}? |
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XT102
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In which month and year was ^CV004_Name born? MONTH: YEAR: IWER: Month |
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XT103
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In which month and year was ^CV004_Name born? MONTH: ^XT102_DecMonthBirth YEAR: IWER: Year |
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XT008
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We would like to know more about the circumstances of ^CV004_Name 's death. In what month and year did [he/she] pass away? MONTH: YEAR: IWER: Month |
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XT009
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In what month and YEAR did [he/she] pass away? MONTH: YEAR: IWER: Year |
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XT010
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How old was ^CV004_Name when [he/she] passed away? |
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XT109
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Was ^CV004_Name married at the time of [his/her] death? |
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XT039
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How many children did ^CV004_Name have that were still alive at the time of [his/her] death? Please include 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 ^CV004_Name 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 ^CV004_Name 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 ^CV004_Name stay at hospitals, hospices or nursing homes? |
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XT017
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We would now like to ask you some questions about any expenses which ^CV004_Name incurred as a result of the medical care [he/she] received in the last 12 months 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 of the 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 ^CV004_Name had any [care from a general practitioner/care from specialist physicians/hospital stays/care in a nursing home/hospice stays/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/aids and 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 like to know 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 ^CV004_Name 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 ^CV004_Name have any difficulty remembering what 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 ^CV004_Name have any difficulty recognizing family 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 ^CV004_Name have difficulty doing any of the following activities during the last twelve months of [his/her] life? Please name only difficulties that lasted at least three months. |
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XT022
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Thinking 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 those assets after ^CV004_Name died. I appreciate that this may to have some information about the financial issues surrounding death. that everything you have already told me and anything else you tell me |
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XT026b
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Some people make a will to determine who receives what parts of the estate. Did ^CV004_Name have a will? |
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XT027
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Who were the beneficiaries of the estate, including yourself? IWER: Read out Code all that apply |
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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, please give 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 stocks/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 stocks/jewelry or antiquities] owned by ^CV004_Name 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 make 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 like to know about the deceased's funeral. Was the funeral accompanied by a religious ceremony? |
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XT108
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We have asked you many questions about numerous aspects of ^CV004_Name 's health and finances, and we want to thank you very much for your assistance with them. Is there anything else you would like to add about the life circumstances of ^CV004_Name 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 at the 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. |