Attachment 2_Questions to be Tested

Attachment 2: Questions/Items to be Tested

The following represents every item in each sub-domain of the new instruments. It is anticipated that each item will undergo cognitive testing with the assistance of 5 interviewers. There are 344 items total and 70 respondents. This means each respondent will answer approximately 25 of the following questions. Cognitive interview questions and probes will account for the additional 35 minutes to complete the interview.

Social Appropriateness

Stem Question Content of Question Response Choices

I have trouble	picking out the right clothes for the situation (e.g. casual vs. formal)	Strongly disagree Disagree Agree Strongly agree
	The way I dress fits the situation.	Almost always Usually Sometimes Hardly ever
People often annoy me by	criticizing the way I dress.	Strongly disagree Disagree Agree Strongly agree
I have trouble	bathing (i.e. taking a shower or bath) often enough	Strongly disagree Disagree Agree Strongly agree
People often annoy me by	telling me I need to bathe (i.e. take a shower or bath) more often.	Strongly disagree Disagree Agree Strongly agree
How often do you	bathe (i.e. take a shower or bath)?	More than once per day Daily 5 to 6 times a week 3 to 4 times a week 1 to 2 times per week Less than once a week Never
Other people have said	I need to do personal grooming (e.g. brushing teeth and combing hair) more often.	Strongly disagree Disagree Agree Strongly agree
How often do you	do you do your personal grooming and hygiene. (e.g. brushing teeth and combing hair).	Daily 5 to 6 times a week 3 to 4 times a week 1 to 2 times per week Less than once a week Never
People often annoy me by	telling me I need to do a better job with my personal grooming (e.g. brushing teeth and combing hair).	Strongly disagree Disagree Agree Strongly agree
I have trouble	keeping my hair clean and neat.	Strongly disagree Disagree Agree Strongly agree
I have trouble	keeping myself looking clean and neat.	Strongly disagree Disagree Agree Strongly agree
Other people have said	I need to pay more attention to looking clean and neat.	Strongly disagree Disagree Agree Strongly agree
	I make sure I look clean and neat.	Strongly agree Agree Disagree Strongly disagree

Self Care

How much DIFFICULTY do you currently have	getting dressed in the morning?	None at all A little A lot Unable to do
How much DIFFICULTY do you currently have	getting dressed to go to an appointment (e.g. doctor's visit)	None at all A little A lot Unable to do
Compared to other adults, it takes me more time	to get dressed to go to an appointment?	Strongly disagree Disagree Agree Strongly agree
Compared to other adults, it takes me more time	to get dressed in the morning?	None at all A little A lot Unable to do
How much difficulty do you currently have	eating meals at home?	None at all A little A lot Unable to do
How much difficulty do you currently have	eating meals outside of the home? (away from home)	None at all A little A lot Unable to do
Compared to other adults, it takes me more time	to eat meals at home?	None at all A little A lot Unable to do
Compared to other adults, it takes me more time	to eat meals outside of the home? (away from home)	None at all A little A lot Unable to do
How much DIFFICULTY do you currently have	carrying out your bowel program at home? (e.g., suppository insertion, colostomy bag, digital stimulation and cleaning up)	None at all A little A lot Unable to do Not Applicable
How much DIFFICULTY do you currently have	carrying out your bowel program when you are outside of your home? (e.g., suppository insertion, colostomy bag, digital stimulation and cleaning up)	None at all A little A lot Unable to do Not Applicable
How much DIFFICULTY do you currently have	carrying out your bladder program when you are outside the home(e.g., catheter care, cleaning up)	None at all A little A lot Unable to do Not Applicable
How much DIFFICULTY do you currently have	carrying out your bladder program at home (e.g., catheter care, cleaning up)	None at all A little A lot Unable to do Not Applicable
How much difficulty do you have	using the toilet at home? (This includes wiping yourself, getting on and off the toilet and putting clothes back on)	None at all A little A lot Unable to do
How much difficulty do you have	using the toilet outside of the home? (This includes wiping yourself, getting on and off the toilet and putting clothes back on)	None at all A little A lot Unable to do
Compared to other adults, it takes me more time	to use the toilet when I am outside of the home? (This includes wiping yourself, getting on and off the toilet and putting clothes back on)	None at all A little A lot Unable to do
How much DIFFICULTY do you currently have	bathing yourself (i.e. taking a shower or bath)?	None at all A little A lot Unable to do
Compared to other adults, it takes me more time	to bathe myself (i.e. taking a shower or bath)?	None at all A little A lot Unable to do
How much DIFFICULTY do you currently have	with your personal grooming? (e.g. brushing teeth and combing hair?)	None at all A little A lot Unable to do
Compared to other adults, it takes me more time	to do my personal grooming? (e.g. brushing teeth and combing hair)?	None at all A little A lot Unable to do

