Attachment 1 ? Updated Washington Group instrument to be cognitively tested

Attachment 1 – Updated Washington Group instrument to be cognitively tested.

OMB #0920-0222; Expiration Date: 02/28/10

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1. VISION
Questions	Response Options	Notes/Themes
SS1a: Do you have difficulty seeing, even when wearing glasses?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
1.1a Do you wear glasses to see far away? 1.1b. Do you wear glasses to see up close? 1.1c. Do you wear glasses for another reason? (other): ____________	1) Yes 2) No If yes, read glasses in room question 1) Yes 2) No If yes, read glasses in coin question 1) Yes 2) No If yes, record other
1.3 Do you have difficulty clearly seeing someone’s face across a room [even when wearing your glasses]?	1) No – no difficulty If no, go to 1.4 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
11.1ai How old were you when the difficulty seeing far away began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your difficulty seeing far away due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your difficulty seeing far away limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your difficulty seeing far away limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No
1.4 Do you have difficulty clearly seeing the picture on a coin [even when wearing your glasses]?	1) No – no difficulty If no, go to next section. 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
11.1ai How old were you when the difficulty seeing close up began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your difficulty seeing close up due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your difficulty seeing close up limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your difficulty seeing close up limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No

2. HEARING
Questions	Response Options	Notes/Themes
SS2: Do you have difficulty hearing, even if using a hearing aid?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
2.1 Do you use a hearing aid? 2.2 If yes: How often do you use your hearing aid(s)?	1) Yes 2) No If yes, read hearing aid in noisy room and quiet room 1) All of the time 2) Some of the time 3) Rarely 4) Never
2.3 Do you have difficulty hearing what is said in a conversation with one other person in a noisy room [even when wearing your hearing aid(s)]?	1) No – no difficulty If no difficulty, go to next section. 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
2.4 Do you have difficulty hearing what is said in a conversation with one other person in a quiet room [even when wearing your hearing aid(s)]?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
11.1i How old were you when the difficulty hearing began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your difficulty hearing due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your difficulty hearing limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your difficulty hearing limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No

3. MOBILITY
Questions	Response Options	Notes/Themes
SS3. Do you have any difficulty walking or climbing steps?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
3.1a Do you use any equipment or receive help for getting around? 3.2 If Yes: Do you use any of the following? a. cane or walking stick? b. walker? (Zimmer frame) c. crutches? d. wheelchair? e. prosthesis(es)? f. someone’s assistance? g. other? (specify: ________) 3.3 If more than one: Which [aid/assistance] do you use most often?	1) Yes 2) No 1) Yes 2) No 1) Yes 2) No 1) Yes 2) No 1) Yes 2) No 1) Yes 2) No 1) Yes 2) No 1) Yes 2) No Specify a-g: ___________ **Insert most used aid in the following questions
3.4 Do you have difficulty walking 100 (meters/yards) on level ground, that would be about (insert country-specific example) [without the use of your [insert aid]]?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all If cannot do at all, go to 3.6 -- stairs question
3.5 Do you have difficulty walking 500 (meters/yards) on level ground, that would be about (insert country-specific example) [without the use of your [insert aid]]?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
3.6 Do you have difficulty walking up or down [insert country-specific example: a flight of stairs / 12 steps / a small hill] [without the use of your [insert aid]]?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
3.7 Only if R has difficulty walking 100: Do you have difficulty walking around in your home [without the use of aids, equipment or help]?	1) Yes 2) No I f no aid, go to next section
Only if R uses an aid: 3.8 Do you have difficulty walking 100 (meters/yards) on level ground, that would be about (insert country-specific example), even when using your [insert aid]]?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all If cannot do at all, go to 3.10 -- stairs question
3.9 Do you have difficulty walking 500 (meters/yards) on level ground, that would be about (insert country-specific example), even when using your [insert aid]]?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
11.1ai How old were you when the difficulty walking began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your difficulty walking due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your difficulty walking limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your difficulty walking limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No
3.10 Do you have difficulty walking up or down [insert country-specific example: a flight of stairs / 12 steps / a small hill], even when using your [insert aid]]?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
3.11 Only if R has difficulty walking 100: Do you have difficulty walking around in your home, even when using your [insert aid]]?	1) Yes 2) No
11.1ai How old were you when the difficulty walking up or down [insert country-specific example: a flight of stairs / 12 steps / a small hill] began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your difficulty walking up or down [insert country-specific example: a flight of stairs / 12 steps / a small hill] due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your difficulty walking up or down [insert country-specific example: a flight of stairs / 12 steps / a small hill] limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your difficulty walking up or down [insert country-specific example: a flight of stairs / 12 steps / a small hill] limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No

