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SH1
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Due to health problems, did someone used to help (NAME) with at least one activity such as walking across a room, bathing or showering, eating, such as cutting his/her food, getting in or out of bed, using the toilet, including getting on and off the toil |
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SH2
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Please tell me who helped (NAME) with these activities. |
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SH3
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If the person is included in any roster, note the corresponding registration number. If it's a child in law or a grandchild, note the registration number to whom he/she is related. If person is not in any roster, record 666 |
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SH4
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What relationship did (NAME OF PERSON WHO HELPED) have to (NAME)? |
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SH5
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During the last month of his/her life, about how many days did he/she help (NAME)? |
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SH6
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On those days that he/she helped (NAME), about how many hours per day did he/ she help? |
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SH7
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Now I will mention other activities with which people may have problems due to a physical, mental, emotional or memory related problem. Please tell me about the help that (NAME) received in the LAST THREE MONTHS BEFORE HIS/HER DEATH. Due to a health probl |
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SH8
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Please tell me who helped (NAME) with these activities. |
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SH9
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If the person is included in any roster, note the registration number If it's a child in law or a grandchild, note the registration number to whom he/she is related. If person is not in any roster, record 666 |
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SH10
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What relationship did (NAME OF PERSON WHO HELPED) have to (NAME)? |
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SH11
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During the last month of his/her life, about how many days did he/she help (NAME)? |
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SH12
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On those days that he/she helped (NAME), about how many hours per day did he/ she help? |