45 Instrumental Activities of Daily Living

Attachment 45
Instrumental Activities of Daily Living (IADL) - Adults

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

Instrumental Activities of Daily Living (IADL) - Adults
Estimated time burden: 3 minutes
[00IADLs]

On the next screens, we will ask about any difficulties you have doing a variety
of activities. Read each question carefully and answer as well as you can. 1
After you make your choice, the computer will automatically go on to the next
question. If you want to change your answer, click on the GO BACK button to
return to the previous question and then choose a different answer.
Click on the CONTINUE button when you are ready to begin.
[01IADLs]

By yourself and without using any special equipment, how much difficulty do you
have managing your money (such as keeping track of your expenses or paying
bills)?
NO DIFFICULTY
SOME DIFFICULTY
MUCH DIFFICULTY
UNABLE TO DO
DO NOT DO THIS ACTIVITY
PREFER NOT TO ANSWER
DON'T KNOW

Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response, 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
20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[02IADLs]

By yourself and without using any special equipment, how much difficulty do you
have doing chores around the house (like vacuuming, sweeping, dusting, or
straightening up)?
NO DIFFICULTY
SOME DIFFICULTY
MUCH DIFFICULTY
UNABLE TO DO
DO NOT DO THIS ACTIVITY
PREFER NOT TO ANSWER
DON'T KNOW

[03IADLs]

By yourself and without using any special equipment, how much difficulty do you
have preparing your own meals?
NO DIFFICULTY
SOME DIFFICULTY
MUCH DIFFICULTY
UNABLE TO DO
DO NOT DO THIS ACTIVITY
PREFER NOT TO ANSWER
DON'T KNOW

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[04IADLs]

By yourself and without using any special equipment, how much difficulty do you
have going out to things like shopping, movies, or sporting events?
NO DIFFICULTY
SOME DIFFICULTY
MUCH DIFFICULTY
UNABLE TO DO
DO NOT DO THIS ACTIVITY
PREFER NOT TO ANSWER
DON'T KNOW

By yourself and without using any special equipment, how much difficulty do you
have participating in social activities (visiting friends, attending clubs or
meetings, or going to parties)?
NO DIFFICULTY
SOME DIFFICULTY
MUCH DIFFICULTY
UNABLE TO DO
DO NOT DO THIS ACTIVITY
PREFER NOT TO ANSWER
DON'T KNOW

[06IADLs]

By yourself and without using any special equipment, how much difficulty do you
have doing things to relax at home or for leisure (reading, watching TV, sewing,
listening to music)?
NO DIFFICULTY

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
SOME DIFFICULTY
MUCH DIFFICULTY
UNABLE TO DO
DO NOT DO THIS ACTIVITY
PREFER NOT TO ANSWER
DON'T KNOW

[07IADLs]

Can you use the telephone without help (including looking up numbers and
dialing)?
Yes
No

[08IADLs]

Can you drive your own car or travel alone on buses or taxis?
Yes
No

[09IADLs]

Can you go shopping for groceries or clothes without help (taking care of all
shopping needs yourself, assuming you had transportation)?
Yes
No

[10IADLs]

Can you take your medicine without help (in the right doses at the right time)?
Yes
No

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[11IADLs]

Are you able to do heavy work around the house like washing windows, walls or
floors without help?
Yes
No