Attachment 1a: WHO Questionnaire

Attachment 1a: WHO Questionnaire

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 90 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 06/30/2015

I want to understand the kinds of problems you experience in your life.

By problems I mean not getting things done or not getting things done in the way you want to.

These problems may arise because of a health condition or because of the environment you live in. These problems may also arise because of the attitudes or behaviours of people around you.

Please think about the last 30 days taking both good and bad days into account.

Please keep in mind everything that makes it easier or harder to get things done.

I will begin with some questions about these things.

I3001	Do you have someone to assist you with your day to day activities?	1 Yes 5 No
I3002	Do you use any assistive devices such as glasses, hearing aids, mobility aids [e.g. cane, crutch, wheelchair, walking frame, prosthesis or orthopaedic devices] or aids for self-care [e.g. hand, arm brace or grasping tool]?	1 Yes 5 No
I3003	Do you take medication for symptom control, such as for pain, sleep disturbances or high blood pressure?	1 Yes 5 No
I3004	Are there any assistance or modifications that make it easier for you to be at home [e.g. modifications at home], to work [e.g. accessible offices, adapted work hours], to get education [e.g. extra time for exams] or to participate in community [e.g. accessible public transportation]?	1 Yes 5 No
For all the questions I am now going to ask you, please take into account people who help you, any assistive devices you use or any medication you take.

		1 Not at all	2 Yes, a little	3 Yes, to some extent	4 Yes, to a moderate extent	5 Yes, extreme	8 Don’t Know
MOBILITY
I3005	Does standing up from sitting down pose a problem for you?	1	2	3	4	5	8
I3006	Does standing for long periods such as 30 minutes pose a problem for you?	1	2	3	4	5	8
I3007	Is getting out of your home a problem for you?	1	2	3	4	5	8
I3008	Is walking a short distance such as a 100m a problem for you?	1	2	3	4	5	8
I3009	Is walking a kilometre a problem for you?	1	2	3	4	5	8
I3010	Is engaging in vigorous activities, such as [add country specific examples] a problem for you?	1	2	3	4	5	8
I3011	Is getting where you want to go a problem for you?	1	2	3	4	5	8
I3012	Does using public or private transportation pose a problem for you?	1	2	3	4	5	8
HAND AND ARM USE
I3013	Is doing things that require the use of your hands and fingers, such as picking up small objects or opening a container a problem for you?	1	2	3	4	5	8
I3014	Is lifting an object over your head a problem for you?	1	2	3	4	5	8
Once again, please take into account people who help you, any assistive devices you use or any medication you take.
SEEING
I3015	Is seeing things at a distance such as across the street a problem for you?	1	2	3	4	5	8
I3016	Is seeing an object at arm's length a problem for you?	1	2	3	4	5	8
HEARING
I3017	Is hearing soft sounds a problem for you?	1	2	3	4	5	8
I3018	Is hearing loud sounds a problem for you?	1	2	3	4	5	8
PAIN
I3019	Is having pain a problem for you?	1	2	3	4	5	8
ENERGY AND DRIVE
I3020	Does sleep pose a problem for you?	1	2	3	4	5	8
I3021	Is not having enough energy a problem for you?	1	2	3	4	5	8
BREATHING
I3022	Does shortness of breath pose a problem for you?	1	2	3	4	5	8
I3023	Is coughing or wheezing a problem for you?	1	2	3	4	5	8
AFFECT (DEPRESSION AND ANXIETY)
I3024	Do you feel sad, low or depressed?	1	2	3	4	5	8
I3025	Do you feel worried, nervous or anxious?	1	2	3	4	5	8
Please continue taking into account people who help you, any assistive devices you use or any medication you take.
SELF-CARE
I3026	Does getting clean and dressed pose a problem for you?	1	2	3	4	5	8
I3027	Does eating and drinking pose a problem for you?	1	2	3	4	5	8
I3028	Does toileting pose a problem for you?	1	2	3	4	5	8
I3029	Does cutting your toenails pose a problem for you?	1	2	3	4	5	8
I3030	Is looking after your health, eating well, exercising or taking your medicines a problem for you?	1	2	3	4	5	8
INTERPERSONAL RELATIONSHIPS
I3031	Is getting along with people who are close to you, including your family and friends, a problem for you?	1	2	3	4	5	8
I3032	Does dealing with people you do not know pose a problem for you?	1	2	3	4	5	8
I3033	Is initiating and maintaining friendships a problem for you?	1	2	3	4	5	8
I3034	Is having an intimate relationship a problem for you?	1	2	3	4	5	8
HANDLING STRESS
I3035	Is handling stress, such as dealing with the important things in your life a problem for you?	1	2	3	4	5	8
Please remember to take into account people who help you, any assistive devices you use or any medication you take.
COMMUNICATION
I3036	Is being understood a problem for you?	1	2	3	4	5	8
I3037	Is understanding others a problem for you?	1	2	3	4	5	8
COGNITION
I3038	Is forgetfulness a problem for you?	1	2	3	4	5	8
I3039	Does remembering to do the important things in your day to day life a problem for you?	1	2	3	4	5	8
I3040	Is finding solutions to day to day problems a problem for you?	1	2	3	4	5	8
HOUSEHOLD TASKS
I3041	Does getting your household tasks done pose a problem for you?	1	2	3	4	5	8
I3042	Is managing your money a problem for you?	1	2	3	4	5	8