Domestic

How much difficulty do you currently have	doing your grocery shopping?	None at all A little A lot Unable to do Does not apply
Compared to other adults, it takes me more time	to do my grocery shopping?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	running errands? (e.g. going to the bank or library)	None at all A little A lot Unable to do Does not apply
Compared to other adults, it takes me more time	to run errands? (e.g. going to the bank or library)	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	doing minor household repairs? (e.g. fixing a leaky faucet)	None at all A little A lot Unable to do Does not apply
How much DIFFICULTY do you currently have	doing heavy housework (e.g., scrubbing floors, washing windows, moving furniture to clean)?	None at all A little A lot Unable to do Does not apply
Compared to other adults, it takes me more time	to do heavy housework (e.g., scrubbing floors, washing windows, moving furniture to clean)?	None at all A little A lot Unable to do Does not apply
How much DIFFICULTY do you currently have	doing light house work (e.g., dusting or sweeping)?	None at all A little A lot Unable to do Does not apply
Compared to other adults, it takes me more time	to do light house work (e.g., dusting or sweeping)?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	preparing light meals or snacks (e.g. sandwiches, cereal etc)	None at all A little A lot Unable to do Does not apply
Compared to other adults, it takes me more time	to prepare light meals or snacks (e.g. sandwiches, cereal etc)	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	preparing dinner? (e.g. cooking several dishes)	None at all A little A lot Unable to do Does not apply
Compared to other adults, it takes me more time	to prepare dinner? (e.g. cooking several dishes)	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	taking your medications correctly?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	following your doctor's orders or instructions.	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	keeping health or medical appointments?	None at all A little A lot Unable to do Does not apply

Transportation

Do you currently	drive a car?	Y/N
Do you currently	use public transportation (i.e. bus, train or subway)?	Y/N
How much difficulty do you currently have	getting where you need to go each day?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	getting a ride to where you need to go on time?	None at all A little A lot Unable to do Does not apply
	I can drive to and from home on my own.	Strongly agree Agree Disagree Strongly disagree
How much difficulty do you currently have	driving in bad weather?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	driving at night?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	driving at night in the rain?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	driving in heavy city traffic?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	driving in heavy highway traffic?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	driving on narrow, winding roads?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	parking your car?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	staying within your lane while driving?	None at all A little A lot Unable to do Does not apply
	I am limited in driving short distances.	Strongly agree Agree Disagree Strongly disagree
	I am limited in driving long distances.	Strongly agree Agree Disagree Strongly disagree
How much difficulty do you currently have	merging onto a busy road?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	looking both ways at an intersection when driving?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	driving in your own neighborhood?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	backing out of a driveway?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	getting to the bus stop or train station on time?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	paying the bus or train fare (e.g. using tickets, cash or a fare card)?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	using the bus or train schedule to plan a trip with no transfers?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	using the bus or train schedule to plan a trip with one or more transfers?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	identifying the correct bus or train you need?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	getting on to a bus or train?	None at all A little A lot Unable to do Does not apply
How much difficulty do you currently have	getting off the bus or train before the doors close.	None at all A little A lot Unable to do Does not apply

