Form 1 Item Bank Behavioral Health Questions

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Attach A_REVISED_All Behavioral Health CAT Items_11-5-2013

Sub-study #33_User Simulation Study for NIH-SSA Collaboration to Improve Disability Determination (Revised)

OMB: 0925-0642

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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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