Family Interview Form (Page 2 of 8) in pdf

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

FAMILY INTERVIEW

Screening Questions

The questioning below screens the interviewee to see if she/he knows the resident well enough to complete the rest of the

interview. Based on answers to question 1, decide whether you can complete the interview, can complete it partially if the

family member knows about some areas of the resident’s care, or should conclude the interview. If you find that the family

member has little or no knowledge of the resident’s past history, you may want to discontinue the interview. However, if

he/she visits the facility frequently, his/her answers may give information about the current care of the resident.

Ask about the nature and extent of the relationship between the interviewee and resident both prior to and during nursing home

residence:

a. With whom did your relative/friend live before coming to the nursing home? If the resident did not live with you, how

often did you see her/him?

b. Are you familiar with her/his preferences and daily routines when she/he was more independent and more able to make

choices and express preferences? (If the resident has had a lifelong disability, ask about choices and preferences prior to

moving to this facility. Adapt additional questions as necessary.) If No, conclude interview.

c. How often do you visit the resident now? When do you visit (time of day, day of the week)?

If you decide you must conclude this interview because the interviewee has little or no knowledge of the resident or only visits

occasionally, ask a general question that lets the family member say what he/she wishes about the facility such as: “Is there

anything you would like to tell me about this facility and how your relative is treated?” Record any pertinent information in the

comments section.

Comments:

FORM CMS-20049 (7/2012)

Family Interview Form Page 2