Chapter 3: Select the Survey Instrument
Chapter 3 in PDF format
This Toolkit contains nine survey instruments to assess programs and to learn about service recipients. The survey instruments are designed to be administered by telephone; however, it is possible to administer them by mail, or, in the case of congregate meals, in person. The POMP grantees field-tested and refined these survey instruments over several years, and they conducted reliability and validity testing to ensure they were psychometrically sound.
Table 3-1. POMP Survey Instruments
|Field-Tested Survey Instruments
for Five Services*
- Caregiver Services
- Case Management
- Congregate Meals
- Home-Delivered Meals
Instruments about Service
Recipients’ Characteristics that
Can Accompany the
- Additional Services Rendered
- Physical Functioning and Health
- Social and Emotional
*The workgroup also developed survey instruments for additional services that did not have the benefit of complete testing. These covered information and referral/assistance and senior centers.
For the information and referral assistance report see
For the senior center report please see http://elderaffairs.state.fl.us/doea/sc_toolkit.php
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Assessing Specific Programs and/or Services
Caregiver Services Survey Instrument
The core Caregiver Services Survey Instrument has 16 questions. The topics covered are services received, service quality, and service impact on the caregiver and care recipient. In addition, the survey instrument includes seven optional modules.
To view the Caregiver Services Survey Instrument, see Appendix A.
Table 3-2. Comprehensive Survey Modules on Caregiver Satisfaction and Outcomes
||Number of Questions
||Burdens and Rewards of Caregiving
||Impact on Employment
||Health of Caregiver
||Health and Physical Functioning
of Care Recipient
||Service and Information Needs
Case Management Survey Instrument
The Case Management Survey Instrument has 20 questions. The topics covered are quality of service and the extent to which the case management service helped the service recipient receive needed care.
To view the Case Management Survey Instrument, see Appendix A.
Congregate Meals Survey Instrument
The Congregate Meals Survey Instrument has 51 questions about the frequency of program participation, food intake, service quality, self- reported outcomes, nutrition education and food security.
To view the Congregate Meals Survey Instrument, see Appendix A.
Home-Delivered Meals Survey Instrument
The Home-Delivered Meals Survey Instrument has 47 questions about the frequency of program participation, food intake, service quality, self-reported outcomes, and food security.
To view the Home-delivered Meals Survey Instrument, see Appendix A.
Transportation Survey Instrument
The Transportation Survey Instrument has 27 questions. The topics covered are frequency of and reason for use, overall experience with service, service quality, self-reported outcomes, and ease of access to transportation.
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To view the Transportation Survey Instrument, see Appendix A.
The cross-cutting modules focus on service recipient characteristics and well-being. These instruments allow agencies to make comparisons between service recipients’ characteristics at the local level with AoA National Survey data or to see if responses to self-reported service outcomes vary by demographic, frailty, or other factors. These modules may be used in conjunction with any of the previously discussed survey instruments and are administered by telephone, mail, or in-person.
To view the Cross-Cutting Modules, see Appendix A.
The Demographics Module has ten questions related to gender, age, race, marital status, and income, and they follow standard wording used in many national surveys.
To view the Demographics Module, Appendix A.
Physical Functioning and Health Module
The Physical Functioning and Health Module has 21 questions. The topics covered are self-assessment of health, limitations in activities of daily living and instrumental activities of daily living, and use of one or more assistive devices (e.g., walker, wheelchair, hearing aid).
To view the Physical Functioning and Health Module, see Appendix A.
Social and Emotional Well-Being Survey Module
The Social and Emotional Well-Being Module has seven questions. The topics covered are frequency of contact with other people, frequency of leaving home for social activities, self-assessment of emotional well-being, and frequency of negative feelings (e.g., stress, grief, worry) and their impact on participation in social activities.
To view the Social and Emotional Well-Being Module, see Appendix A.
Additional Services Received Module
The Additional Services Received Module has 20 questions. The topics covered are receipt of other services and self-reported outcomes associated with the receipt of these services.
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To view the Additional Services Received Module, see Appendix A.