Physical

Are you able to	wash and rinse your hair while standing in the shower?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	climb in and out of a bathtub?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	step in and out of a shower?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	get into and out of an SUV or truck?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	reach into a cabinet from a step ladder or stool?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	squat to use a dust pan on the floor?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	bend forward to brush your teeth?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	look over your shoulder as you back up in a car?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	look overhead to examine a crack in the ceiling?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	look under your bed or couch?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	load and unload a front loading washer or dryer?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	kneel to tie a shoe?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	squat to look under a car ?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	sit in car for a long drive (i.e. more than 2 hours) with short breaks?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	change a tire?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	crawl into an attic to get a box?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	push a broom or mop (to clean a floor)?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	pull open a dresser drawer?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	pull open a cabinet door?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	push your chair back to get up from sitting at a table?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	pull a small carry on suitcase by the handle?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	unload a truck full of boxes and furniture?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	lift a 2 liter soda bottle from the floor to a high shelf in the fridge? (hint: soda bottle= 3.5 lbs/1.5 kg)	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	clean out a closet?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	lift a stack of magazines from the floor to table height?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	carry a bag over your shoulder (e.g. purse, book bag or camera bag)?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	carry your jacket?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	lift a mail/UPS package weighing 10 lbs?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	carry a full kitchen trash bag outside?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	transfer a 12 pack of soda cans from a grocery shelf to a grocery cart?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	transfer a full cart of groceries from a shopping cart to the trunk of a car?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	Are you able to lift a full small (carry-on size) suitcase from the floor to a high shelf? Hint: A full carry-on suitcase weighs 20 pounds/8 kg.	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	Are you able to lift a full large (check-in size) suitcase from the floor to a high shelf? Hint: A full large suitcase weighs 40-50 pounds/18-23 kg.	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	unload a full trunk of groceries from the car into the house?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	load and unload the dishwasher?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	move a sofa to clean under it?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	clean a kitchen counter?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	reach into a mailbox?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	make a bed, including spreading and tucking in bed sheets?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	a carry small back pack with a notebook and two books weighing 10 lbs?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	push a lawn mower?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	go bowling?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	grip the steering wheel during a long drive (a couple of hours)?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	change a light bulb overhead?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	chop or slice vegetables for a large meal? (e.g.,onions or peppers)	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	hold the handle of a lawn mower to mow a lawn?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	use a pair of pliers?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	use a nut cracker?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	clean the floor using a broom and dustpan?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	remove a dollar bill from your wallet?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	remove coins from a purse?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	push the correct buttoms on an ATM machine, phone or gas pump?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	type a text message on your cell/mobile phone?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	select what you need to on a computer screen using a computer mouse?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	close a zip lock bag?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	secure a twist tie on a bread bag?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	remove a sticker from something you have purchased?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	open and close a 2 liter bottle of soda?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	insert a plug in an electric outlet?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	use a chip clip to close a bag?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	turn a dial on a radio?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	use the trigger on a spray bottle?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	type an email?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	button your shirt?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	put on a watch?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	walk from a parking lot into a store?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	walk the aisles of a grocery store using a shopping cart?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	walk from store to store while shopping (e.g. in a shopping mall)?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	climb bleachers at sporting event?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	walk to the bathroom?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	walk to your mailbox?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know
Are you able to	stand on your tiptoes and reach for something above your head?	Yes, without difficulty Yes, with a little difficulty Yes, with some difficulty Yes, with a lot of difficulty Unable to do I don't know

