39 Initial Adult Questionaire

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Attachment 39 Initial Questionnaire – SELF

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Expiration Date: XX/XX/XXXX

Initial Questionnaire
Estimated time burden: 12 minutes
Initial Questionnaire – Adult
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Thank you for participating in the NIH Toolbox Project. Prior to your appointment, please
take a few minutes to complete this survey. Your participation is voluntary. You may
choose not to answer any questions and you may stop taking the survey at any time.
There are no known risks or benefits to completing this survey. The survey is estimated to
take 12 minutes to complete.
Please bring this completed survey with you to your testing appointment. If you have
any questions about the study, please call the study's toll-free number, 1-xxx-xxx-xxxx.
Thank you!
(Note: Throughout the survey, instructions are printed in italics.)
Instructions: Please mark only one response per question unless otherwise noted.
[SDNorm01]

1) Today's Date:
_____/_____/_____
dd mm yyyy
[SDNorm02]

2) What is your date of birth?
_____/_____/_____
dd mm yyyy
[SDNorm03]

3) What is your gender?

Male
Female

[SDNorm04]

4) Are you Spanish/Hispanic/Latino?

Yes (if yes, complete question 4a below)
No

[SDNorm4a]

4a) Are you...?

Mexican, Mexican-American, Chicano
Puerto Rican
Cuban, Cuban-American
Other Spanish/Hispanic/Latino

Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response for the entire project
and 12 minutes for this questionnaire, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct
or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 208927974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.

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[SDNorm05]

5) What is your race? Mark one or more.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

[SDNorm06]

6) In what country were you born?

United States
Other Country
[SDNorm06a]

6a) If Other Country, which?
_____________________________________
[SDNorm06b]

6b) If Other Country, in what year did you come to the United States to stay?
______
yyyy
[OQ00]

Instructions: The next few questions are about your employment status. Please mark only
one response per question unless otherwise noted.
[OQ01]

1) Which of the following were you doing last week?

Working for pay at a job or business
Working, but not for pay, at a family-owned job or business
Employed by a job or business but not at work
Looking for work
Not working at a job or business and not looking for work
Prefer not to answer

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[OQ02]

2) How many hours did you work LAST WEEK at ALL jobs or businesses?
_________________. If you did NOT work last week, please answer the following question:
[OQ01a]

2a) What is the main reason you did not work last week?

Taking care of house or family
Going to school
Retired
On a planned vacation from work
On family or maternity leave
Temporarily unable to work for health reasons
Have job/contract and off-season
On layoff
Disabled
Other
Prefer not to answer

[OQ02a]

3) Do you USUALLY work 35 hours or more per week in total at ALL jobs or businesses?

Yes
No

[OQ03]

4) During the PAST 12 MONTHS (52 weeks), how many weeks DID you work, even for a few hours,
including paid vacation, paid sick leave, and military service?

50 to 52 weeks
48 to 49 weeks
40 to 47 weeks
27 to 39 weeks
14 to 26 weeks
13 weeks or less

[OQ04]

5) During the PAST 12 MONTHS, in the WEEKS WORKED, how many hours did you usually work each WEEK?
_________________ hours

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[OQ06]

6) If currently employed for wages or self-employed, what percent of the family’s total household income
do you provide?

0-25%
26-50%
51-75%
76-100%
Don’t know
Not applicable/Not employed

[OQ05]

7) Since completing your education, approximately what percent of the time have you been employed?

0-25%
26-50%
51-75%
76-100%
Don’t know
Not applicable

[OQ06-Instructions]

Instructions: The following questions are about your current or most recent job activity. If
you have more than one job, please describe the one at which you work the most hours.
Please mark only one response per question unless otherwise noted.
[OQ07]

8) If you are currently working, are you…(if not currently working, skip to question 9)

An employee of a PRIVATE FOR PROFIT company or business, or of an
individual, for wages, salary, or commissions
An employee of a PRIVATE NOT FOR PROFIT, tax-exempt, or charitable
organization
A local GOVERNMENT employee (city, county, etc.)
A state GOVERNMENT employee
A Federal GOVERNMENT employee
SELF-EMPLOYED in own NOT INCORPORATED business, professional practice, or farm
SELF-EMPLOYED in own INCORPORATED business, professional practice, or farm
Working WITHOUT PAY in family business or farm
On active duty in the Armed Forces

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[OQ15]

9) What is your current or most recent occupation? If you are retired, what is the occupation you held
for the longest time before you retired?

