Attachment 1b: Washington Group Questionnaire

Attachment 1b: Washington Group 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

The next questions ask about difficulties you may have in doing certain activities and problems you experience in your life.

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

MOBILITY
		1 Not at all	2 Yes, a little	3 Yes, a lot	4 Cannot do at all		8 Don’t Know
	Do you have difficulty walking or climbing steps?	1	2	3	4		8
	Do you have difficulty walking 100 meters on level ground, that would be about the length of one football field or one city block?	1	2	3	4		8
	Do you have difficulty walking half a km on level ground, that would be about the length of five football field or five city blocks?	1	2	3	4		8
	Do you have difficulty walking up or down 12 steps?	1	2	3	4		8
I3005	Does standing up from sitting down pose a problem for you?	1	2	3	4		8
I3006	Does standing for long periods such as 30 minutes pose a problem for you?	1	2	3	4		8
I3007	Is getting out of your home a problem for you?	1	2	3	4		8
I3010	Is engaging in vigorous activities, such as [add country specific examples] a problem for you?	1	2	3	4		8
I3011	Is getting where you want to go a problem for you?	1	2	3	4		8
I3012	Does using public or private transportation pose a problem for you?	1	2	3	4		8

HAND AND ARM USE
		1 Not at all	2 Yes, a little	3 Yes, a lot	4 Cannot do at all		8 Don’t Know
	Do you have difficulty raising a 2 liter bottle of water or soda from waist to eye level?	1	2	3	4		8
	Do you have difficulty using your hands and fingers, such as picking up small objects, for example a button or a pencil, or opening or closing containers or bottles?	1	2	3	4		8
SEEING
		1 Yes				5 No	8 Don’t Know
	Do you wear glasses?	1				5	8
		1 Not at all	2 Yes, a little	3 Yes, a lot	4 Cannot do at all		8 Don’t Know
	Do you have difficulty seeing, even when wearing your glasses?	1	2	3	4		8
I3015	Is seeing things at a distance such as across the street a problem for you?	1	2	3	4		8
I3016	Is seeing an object at arm's length a problem for you?	1	2	3	4		8
HEARING
		1 Yes				5 No	8 Don’t Know
	Do you use a hearing aid?	1				5	8
		1 Not at all	2 Yes, a little	3 Yes, a lot	4 Cannot do at all		8 Don’t Know
	Do you have difficulty hearing, even when using your hearing aid?	1	2	3	4		8
	Do you have difficulty hearing what is said in a conversation with one other person in a quiet room?	1	2	3	4		8
	Do you have difficulty hearing what is said in a conversation with one other person in a noisier room?	1	2	3	4		8

PAIN
		1 Never	2 Some days	3 Most days	4 Every day		8 Don’t Know
	In the past 3 months, how often did you have pain?	1	2	3	4		8
		1 A little	2 A lot	3 Between a little and a lot			8 Don’t Know
	Thinking about the last time you had pain, how much pain did you have?	1	2	3			8
		1 Not at all	2 Yes, a little	3 Yes, a lot	4 Cannot do at all		8 Don’t Know
I3019	Is having pain a problem for you?	1	2	3	4		8
ENERGY AND DRIVE
		1 Never	2 Some days	3 Most days	4 Every day		8 Don’t Know
	In the past 3 months, how often did you feel tired or exhausted?	1	2	3	4		8
		1 Some of the day	2 Most of the day	3 All of the day			8 Don’t Know
	Thinking about the last time you felt tired or exhausted, how long did it last?	1	2	3			8
		1 A little	2 A lot	3 Between a little and a lot			8 Don’t Know
	Thinking about the last time you felt tired or exhausted, how would you describe the level or tiredness?	1	2	3			8
		1 Not at all	2 Yes, a little	3 Yes, a lot	4 Cannot do at all		8 Don’t Know
I3020	Does sleep pose a problem for you?	1	2	3	4		8
I3021	Is not having enough energy a problem for you?	1	2	3	4		8
BREATHING
I3022	Does shortness of breath pose a problem for you?	1	2	3	4		8
I3023	Is coughing or wheezing a problem for you?	1	2	3	4		8