		1 Not at all	2 Yes, a little		3 Yes, to some extent	4 Yes, to a moderate extent	5 Yes, extreme	8 Don’t Know	9 Not applicable
CARING FOR OTHERS
I3043	Does providing care or support for others pose a problem for you?	1	2		3	4	5	8	9
WORK & SCHOOLING
I3044	Is getting things done as required at work a problem for you?	1		2	3	4	5	8	9
I3045	Is getting things done as required at school a problem for you?	1		2	3	4	5	8	9
				1 Not at all	2 Yes, a little	3 Yes, to some extent	4 Yes, to a moderate extent	5 Yes, extreme	8 Don’t Know
RECREATION, LEISURE, & COMMUNITY PARTICIPATION
I3046	Is doing things for relaxation or pleasure a problem for you?			1	2	3	4	5	8
I3047	Is joining in community activities, such as festivities, religious or other activities a problem for you?			1	2	3	4	5	8
CITIZENSHIP
I3048	Do you have the freedom to make choices about where you live, where you work, and who your friends are?			1	2	3	4	5	8
I3049	Do you participate in local and community affairs?			1	2	3	4	5	8
I3050	Do you participate in political parties and in civil society organisations, such as labour unions and non governmental organizations?			1	2	3	4	5	8
I3051	Does living with dignity pose a problem to you?			1	2	3	4	5	8
I3052	Generally, do you exercise your right of voting?			1	2	3	4	5	8

I have asked you many questions about the kinds of problems you experience in your life.

I now want to ask you a few more questions even though some of them might seem to be questions I have asked you already. I would very much appreciate your answering them.

GENERAL FUNCTIONING
The next questions ask about difficulties you may have doing certain activities because of a HEALTH PROBLEM.
		No - no difficulty	Yes – some difficulty	Yes – a lot of difficulty	Cannot do at all
I3053	Do you have difficulty seeing, even if wearing glasses?	1	2	3	4
I3054	Do you have difficulty hearing, even if using a hearing aid?	1	2	3	4
I3055	Do you have difficulty walking or climbing steps?	1	2	3	4
I3056	Do you have difficulty remembering or concentrating?	1	2	3	4
I3057	Do you have difficulty (with self-care such as) washing all over or dressing?	1	2	3	4
I3058	Using your usual (customary) language, do you have difficulty communicating, for example understanding or being understood?	1	2	3	4

Health Insurance Exchange Questions

E1

What kind of health insurance or health care coverage do you have? INCLUDE those that pay for only one type of service (nursing home care, accidents, or dental care). EXCLUDE private plans that only provide extra cash when hospitalized. Private health insurance Medicare Medi-Gap Medicaid SCHIP (CHIP/Children’s Health Insurance Program) Military health care (TRICARE/VA/CHAMP-VA) Indian Health Service State-sponsored health plan Other government program Single service plan (e.g. dental, vision, prescriptions) No coverage of any type Don’t Know

E2 [SKIP if E1=k or l]

Under your health insurance or health care coverage plan, is there an enrollment fee or premium?

1. Yes

2. No

3. Don’t Know

E3 [SKIP if E1=k or l AND E2= b or c]

Is the fee or premium paid for this plan based on income?

1. Yes

2. No

3. Don’t Know

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