Form 1 Item Bank Behavioral Health Questions

Attachment A: List of All Behavioral Health CAT Items

OMB No.: 0925-0642

Expiration Date: 09/30/2014

Public reporting burden for this collection of information is estimated to range from 5 to 30 minutes 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 (0925-0642). Do not return the completed form to this address.

Below is a list of all the questions that could potentially be asked by the interviewer to the respondent. Because of the adaptive nature of the application, a respondent may be asked to respond to anywhere from 5 to 30 questions to assess the nature of their current functional status for behavioral aspects. This application will take into account the person’s previous response to choose the next question and number of remaining questions.

Scale Code for the Behavioral Health Function CATs

BC = Behavioral Control

ME = Mood & Emotions

SC = Self-Confidence

SI = Social Interactions

Introduction:

This study is a collaboration between the Social Security Administration and the National Institutes of Health to test the usability of a new computer program that has been designed to assess your level of disability. This new software program generates questions for you to answer.

Our research will not analyze your responses and we will not retain your answers.  The objective of this study is to assess the usability of the Computer Adaptive Test (CAT) software during the SSA disability application process.

These questions will not be used in your application for benefits and your answers to these questions will not affect your current or any future application.  It is up to you whether you want to answer these questions or not. You can skip any questions that you do not want to answer. Some of these questions may be similar to other questions you may have answered already or may come up during the application process.  Is it okay if I ask you these additional questions?

Choose one response to these questions:

Strongly Agree, Agree, Disagree, Strongly Disagree, or Does not apply.

Scale	Content	Source
BC	In the past 7 days, I was stubborn with others.	Promis/NeuroQol
BC	In the past 7 days, I was in conflict with others.	Promis/NeuroQol
BC	I get very loud when I do not get what I want.	PNI
BC	I sometimes get physical when I'm angry.	BASIS-R
BC	Sometimes I shout or yell for no reason.	KAS-R
BC	People know that I get angry easily.	KAS-R
BC	In the past 7 days, I was resentful when I didn't get my way.	Promis/NeuroQol
BC	It's easy to do what people in authority ask me to do.	Sue R./new item
BC	I can't stop myself from doing the same thing over and over.	Sue R./new item
BC	In the past 7 days, I threatened violence toward people or property .	Promis/NeuroQol
BC	In the past 7 days, I tried to get even when I was angry at someone.	Promis/NeuroQol
BC	In the past 7 days, I held grudges toward others.	Promis/NeuroQol
BC	In the past 7 days, I had trouble controlling my temper.	Promis/NeuroQol
BC	In the past 7 days, people told me that I talked in a loud or excessive manner.	Promis/NeuroQol
BC	In the past 7 days, I said or did things that other people probably thought were inappropriate.	Promis/NeuroQol
ME	In the past 7 days, I felt hopeless about the future.	NEURO-QOL adult anxiety
ME	I feel good about myself.	PNI
ME	I have a lot of energy.	KAS-R
ME	In the past 7 days, I was bothered if I had to depend on others for help.	Promis/NeuroQol
ME	In the past 7 days, I got fidgety. Hint: Fidgety meaning unable to sit still.	Sue R./new item
ME	I am so tired when I wake up, it's hard to get going.	Sue R./new item
ME	I am unable to think with all the noise in my head.	Sue R./new item
ME	When I'm stressed, I can't figure out what to do.	Sue R./new item
ME	I worry people are criticizing me even when they are not.	Sue R./new item
ME	I feel sick when I have to speak in front of people.	Sue R./new item
ME	In the past 7 days, I was afraid of what the future holds for me.	NEURO-QOL adult anxiety
ME	In the past 7 days, I felt something awful would happen.	Promis/NeuroQol
ME	In the past 7 days, I felt nervous when my normal routine was disturbed.	Promis/NeuroQol
ME	In the past 7 days, I felt indecisive. Hint: Indecisive meaning having trouble making decisions	Promis/NeuroQol
ME	In the past 7 days, I had sudden feelings of panic.	Promis/NeuroQol
ME	In the past 7 days, many situations made me worry.	Promis/NeuroQol
ME	In the past 7 days, I suddenly became emotional for no reason.	Promis/NeuroQol
ME	In the past 7 days, I felt that I had nothing to look forward to.	Promis/NeuroQol
ME	In the past 7 days, I felt that nothing was interesting.	Promis/NeuroQol
ME	In the past 7 days, I felt that nothing could cheer me up.	Promis/NeuroQol
ME	In the past 7 days, I was critical of myself for my mistakes.	Promis/NeuroQol
ME	In the past 7 days, I felt emotionally exhausted.	Promis/NeuroQol
ME	In the past 7 days, I had trouble enjoying the things I used to enjoy.	Promis/NeuroQol
ME	In the past 7 days, it was hard to keep up enthusiasm to get things done.	Promis/NeuroQol
ME	In the past 7 days, I was preoccupied with my worries.	Promis/NeuroQol
ME	In the past 7 days, I had trouble paying attention.	Promis/NeuroQol
ME	In the past 7 days, it was hard to adjust to unexpected changes.	Promis/NeuroQol
ME	In the past 7 days, just being around people irritated me.	Promis/NeuroQol
ME	In the past 7 days, I have trouble keeping in touch with others.	Promis/NeuroQol
ME	In the past 7 days, I avoided public places or activities.	Promis/NeuroQol
ME	I dwell on my problems.	Sue R./new item
ME	I don't know why I cry so often.	Sue R./new item
ME	I am so tired that I rest or sleep most of the day.	Sue R./new item
SC	I get along well with people outside my family.	BASIS-R
SC	I feel people are against me	BASIS-R
SC	I feel that there are people I can turn to.	UCLA loneliness scale
SC	I respect other people's point of view.	Sue R./new item
SC	I am good at making new friends.	WHO disability assessment
SC	I can easily begin talking with others.	Sue R./new item
SC	I'm comfortable trying different ways to do things.	Sue R./new item
SC	Trying new things is fun.	Sue R./new item
SC	When I'm asked to do a really difficult task, I keep at it until I get it done.	Sue R./new item
SC	If I make a mistake, I know I can deal with it.	Sue R./new item
SC	I think people trust me.	Sue R./new item
SC	I look at both sides of an issue.	Sue R./new item
SC	I am willing to accept help from others.	Sue R./new item
SC	I am comfortable making eye contact with others.	Sue R./new item
SC	I can get back on track when I am distracted.	new from meeting
SC	I like large family gatherings.	Sue R./new item
SC	People tell me I'm flexible and agreeable.	Sue R./new item
SC	Most people like what I have to say.	Sue R./new item
SC	I'm usually able to help solve other people's problems.	Sue R./new item
SC	I'm comfortable just seeing what the day brings.	Sue R./new item
SC	I look for the good in difficult situations.	Sue R./new item
SC	I learn from my mistakes.	Sue R./new item
SC	I believe that things end up alright most of the time.	Sue R./new item
SI	In the past 7 days, I look forward with enjoyment to upcoming events.	Promis/NeuroQol
SI	In the past 7 days, I can keep up with my family responsibilities.	Promis/NeuroQol
SI	In the past 7 days, I am able to do all the family activities that I am expected to do.	Promis/NeuroQol
SI	In the past 7 days, I can keep up with my social commitments. Hint: Social commitments meaning plans you’ve made with others	Promis/NeuroQol
SI	In the past 7 days, I am able to do all of my usual work (including work at home).	Promis/NeuroQol
SI	I feel that I'm an important part of the community where I live.	Sue R./new item

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