Cognition

How much difficulty do you currently have	learning new tasks ?	Unable, A lot, A little, None
How much difficulty do you currently have	learning new instructions ?	Unable, A lot, A little, None
How much difficulty do you currently have	shifting back and forth between two activities that require thinking	Unable, A lot, A little, None
How much difficulty do you currently have	Adjusting to a new situation or change	Unable, A lot, A little, None
How much difficulty do you currently have	Handling an unfamiliar problem (e.g., getting household appliances repaired)?	Unable, A lot, A little, None
Please specify your level of agreement with the following statement:	I am thorough when I work	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	checking the accuracy of financial documents, (e.g., bills, checkbook, or bank statements)?	Unable, A lot, A little, None
Please specify your level of agreement with the following statement:	I have had to work really hard to pay attention or I would make a mistake	Strongly agree, Agree, Disagree, Strongly Disagree
Please specify your level of agreement with the following statement:	People often tell me I dodn’t recognize my mistakes	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	Counting the correct amount of money when making purchases (hint: cost of item if two for one, cost of items on sale)	Unable, A lot, A little, None
How much difficulty do you currently have	Calculating how much money I have to spend for the month	Unable, A lot, A little, None
How much difficulty do you currently have	Planning your budget and meeting your financial obligations (spending, saving, paying bills, etc.)	Unable, A lot, A little, None
Specify your level of agreement with the following statement:	I have been able to add and subtract numbers in my head without difficulty	Strongly agree, Agree, Disagree, Strongly Disagree
Please specify your level of agreement with the following statement:	I have difficulty completing tasks that I start	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	Completing routine tasks within a reasonable amount of time	Unable, A lot, A little, None
How much difficulty do you currently have	getting started on very simple tasks	Unable, A lot, A little, None
Specify your level of agreement with the following statement:	When I had something to do that takes a long time, I had trouble deciding where to start	Strongly agree, Agree, Disagree, Strongly Disagree
Specify your level of agreement with the following statement:	I have been able to handle many tasks at once without losing track of what I was doing	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	Following a series of dialing instructions (e.g., a recorded message “Press 1 for...")	None, A little, Somewhat, A lot, Cannot do
Specify your level of agreement with the following statement:	I am able to think as clearly as usual without extra effort	Strongly agree, Agree, Disagree, Strongly Disagree
Specify your level of agreement with the following statement:	I have trouble gathering and putting my thoughts together	Strongly agree, Agree, Disagree, Strongly Disagree
Specify your level of agreement with the following statement:	My thinking has been (is) slow.	Strongly agree, Agree, Disagree, Strongly Disagree
Specify your level of agreement with the following statement:	My thinking has been (is) confused.	Strongly agree, Agree, Disagree, Strongly Disagree
Specify your level of agreement with the following statement:	I am easily confused when in a busy or noisy environment.	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	keeping track of what you are doing, even if you are interrupted	Unable, A lot, A little, None
Specify your level of agreement with the following statement:	I have trouble keeping my mind on what I am doing or thinking about	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	paying attention for a long period of time	Unable, A lot, A little, None
How much difficulty do you currently have	keeping track of your daily tasks and activities.	Unable, A lot, A little, None
How much difficulty do you currently have	Planning for and keeping appointments that are not part of your weekly routine, e.g., a therapy, doctor appointment, or a social gathering with friends and family?	Unable, A lot, A little, None
How much difficulty do you currently have	Using bank cards and automatic teller machines (ATMs)	Unable, A lot, A little, None
How much difficulty do you currently have	Making purchases (choosing merchandise, mode of payment, purchases by telephone, etc.)	Unable, A lot, A little, None
How much difficulty do you currently have	Working hard on tasks that are not liked	Unable, A lot, A little, None
How much difficulty do you currently have	Planning for and completing regularly scheduled tasks; such as taking out the trash or doing laundry?	Unable, A lot, A little, None
How much difficulty do you currently have	Following through with arrangements you make (ex: if promises to meet someone, meets that person, etc.)	Unable, A lot, A little, None
Specify your level of agreement with the following statement:	I feel capable of making important decisions in my life	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	making everyday decisions	Unable, A lot, A little, None
How much difficulty do you currently have	thinking about what could happen before making decisions (ex: refraining from acting impulsively, thinking about important information)	Unable, A lot, A little, None
How much difficulty do you currently have	Recalling information that you have always known; such as birthdays or addresses	Unable, A lot, A little, None