Professional, Technical, & Related (teacher/professor, nurse, lawyer,
physician, engineer)
Manager, Administrator, or Proprietor (sales manager, real estate agent, or
postmaster)
Clerical & Related (secretary, clerk, mail carrier)
Sales (salesperson, demonstrator, agent, broker)
Service (police, cook, hairdresser)
Skilled Crafts & Related (carpenter, repairer, telephone line worker)
Equipment or Vehicle Operator & Related (driver, railroad brakeman, sewer worker)
Laborer (helper, longshoreman, warehouse worker)
Farmer (owner, manager, operator, tenant)
Member of the military
Homemaker
Student

[OQ16]

10) What kind of work are (were) you doing? (for example: registered nurse, personnel manager,
supervisor of order department, secretary, accountant)

__________________________________________________________________________________________
[OQ17]

11) How long have you had (did you have) this job?

Less than 6 months
6 months to a year
A year or more

[OQ13]

12) What was the family's total household income in 2010 before taxes? Please include income from all
sources including child support, alimony, disability, SSI, unemployment. (Remember your answers are
confidential.)

Less than $5,000
$5,000 to $9,999
$10,000 to $19,999
$20,000 to $39,999
$40,000 to $74,999
$75,000 to $99,999
$100,000 or more
Don’t know

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[OQ14]

13) How many children under 18 and adults in the household depend on this income?
________________
Number of children under 18
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[OQ14a]

________________
Number of adults

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Instructions: The following questions ask about your current health and health
history. Please mark only one response per question unless otherwise noted.
[SDMC1_Self_01]

1) Has a health professional told you that you have any of the following?
Please mark one or more.

A specific learning disability
Mental retardation
A serious emotional disturbance
Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD)
Autism
Asperger’s syndrome
Pervasive Developmental Disorder (PDD)
Other autism spectrum disorder
Developmental delay
None of the above

[SDMC1_Self_01a]

1a) If you marked any of the conditions above, please answer the following question. Otherwise
go to question 2.
Does your condition affect your ability to learn?

Yes
No

[SDMC1_Self_01f]

2) Do you have or have you had any of the following?
Please mark one or more.

Deafness (profound hearing loss)
Other hearing impairment (please specify): __________________________________
Total blindness (no light perception)
Other visual impairment not corrected with glasses (please specify):
_____________________________________________________________________________
A speech or language impairment (please specify): __________________________
An orthopedic impairment (please specify): __________________________________
Joint replacement
Dizziness or Vertigo
None of the above

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[SDMC1_Self_02]

3) Do you have a history of any of the following medical conditions?
Please mark one or more.

Hypertension/high blood pressure
Peripheral vascular disease (problems with circulation, blocked arteries to the legs)
Diabetes
Cerebral palsy
Dementia/Alzheimer’s disease
Bipolar Disorder or Schizophrenia
Depression/anxiety/emotional problem
Epilepsy, seizures
Traumatic Brain Injury (TBI)
Multiple sclerosis (MS)
Muscular Dystrophy (MD)
Parkinson’s disease
Thyroid problems, Graves’ disease
HIV/AIDS
Alcohol abuse
Drug abuse
None of the above

[SDMC1_Self_02b]

4) Do you have or has a health professional told you that you have any of the following?
Please mark one or more.

Heart problem (heart attack, angina, other)
Stroke problem or TIA (transient ischemic attack)
Lung/breathing problem (such as asthma, emphysema, COPD)
Problems with your hip, knee or ankle joints
Cervical spine instability
None of the above

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[SDMC1_Self_09]

5) Do you use any of the following?
Please mark one or more.

