Survey of Neurological Conditions in Institutions in Canada

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For Information onlyThis is an electronic survey example for information purposes only. This is not a working questionnaire.

INTRODUCTION

Name of person completing this questionnaire (please print)

  • 1: Last Name
  • 2: First Name
  • 3: Telephone Number
  • 4: Extension
  • 5: Fax Number
  • 6: Title
  • 7: E-mail address

Please enter your reporting date here:

  • 1: Year
  • 2: Month
  • 3: Day

Purpose

This survey collects data on the prevalence of several neurological conditions in long-term care facilities.

Authority

This survey is conducted under the authority of the Statistics Act, Revised Statutes of Canada, 1985, Chapter S-19.

Confidentiality

Your answers are confidential.
Statistics Canada is prohibited by law from releasing any information it collects which could identify any person, business, or organization, unless consent has been given by the respondent or as permitted by the Statistics Act. The information from this survey will be used for statistical purposes and published in aggregate form only.

Data-sharing agreements

To avoid duplication of surveys and reduce respondent burden, Statistics Canada has entered into data-sharing agreements with federal, provincial and territorial government organizations, which have agreed to keep the data confidential and use them only for statistical purposes.

Section 12 of the Statistics Act provides for the sharing of information with federal, provincial or territorial government organizations. Under Section 12, you may refuse to share your information with any of these organizations by writing a letter of objection to the Chief Statistician and returning it with the completed questionnaire.

For this survey, there are Section 12 agreements with the Public Health Agency of Canada, Health Canada, the Institut de la Statistique du Québec, and the provincial and territorial health ministries. Please specify the organizations with which you do not want to share your data.

Record linkage

To enhance the data from this survey, Statistics Canada will combine them with information from other surveys or from administrative sources. These include the 2010 Residential Care Facilities Survey, the Rapports statistiques annuels and the Système M30.

Return procedures

Please return the completed questionnaire in the enclosed envelope within 21 days of receipt.

Even if you had only a few or no residents with neurological conditions in your facility on the reporting date, please complete and return the questionnaire.

Statistics Canada advises you that there could be a risk of disclosure during facsimile or other electronic transmission. However, upon receipt, Statistics Canada will provide the guaranteed level of protection afforded all information collected under the authority of the Statistics Act.

You may return the questionnaire by fax toll-free to 1-888-883-7999.

Assistance

For assistance and information please call the number provided in the label area.

You may also visit Statistics Canada's website, www.statcan.gc.ca - see Information for survey participants.

Definitions

1. Multiple sclerosis

A disease affecting the protective coating of the nerves of the brain and spinal cord.

2. Epilepsy

A brain disorder that causes the brain to send out the wrong signals, resulting in seizures.

3. Cerebral palsy

A disorder caused by damage to the brain either before birth or early on in life resulting in difficulties with movement,muscle control or posture.

4. Spina bifida

A birth defect in which the spine does not form completely and the spinal cord is not fully protected usually resulting in nerve damage and some paralysis of the legs.

5. Hydrocephalus

A build-up of too much fluid on the brain. It can be present at birth or can develop later on in life.

6. Muscular dystrophy

A group of genetic disorders that cause muscle weakness and muscle loss.

7. Dystonia

A movement disorder which causes involuntary contractions of muscles.

8. Tourette's syndrome

A disorder which causes tics such as throat clearing, eye blinking or repeating words.

9. Parkinson's disease

A progressive nervous system disease, characterized by muscular tremor, slowing of movement, partial facial paralysis, trouble walking, distorted posture, weakness and muscular rigidity.

10. Amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease)

A disease of the nervous system that attacks nerve cells in the brain and spinal cord. ALS is a fatal disease with no effective treatment and no cure. Eighty percent of people with ALS die within two to five years of diagnosis.

11. Huntington's disease

A genetic disease that causes certain nerve cells in the brain to waste away.

12. Stroke

Occurs when the flow of blood to a part of the brain is cut off. This can be due to a blood clot obstructing an artery that leads to the brain (ischemic stroke), or it can be caused by a burst blood vessel bleeding into the brain (hemorrhagic stroke).

13. Traumatic brain injury

Damage to the brain that results in difficulties with attention,cognition, language, memory, behaviour or movement.

14. Traumatic spinal cord injury

Damage to the spinal cord caused by trauma that results in paralysis, loss of strength, loss of sensation, or difficulty controlling the bladder or bowel.

15. Brain or spinal cord tumour

A growth of abnormal cells inside the skull. A growth of abnormal cells in or surrounding the spinal cord.

16. Alzheimer's disease or any other dementia

Alzheimer's disease is the most common form of dementia in the elderly and causes impairment of memory and mental abilities.

A. AGE AND SEX OF RESIDENTS IN FACILITY ON THE REPORTING DATE

Age and sex of residents in facility on the reporting date

Number of males

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: Total residents
    (sum of lines 1 to 5)

Number of females

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: Total residents
    (sum of lines 1 to 5)

Grand Total Residents

B. NEUROLOGICAL CONDITIONS OF MALE RESIDENTS IN THE FACILITY ON THE REPORTING DATE

Neurological conditions of males residents in the facility on the reporting date

Number of males diagnosed with multiple sclerosis

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with epilepsy

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with cerebral palsy

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with spina bifida

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with hydrocephalus

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with muscular dystrophy

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with dystonia

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with Tourette's syndrome

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with Parkinson's disease

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease)

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with Huntington's disease

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with stroke

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with traumatic brain injury

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with traumatic spinal cord injury

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with brain or spinal cord tumour

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

Number of males diagnosed with Alzheimer's disease or any other dementia

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL males with the condition

C. NEUROLOGICAL CONDITIONS OF FEMALE RESIDENTS IN THE FACILITY ON THE REPORTING DATE

Neurological conditions of females residents in the facility on the reporting date

Number of females diagnosed with multiple sclerosis

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with epilepsy

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with cerebral palsy

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with spina bifida

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with hydrocephalus

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with muscular dystrophy

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with dystonia

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with Tourette's syndrome

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with Parkinson's disease

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease)

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with Huntington's disease

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with stroke

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with traumatic brain injury

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with traumatic spinal cord injury

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with brain or spinal cord tumour

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

Number of females diagnosed with Alzheimer's disease or any other dementia

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: TOTAL females with the condition

D. RESIDENTS WITH AT LEAST ONE NEUROLOGICAL CONDITION ON THE REPORTING DATE

Residents with at least one neurological condition on the reporting date

Number of males with at least one neurological condition

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: Total residents with at least one neurological condition (Sum of lines 1 to 5)

Number of females with at least one neurological condition

  • 1: Under 18 years
  • 2: 18 to 44 years
  • 3: 45 to 64 years
  • 4: 65 to 79 years
  • 5: 80 years and over
  • 6: Total residents with at least one neurological condition (Sum of lines 1 to 5)

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