How much difficulty do you currently have	Remembering things for a short time; like the digits of a phone number	Unable, A lot, A little, None
How much difficulty do you currently have	remembering something you read or heard about earlier in the day	Unable, A lot, A little, None
Specify your level of agreement with the following statement:	I had trouble keeping track of important events	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	Remembering to do your everyday tasks	Unable, A lot, A little, None
How much difficulty do you currently have	Remembering a list of 4 or 5 errands without writing it down?	Unable, A lot, A little, None
How much difficulty do you currently have	keeping track of time (e.g.., using a clock, watch, etc)?	Unable, A lot, A little, None
Specify your level of agreement with the following statement:	I have trouble remembering where I put things like my keys or my wallet	Strongly agree, Agree, Disagree, Strongly Disagree
Specify your level of agreement with the following statement:	I have trouble remembering whether I did things I was supposed to do, like taking a medicine or buying something I needed	Strongly agree, Agree, Disagree, Strongly Disagree
Specify your level of agreement with the following statement:	I have had trouble remembering new information like telephone numbers or simple instructions	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	paying attention to both the left and right sides (avoid bumping into things, tripping, stumbling, falling, or being clumsy)	Unable, A lot, A little, None
Specify your level of agreement with the following statement:	I reacted slowly to things that were said or done	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	Finding restrooms or other necessary rooms in a building by yourself	Unable, A lot, A little, None
How much difficulty do you currently have	Remembering how to get around familiar places	Unable, A lot, A little, None
How much difficulty do you currently have	keeping track of the day or date	Unable, A lot, A little, None
Please specify your level of agreement with the following statement:	I am able to plan ahead for events or things that I want to do	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	getting and staying organized.	Unable, A lot, A little, None
How much difficulty do you currently have	Keeping important personal papers such as bills, insurance documents, and tax forms organized	Unable, A lot, A little, None
How much difficulty do you currently have	planning out steps of a task	Unable, A lot, A little, None
How much difficulty do you currently have	Routinely arriving or returning places on time	Unable, A lot, A little, None
How much difficulty do you currently have	Managing your time to do most of your daily activities?	Unable, A lot, A little, None
Specify your level of agreement with the following statement:	I am able to realize my errors and mistakes when they occur	Strongly agree, Agree, Disagree, Strongly Disagree
Specify your level of agreement with the following statement:	I try to correct mistakes I make when they occur	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	finding new ways to solve problems	Unable, A lot, A little, None
How much difficulty do you currently have	Using resources (for example: dictionary, phone book, website, internet) to find information	Unable, A lot, A little, None
How much difficulty do you currently have	Asking for help from others when difficult problems come up	Unable, A lot, A little, None
How much difficulty do you currently have	Analyzing or thinking through problems before trying to solve them	Unable, A lot, A little, None
How much difficulty do you currently have	Solving everyday problems?	Unable, A lot, A little, None
How much difficulty do you currently have	understanding complex reading materials, such as long forms, legal documents, or instruction manuals.	Unable, A lot, A little, None
Specify your level of agreement with the following statement:	I have (need) to read something several times to understand it.	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	Reading a long book (over 100 pages) over a number of days	Unable, A lot, A little, None
How much difficulty do you currently have	Reading simple material (e.g., a menu or the TV or radio guide)?	Unable, A lot, A little, None
Specify your level of agreement with the following statement:	I have trouble recognizing familiar words on a page	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	Reading and following complex instructions (e.g., directions for a new medication)	Unable, A lot, A little, None
Specify your level of agreement with the following statement:	Others have told me that my actions put my health and safety at risk.	Strongly agree, Agree, Disagree, Strongly Disagree
Specify your level of agreement with the following statement:	I recognize danger when I see it	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	following procedures for contacting community services in case of an emergency	Unable, A lot, A little, None
How much difficulty do you currently have	Reading and obeying common signs (ex: Do Not Enter, Exit, Stop)	Unable, A lot, A little, None
How much difficulty do you currently have	Following safety rules and regulations	Unable, A lot, A little, None
How much difficulty do you currently have	following general safety procedures and standards (ex: fire alarm, work illness policy, etc.)	Unable, A lot, A little, None
How much difficulty do you currently have	following procedures for assisting an injured person (CPR, call 911, etc.)	Unable, A lot, A little, None
How much difficulty do you currently have	following home safety procedures (e.g., locking doors, turning off the stove)	Unable, A lot, A little, None