Hearing aid(s)
Cochlear implant
Eyeglasses or contact lenses
Hand or wrist splints
Cane
Walker
Leg or ankle braces
Manual wheelchair
Motorized wheelchair
Scooter
Special telephone
Prosthetic limb (Please specify) ___________________________________________________
Other (Please specify) ___________________________________________________________
None of the above

[SDMC1_Self_11]

6) Can you stand independently, without an assistive device, for at least 3 minutes?

Yes
No

[SDMC1_Self_13]

7) Have you experienced a neck injury in the last 12 months?

Yes
No

[SDMC1_Self_19]

8) How many times have you fallen in the last 6 months?

No falls (if no falls, please go to question 9)
One time
More than one time

[SDMC1_Self_19a]

8a) If you fell one or more times, please specify the reason(s) for your fall(s).
____________________________________________________________________________________
[SDMC1_Self_39]

9) Has a doctor or other medical professional ever told you that you have an allergy or sensitivity
to propylthiourucil, also known as PROP or PTU? PROP is sometimes used in treating
hyperthyroidism.

Yes
No

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[SDMC1_Self_40]

10) Has a doctor or other medical professional ever told you that you have an allergy or sensitivity
to quinine? Quinine is sometimes used in treating malaria.

Yes
No
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[SDMC1_Self_16]

11) If female, are you currently pregnant, or do you think that you might be pregnant?

Yes, 3 months or greater
Yes, less than 3 months
No

12) Do you have a history of any of the following?
Please mark one or more.

I have been hospitalized for emotional problems
I have had hand surgery in the last 3 months
I have had brain surgery
None of the above

[SDMC1_Self_6]

13) Are you limited in any way in any activities because of a physical problem?

Yes (if yes, complete questions 13a and 13b below)
No

[SDMC1_Self_06a]

13a) What physical problem(s) limit your activities? Please specify.
_______________________________________________________________________________________
_______________________________________________________________________________________
[SDMC1_Self_06b]

13b) In what ways are you limited by this/these physical problem(s)? Please describe.
_______________________________________________________________________________________
_______________________________________________________________________________________
[SDMC1_Self_03]

14) How tall are you without shoes?
_____ feet _____ inches
[SDMC1_Self_04]

15) How much do you weigh without shoes?
__________ pounds

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[SDMC1_Self_08]

16) Do you consider yourself to be a person with a disability?

Yes
No

[SDMC1_Self_08a]

16a) Have you ever applied for disability benefits?

Yes, I have applied for and been denied disability benefits
Yes, I have applied for and received disability benefits
No, I have never applied for disability benefits

[SDMC1_Self_02c]

17) Do you regularly exercise?

Yes (answer question 17a)
No

[SDMC1_Self_02e]

17a) If yes, what type and how often?
_________________________________________________________________________________________
[02d_SDMC1_Self]

18) Do you regularly have problems climbing stairs?

Yes
No

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[ATLP_Instructions]

Instructions: The next few questions are about the language or languages that you
speak. Please mark only one response per question.

[ATLPS_00]

1) What language do you mainly speak at home?

English
Spanish
Spanish and English equally
Some other language

[ATLPS_01a]

2) What was the first language you learned?

English
Spanish
Some other language

[ATLPS_02a]

3) What language do you usually speak with your spouse or the person who is the closest to you?

Only Spanish
Mostly Spanish
Spanish and English equally
Mostly English
Only English
Some other language

[ATLPS_03]

4) How frequently do you speak English in your day-to-day life?

Never
Rarely
Often
Every day

[ATLPS_04]

5) How frequently do you speak Spanish in your day-to-day life?

Never
Rarely
Often
Every day

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[ATLPS_5a]

6) Did you go to school in the U.S.?

Yes (answer question 6a)
No

[ATLPS_05b]

6a) If yes (went to school in the U.S.), what was the highest level or grade you completed?
__________________________________

7) Were you born outside of the U.S.?

Yes (answer question 7a)
No

[ATLPS_6a]

7a) If yes (born outside of U.S.), did you go to school in your country of origin?

Yes (answer question 7b)
No

[ATLPS_06b]

7b) If yes (went to school in your country of origin), what was the highest level or grade you
completed?
__________________________________

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