14 Vision Health Related QOL Survey

Attachment 14
Vision Health-Related Quality of Life Survey

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Name of test: Vision Health-Related Quality of Life Survey 1
Estimated time burden: 13 minutes
Number of items: 53
Instructions to Subjects:
On the next screens, we will ask you questions about how your vision affects your life.
Answer the questions thinking of your vision as it is when corrected by any glasses or
contact lenses that you usually use.
Read each question carefully and answer as well as you can. 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.

The first few questions ask about color vision.
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how difficult is it for you to match
the colors of your clothes?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how difficult is it for you to
recognize colors?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how difficult is it for you to
distinguish between colors?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How difficult is it
for you to see in bright sunlight?

Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to see in bright sunlight

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
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How difficult is it
for you to see in fluorescent lighting such as
in stores and offices?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How difficult is it
for you to see at night?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How difficult is it
for you to see street signs at night when you
are in a car?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How difficult is it
for you to see when you go from a lighted
area into a dark place?

Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to see in fluorescent lighting
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to see at night
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to see street signs from a car at night

Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to see when going from a lighted area
into a dark place
Answer the questions thinking of your vision as Not difficult at all
it is when corrected by any glasses or contact
A little bit difficult
lenses that you usually use. Because of your
Somewhat difficult
eyesight, how difficult is it for you to read in Very difficult
Unable to read in dim light
dim light?
Unable to read in dim light because of
another reason
Answer the questions thinking of your vision as Not difficult at all
it is when corrected by any glasses or contact
A little bit difficult
lenses that you usually use. Because of your
Somewhat difficult
eyesight, how difficult is it for you to go up or Very difficult
Unable to do because of eyesight
down steps, stairs, or curbs?
Unable to go up or down steps, stairs, or
curbs because of another reason
Answer the questions thinking of your vision as Not difficult at all
it is when corrected by any glasses or contact
A little bit difficult
lenses that you usually use. Because of your
Somewhat difficult
Very difficult
eyesight, how difficult is it for you to get
Unable to do because of eyesight
around outdoors?
Unable to get around outdoors because of
another reason

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How difficult is it
for you to see moving objects?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How difficult is it
for you to see street signs?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how difficult is it for you to see
television?

Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how difficult is it for you to drive at
night?

Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how difficult is it for you to drive
due to glare from oncoming headlights?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how difficult is it for you to
recognize people from across a room?
The next few questions ask about your general
vision while wearing any glasses or contact
lenses that you usually use. In general, how
would you rate your eyesight for seeing
things at a distance?

Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight
Unable to see television because of another
reason
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight
Unable to drive at night because of another
reason
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight
Unable to drive because of another reason
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight
Poor
Fair
Good
Very Good
Excellent

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How much of a
problem do you have with seeing things at a
distance during the day?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How much of a
problem do you have with seeing things at a
distance at nighttime?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In general, how
would you rate your eyesight for seeing
things close up?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How much of a
problem do you have with seeing things close
up during the day?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How much of a
problem do you have with seeing things close
up at nighttime?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how difficult is it for you to read a
newspaper or book?

Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how difficult is it for you to find an
item on a crowded shelf?

Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How difficult is it
for you to see a sign when there are other
signs around it?

No problem at all
A little bit of a problem
Somewhat of a problem
Very much of a problem
Unable to see
No problem at all
A little bit of a problem
Somewhat of a problem
Very much of a problem
Unable to see
Poor
Fair
Good
Very Good
Excellent
No problem at all
A little bit of a problem
Somewhat of a problem
Very much of a problem
Unable to see
No problem at all
A little bit of a problem
Somewhat of a problem
Very much of a problem
Unable to see
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight
Unable to read a newspaper or book because
of another reason
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight
Unable to find an item on a crowded shelf
because of another reason
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how difficult is it for you to read
small print on medicine bottles, telephone
books, legal forms, or bills you receive in the
mail?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how difficult is it for you to use a
computer?

Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight
Unable to read labels or instructions because
of another reason
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight
Unable to use a computer because of another
reason
Answer the questions thinking of your vision as Not difficult at all
it is when corrected by any glasses or contact
A little bit difficult
Somewhat difficult
lenses that you usually use. Because of your
eyesight, how difficult is it for you to operate Very difficult
Unable to do because of eyesight
a household appliance like a microwave, a
Unable to operate a household appliance
washing machine, or a toaster oven?
because of another reason
Answer the questions thinking of your vision as Not difficult at all
it is when corrected by any glasses or contact
A little bit difficult
lenses that you usually use. Because of your
Somewhat difficult
Very difficult
eyesight, how difficult is it for you to write?
Unable to do because of eyesight
Unable to write because of another reason
Answer the questions thinking of your vision as Not difficult at all
it is when corrected by any glasses or contact
A little bit difficult
Somewhat difficult
lenses that you usually use. Because of your
eyesight, how difficult is it for you to do work Very difficult
Unable to do because of eyesight
or hobbies that require you to see up close,
Unable to do work or hobbies that require me
such as cooking or fixing things around the
to see up close because of another reason
house?
Answer the questions thinking of your vision as Not difficult at all
it is when corrected by any glasses or contact
A little bit difficult
lenses that you usually use. Because of your
Somewhat difficult
Very difficult
eyesight, how difficult is it for you to
Unable to do because of eyesight
recognize people when they are standing or
sitting near you?
Please remember that all the questions ask
No problem at all
about your vision while wearing any glasses or
A little bit of a problem
contact lenses that you usually use. In the last 7 Somewhat of a problem
Very much of a problem
days, how much of a problem did you have
with glare from bright lights?

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how much of a problem did you have with
burning or stinging eyes?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how much of a problem did you have with
redness in your eyes?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how much of a problem did you have with
headaches because of your vision, or because
of your glasses or contact lenses?

No problem at all
A little bit of a problem
Somewhat of a problem
Very much of a problem

Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how much of a problem did you have with
your eyes being sensitive to light?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how much of a problem did you have with
blurry vision?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how much of a problem did you have with
itching in or around your eyes?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how frustrated or upset did you feel because
of your eyesight?

No problem at all
A little bit of a problem
Somewhat of a problem
Very much of a problem

Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how annoyed or angry did you feel because
of your eyesight?

Did not feel annoyed or angry at all
Felt a little bit annoyed or angry
Felt somewhat annoyed or angry
Felt annoyed or angry a lot

No problem at all
A little bit of a problem
Somewhat of a problem
Very much of a problem
No problem at all
A little bit of a problem
Somewhat of a problem
Very much of a problem

No problem at all
A little bit of a problem
Somewhat of a problem
Very much of a problem
No problem at all
A little bit of a problem
Somewhat of a problem
Very much of a problem
Did not feel frustrated or upset at all
Felt a little bit frustrated or upset
Felt somewhat frustrated or upset
Felt frustrated or upset a lot

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how much did you feel like a burden on
others because of your eyesight?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how sad or depressed did you feel because of
your eyesight?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how socially isolated did you feel because of
your eyesight?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how concerned or worried about your safety
at home did you feel because of your
eyesight?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. In the last 7 days,
how worried were you about your eyesight?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. How much do you
have to rely on other people to do things
because of your eyesight?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how difficult is it for you to visit
with friends or family?

Please remember that all the questions ask
about your vision while wearing any glasses or
contact lenses that you usually use. Because of
your eyesight, how limited are you in doing
your daily activities?

Did not feel like a burden at all
Felt a little bit like a burden
Felt somewhat like a burden
Felt like a burden a lot
Did not feel sad or depressed at all
Felt a little bit sad or depressed
Felt somewhat sad or depressed
Felt sad or depressed a lot
Did not feel socially isolated at all
Felt a little bit socially isolated
Felt somewhat socially isolated
Felt socially isolated a lot
Did not feel concerned or worried at all
Felt a little bit concerned or worried
Felt somewhat concerned or worried
Felt concerned or worried a lot

Not worried at all
A little bit worried
Somewhat worried
A lot worried
Do not rely on other people at all
Rely a little bit on other people
Rely somewhat on other people
Rely a lot on other people
Not difficult at all
A little bit difficult
Somewhat difficult
Very difficult
Unable to do because of eyesight
Unable to visit with friends or family
because of another reason
Not limited at all
A little bit limited
Somewhat limited
A lot limited
Unable to do because of eyesight
Unable or limited in daily activities because
of another reason

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how limited are you in doing your
daily work whether inside or outside the
house?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how much less do you accomplish
than you would like?
Answer the questions thinking of your vision as
it is when corrected by any glasses or contact
lenses that you usually use. Because of your
eyesight, how much are you limited in how
long you can work or do other activities?

Not limited at all
A little bit limited
Somewhat limited
A lot limited
Unable to do because of eyesight
Unable or limited in daily work because of
another reason
Do not accomplish less at all
Accomplish a little bit less
Accomplish somewhat less
Accomplish a lot less

Not limited at all
A little bit limited
Somewhat limited
A lot limited
Unable to do because of eyesight
Unable or limited in work or other activities
because of another reason
Answer the questions thinking of your vision as Do not require help from others at all
it is when corrected by any glasses or contact
Require help from others a little bit
lenses that you usually use. Because of your
Require help from others somewhat
eyesight, how much do you require help from Require help from others a lot
Unable to do because of eyesight
others with your work or other activities?
Unable or require help from others with
work or other activities because of another
reason