Communication

How much difficulty do you currently have	following conversations with a group of people	Unable, A lot, A little, None
How much difficulty do you currently have	following conversations with one person	Unable, A lot, A little, None
How much difficulty do you currently have	understanding non-verbal communication (meaning other people's gestures, facial expressions, tone of voice changes, or other nonverbal behaviors)	Unable, A lot, A little, None
How much difficulty do you currently have	Understanding pictures that explain something (ex: instructions for appliances, furniture assembly, safety warnings)	Unable, A lot, A little, None
How much difficulty do you currently have	understanding what's heard on television, radio, or at the movies	Unable, A lot, A little, None
How much difficulty do you currently have	Understanding people during short conversations	Unable, A lot, A little, None
How much difficulty do you currently have	Understanding people during long conversations (for example during: long or complex instructions, conversations, or speeches)	Unable, A lot, A little, None
How much difficulty do you currently have	Understanding people on the phone?	Unable, A lot, A little, None
How much difficulty do you currently have	understanding people when there was background noise (hint: in noisy or distracting environments such as a crowded store)	Unable, A lot, A little, None
How much difficulty do you currently have	talking so that others can understand you	Unable, A lot, A little, None
Please specify your level of agreement with the following statement:	I slurr or stutter while speaking	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	speaking clearly	Unable, A lot, A little, None
Please specify your level of agreement with the following statement:	I have to talk very slowly to make myself understood	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	Putting words together to form grammatically correct sentences	Unable, A lot, A little, None
How difficult is it for you to	participate in group conversations or discussions	Unable, A lot, A little, None
How difficult is it for you to	Be understood by others?	Unable, A lot, A little, None
How much difficulty do you currently have	Organizing what you want to say?	Unable, A lot, A little, None
Please specify your level of agreement with the following statement:	Words I wanted to use have seemed to be on the “tip of my tongue”	Strongly agree, Agree, Disagree, Strongly Disagree
Please specify your level of agreement with the following statement:	I have had trouble finding the right word(s) to express myself	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	Replying with "yes" or "no" to questions?	Unable, A lot, A little, None
How much difficulty do you currently have	Replying to questions using full sentences	Unable, A lot, A little, None
Please specify your level of agreement with the following statement:	I use the wrong word(s) for what I want to say	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	Explaining how to do something involving several steps to another person?	Unable, A lot, A little, None
How much difficulty do you currently have	getting your point across when you are upset	Unable, A lot, A little, None
How much difficulty do you currently have	telling a doctor or health care provider who you know about your symptoms or medical history	Unable, A lot, A little, None
How much difficulty do you currently have	greeting someone by name	Unable, A lot, A little, None
How much difficulty do you currently have	asking questions/requesting information from people	Unable, A lot, A little, None
How much difficulty do you currently have	telling others your basic needs or wants known (e.g., pain, tired, food dislikes)	Unable, A lot, A little, None
How much difficulty do you currently have	having a conversations in a quiet place	Unable, A lot, A little, None
How much difficulty do you currently have	using the computer to exchange information (email, searching the internet, internet chatting, skype, etc.)	Unable, A lot, A little, None
Please specify your level of agreement with the following statement:	I have trouble exchanging information over the phone (e.g., listening, answering questions)	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	making appointments over the phone for personal services (e.g. haircut, dentist)	Unable, A lot, A little, None
How much difficulty do you currently have	Writing notes to yourself, such as appointments or 'to do' lists?	Unable, A lot, A little, None
How much difficulty do you currently have	Composing a brief note or e-mail to someone, writing in full sentences	Unable, A lot, A little, None
Please specify your level of agreement with the following statement:	I make mistakes when writing down numbers (e.g., phone number, checkbook entry)	Strongly agree, Agree, Disagree, Strongly Disagree
In the past 7 days	I had trouble spelling words correctly when writing	Never, Rarely (once), Sometimes ( 2 or 3 times), Often (about 1 per day), Always
How much difficulty do you currently have	filling out forms, writes business letters (ex: request information, makes complaint, places order, etc.), or completing other official documents	None, A little, Somewhat, A lot, Cannot do
How much difficulty do you currently have	writing down the word(s) you wanted to write down"	Unable, A lot, A little, None
How much difficulty do you currently have	writing your signature or mark to sign your name/initials on paper	Unable, A lot, A little, None