4. COMMUNICATION
Questions	Response Options	Notes/Themes
SS4. Using you usual (customary) language, do you have difficulty communicating, for example understanding or being understood?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
4.1 Do people have difficulty understanding you when you speak?	1) Yes 2) No If no, go to next section
4.2 If Yes: Do you use any of these forms of communication? a. sign language? b. hand writing? c. typed or text messages? d. communication or picture board or cards? e. computer assisted communication device? f. an interpreter? g. other? (specify: ________)	1) Yes 2) No 1) Yes 2) No 1) Yes 2) No 1) Yes 2) No 1) Yes 2) No 1) Yes 2) No
11.1ai How old were you when the difficulty communicating began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your difficulty communicating due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your difficulty communicating limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your difficulty communicating limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No

5. COGNITION (REMEMBERING) – Two Sets
Questions	Response Options	Notes/Themes
SS5. Do you have difficulty remembering or concentrating?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
SET A: 5A.1 How often do you have difficulty remembering important things?	1) Never If never, go to next section 2) Sometimes 3) Often 4) All the time
5A.2 Thinking about the last time you had difficulty remembering important things, how much difficulty did you have?	1) No difficulty 2) Some difficulty 3) A lot of difficulty 4) Could not do at all
SET B: 5B.2 Do you have difficulty remembering a few things, a lot of things, or almost everything?	1) A few things 2) A lot of things 3) Almost everything
11.1ai How old were you when the difficulty remembering or concentrating began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your difficulty remembering or concentrating due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your difficulty remembering or concentrating limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your difficulty remembering or concentrating limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No

6. UPPER BODY
Questions	Response Options	Notes/Themes
SS6. Do you have difficulty raising a 2 liter jug of water from waist to eye level?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
6.1 Do you use any aids or equipment or receive help with lifting? 6.2 If Yes: What types of aids, equipment or assistance do you use?	1) Yes 2) No If no, go to 6.4 – hands and fingers question Specify all: __________
6.3 Only if uses aid: Do you have difficulty raising a 2 litre jug of water from waist to eye level even when using your aid?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
11.1ai How old were you when the difficulty lifting began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your difficulty lifting due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your difficulty lifting limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your difficulty lifting limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No
6.4 Do you use any aids or equipment or receive help when using your hands or fingers? 6.5 What types of aids, equipment or assistance do you use?	1) Yes 2) No If yes, read aid in next question

6.6 Do you have difficulty using your hands and fingers, such as picking up small objects, for example, a button or pencil, or opening or closing containers or bottles [even when using your aid]?	1) No – no difficulty If no, go to next section 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all
11.1ai How old were you when the difficulty using your hands or fingers began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your difficulty using your hands or fingers due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your difficulty using your hands or fingers limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your difficulty using your hands or fingers limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No

7. LEARNING
Questions	Response Options	Notes/Themes
For Adults: 7.2 Do you have difficulty understanding and using information like following directions to get to a new place?	1) No – no difficulty 2) Yes – some difficulty 3) Yes – a lot of difficulty 4) Cannot do at all	If NO, go to next section
11.1ai How old were you when did the difficulty understanding and using information began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your difficulty understanding and using information due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your difficulty understanding and using information limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your difficulty understanding and using information limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No