Social Language

Please specify your level of agreement with the following statement:	I am limited in starting and maintaining a conversation.	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	Carrying on a conversation with a small group of familiar people (ex: family, friends)	None, A little, Somewhat, A lot, Cannot do
How much difficulty do you currently have	getting my point across when talking with someone	Unable, A lot, A little, None
How much difficulty do you currently have	Standing a comfortable distance from others during conversation (not too close)	Unable, A lot, A little, None
How much difficulty do you currently have	Showing interest when others are talking	Unable, A lot, A little, None
How much difficulty do you currently have	adding new information to conversation or discussion topic	Unable, A lot, A little, None
How much difficulty do you currently have	Nodding or smiling to encourage others when they are talking	Unable, A lot, A little, None
How much difficulty do you currently have	Waiting your turn to speak	Unable, A lot, A little, None
Please specify your level of agreement with the following statement:	I have difficulty identifying or adjusting to changes in the the topic of a conversation	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	negotiating or discussing your ideas with others	Unable, A lot, A little, None
How much difficulty do you currently have	receiving and discussing feedback about work or tasks you are performing	Unable, A lot, A little, None
How much difficulty do you currently have	making small talk	Unable, A lot, A little, None
How much difficulty do you currently have	figuring out why a comment or joke is funny	Unable, A lot, A little, None
How much difficulty do you currently have	expressing your thoughts through gestures, facial expression, changing your tone of voice, or other non language behaviors	Unable, A lot, A little, None
How much difficulty do you currently have	understanding non-literal meanings (e.g., "button your lip") or implied or intended information (e.g., "It's getting late," might mean it's time to go)	Unable, A lot, A little, None
Please specify your level of agreement with the following statement:	I am able to settle my own conflicts with others through discussion and compromise.	Strongly agree, Agree, Disagree, Strongly Disagree
How much difficulty do you currently have	Recognizing emotions of friends and others (ex: jealousy, anxiety)	Unable, A lot, A little, None
How much difficulty do you currently have	Recognizing the likes or dislikes of others	Unable, A lot, A little, None
How much difficulty do you currently have	Showing the same level of emotion as others around you (ex: do not downplay or overdramatize a situation is someone is sad or happy)	Unable, A lot, A little, None
Please specify your level of agreement with the following statement:	I understand that others do not know my thoughts unless I say them or tell them what I am thinking	Strongly Agree, Agree, Disagree, Strongly Agree
Please specify your level of agreement with the following statement:	I refrain from entering a group when nonverbal cues indicate that I may not be welcome (ex: people looking away, closing off the circle of conversation)	Strongly Agree, Agree, Disagree, Strongly Agree
Please specify your level of agreement with the following statement:	I change my behavior depending on how well I know the other person I am talking to (ex: acting differently with family member vs. a stranger)	Strongly Agree, Agree, Disagree, Strongly Agree
Please specify your level of agreement with the following statement:	I say that I am sorry for unintended mistakes (ex: bumping into someone; offending someone by accident)	Strongly Agree, Agree, Disagree, Strongly Agree

Behavioral

Please specify your level of agreement	Usually, I can do no wrong	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I like to be the center of attention.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	Sometimes I do things to hurt myself	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I get angry when I'm told what to do	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I find my self being irritable with the people around me.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I am often overly alert (for example, checking to see who is around me).	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I am often watchful or on guard.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I follow the rules.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I do whatever I want, no matter what others think.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I get angry when I'm told how to do something.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I have difficulty calming down.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	People tell me that I am too energetic.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	Sometimes I feel on top of the world for no reason.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I feel that I can do things that others can’t.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I often feel that I have been given special powers.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	My mind is always racing.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	Often my thoughts go a mile a minute.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I find that I have a hard time sitting still when I need to	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I tend to move and do things very slowly	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	Sometimes my actions attract the attention of others.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	It doesn’t take much to set me off	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	Even when I do something very carefully I feel that it is not quite right	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I get behind in my work or daily activities because I repeat things over and over again	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	The same thoughts keep running through my head	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I am able to see a stressful situation as a challenge and face it head on.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	When I am stressed or feel hassled, I find myself losing control.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I find myself thinking a lot about my health.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I often think that something is really wrong with my body.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I seem to worry about my health a lot.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I find emotional support when I need it	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I have a desire to succeed	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I have goals in life that I want to reach	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I am the person most responsible for my own improvement	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I generally accomplish what I set out to do	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	Doing things well is very important to me.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I am confident that I can get things done in my day-to-day life.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I ask for help when I need to	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I feel distant or cut off from people.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I don't have much interest in social activities.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I have difficulty dealing with people I do not know	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I am afraid of being with others	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I show consideration for others	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I am respectful of other people.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I am able to adjust to other people's ways	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I make an effort to get to know other people	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I respect the privacy of others	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I am not comfortable asking what others expect of me	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I do what I can to get along with others.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I have a hard time accepting criticism from other people.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I tend not to feel the same things that others around me feel.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	People say I seem unemotional.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	People have told me that sometimes I act odd or strange	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I work well in a group.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I know how to keep from saying things that might upset others.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I can express myself when I am happy and when I am sad.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I don’t mind it when people give me helpful hints about how to do things.	Strongly agree Agree Disagree Strongly disagree I don't know
Please specify your level of agreement	I avoid going to crowded places, such as the mall, or community gatherings.	Strongly agree Agree Disagree Strongly disagree I don't know

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