8. AFFECT (ANXIETY AND DEPRESSION)
Questions	Response Options	Notes/Themes
8.1a How often do you feel worried, nervous or anxious? Daily, Weekly, Monthly, A few times a year, or Never?	1) Daily 2) Weekly 3) Monthly 4) A few times a year 5) Never If never, go to 8.5 -- depression question
8.2 Do you take medication for anxiety?	1) Yes 2) No If yes, read medication in next question
8.3 Thinking about the last time you felt anxious, how would you describe the level of anxiety [even when taking your medication]? Mild, Moderate or Severe?	1) Mild 2) Moderate 3) Severe
8.4 Thinking about the last time you felt anxious, was the anxiety worse than usual, better than usual, or about the same as usual?	1) Worse than usual 2) About the same as usual 3) Better than usual
11.1ai How old were you when the anxiety began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your anxiety due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your anxiety limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your anxiety limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No
8.5 How often do you feel depressed? Daily, Weekly, Monthly, A few times a year, or Never?	1) Daily 2) Weekly 3) Monthly 4) A few times a year 5) Never If never, go to next section
8.6 Do you take medication for depression?	1) Yes 2) No If yes, read medication in next question
8.7 Thinking about the last time you felt depressed, how depressed did you feel [even when taking your medication], a little, a lot, or somewhere in between a little and a lot? 8.7b If somewhere in between: Would you say the depression was closer to a little, closer to a lot, or exactly in the middle?	1) A little 2) A lot 3) Somewhere in between a little and a lot little a lot middle

8.8 Thinking about the last time you felt depressed, was the depression worse than usual, better than usual, or about the same as usual?	1) Worse than usual 2) About the same as usua1 3) Better than usual
11.1ai How old were you when the depression began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your depression due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your depression limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your depression limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No

9. PAIN
Questions	Response Options	Notes/Themes
9.1a Do you have frequent pain?	1) Yes 2) No
9.2 Do you use medication for pain?	1) Yes 2) No If no to both questions, go to next section If yes, read medication in next question
9.3 If yes: In the past 3 months, how often did you have pain? A few days, Some days, Most days, Almost every day?	A few days Some days Most days Almost every day
9.4 Thinking about the last time you had pain, how long did the pain last [even when taking your medication]? A little of the day, Some of the day, Most of the day, All of the day?	1) A little of the day 2) Some of the day 3) Most of the day 4) All of the day
9.5a Thinking about the last time you had pain, how much pain did you have, a little, a lot, or somewhere in between a little and a lot? 9.5bb If somewhere in between: Would you say the amount of pain was closer to a little, closer to a lot, or exactly in the middle?	1) A little 2) A lot 3) Somewhere in between a little and a lot Little a lot middle

9.6 Thinking about the last time you had pain, was the pain worse than usual, better than usual, or about the same as usual [even when taking your medication]?	1) Worse than usual 2) About the same as usua1 3) Better than usual
How would you describe your pain?
11.1ai How old were you when the pain began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your pain due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your pain limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your pain limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No

10. FATIGUE
Questions	Response Options	Notes/Themes
10.1a Do you have frequent feelings of being tired?	1) Yes 2) No If no, go to next section
10.2 In the past 3 months, how often did you feel tired? A few days, Some days, Most days, Almost every day?	1) A few days 2) Some days 3) Most days 4) Almost every day
10.3 Thinking about the last time you felt tired, how long did the tiredness last? A little of the day, Some of the day, Most of the day, All of the day?	1) A little of the day 2) Some of the day 3) Most of the day 4) All of the day
10.4 Thinking about the last time you felt tired, how would you describe the level of tiredness? Mild, Moderate or severe?	1) Mild 2) Moderate 3) Severe
10.5 Thinking about the last time you felt tired, was the tiredness worse than usual, better than usual, or about the same as usual?	1) Worse than usual 2) About the same as usua1 3) Better than usual

11.1ai How old were you when the tiredness began?	a) less than 1 year b) 1-4 years c) 5-11 d) 12-17 e) 18-24 f) 25-44 g) 45-54 h) 55-64 i) 65-79 j) 80+
12.1i Is your tiredness due to a health problem or something else?	1) Due to a health problem 2) Something else: _____________
13.1i Does your tiredness limit your ability to carry out daily activities?	1) Yes 2) No
13.2bi Does your tiredness limit your ability to carry out other activities that are not part of your day-to-day life?	1) Yes 2) No

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