AFFECT (DEPRESSION AND ANXIETY)
		1 Daily	2 Weekly	3 Monthly	4 A few times a year	5 Never	8 Don’t Know
	How often do you feel depressed?	1	2	3	4		8
		1 Yes				5 No	8 Don’t Know
	Do you take medication for depression?	1				5	8
		1 A little	2 A lot	3 Between a little and a lot			8 Don’t Know
	Thinking about the last time you felt depressed, how depressed did you feel?	1	2	3			8
		1 Daily	2 Weekly	3 Monthly	4 A few times a year	5 Never	8 Don’t Know
	How often do you feel worried, nervous or anxious?	1	2	3	4	5	8
		1 Yes				5 No	8 Don’t Know
	Do you take medication for these feelings?	1				5	8
		1 A little	2 A lot	3 Between a little and a lot			8 Don’t Know
	Thinking about the last time you felt worried, nervous or anxious, how would you describe the level of these feelings?	1	2	3			8
SELF-CARE
		1 Not at all	2 Yes, a little	3 Yes, a lot	4 Cannot do at all		8 Don’t Know
	Do you have difficulty with self-care, such as washing all over or dressing?
I3027	Does eating and drinking pose a problem for you?	1	2	3	4		8
I3028	Does toileting pose a problem for you?	1	2	3	4		8
I3029	Does cutting your toenails pose a problem for you?	1	2	3	4		8
I3030	Is looking after your health, eating well, exercising or taking your medicines a problem for you?	1	2	3	4		8

INTERPERSONAL RELATIONSHIPS
					1 Not at all		2 Yes, a little		3 Yes, a lot		4 Cannot do at all				8 Don’t Know
I3031	Is getting along with people who are close to you, including your family and friends, a problem for you?				1		2		3		4				8
I3032	Does dealing with people you do not know pose a problem for you?				1		2		3		4				8
I3033	Is initiating and maintaining friendships a problem for you?				1		2		3		4				8
I3034	Is having an intimate relationship a problem for you?				1		2		3		4				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				8
COMMUNICATION
	Using you usual language, do you have difficulty communicating, for example understanding or being understood?
I3036	Is being understood a problem for you?				1		2		3		4				8
I3037	Is understanding others a problem for you?				1		2		3		4				8
COGNITION
	Do you have difficulty remembering or concentrating?				1		2		3		4				8
					1 Difficulty remembering only		2 Difficulty concentrating only		3 Difficulty with both						8 Don’t Know
	Do you have difficulty remembering, concentrating or both?				1		2		3						8
					1 Sometimes		2 Often		3 All of the time						8 Don’t Know
	How often do you have difficulty remembering?				1		2		3						8
					1 A few things		2 A lot of things		3 Alost everything						8 Don’t Know
	Do you have difficulty remembering a few things, a lot of things, or almost everything?				1		2		3						8
					1 Not at all		2 Yes, a little		3 Yes, a lot		4 Cannot do at all				8 Don’t Know
I3038	Is forgetfulness a problem for you?				1		2		3		4				8
I3039	Does remembering to do the important things in your day to day life a problem for you?				1		2		3		4				8
I3040	Is finding solutions to day to day problems a problem for you?				1		2		3		4				8
HOUSEHOLD TASKS
I3041	Does getting your household tasks done pose a problem for you?				1		2		3		4				8
I3042	Is managing your money a problem for you?				1		2		3		4				8
		1 Not at all	2 Yes, a little			3 Yes, a lot		4 Cannot do at all				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				8		9
WORK & SCHOOLING
I3044	Is getting things done as required at work a problem for you?	1		2		3		4				8		9
I3045	Is getting things done as required at school a problem for you?	1		2		3		4				8		9
				1 Not at all		2 Yes, a little		3 Yes, a lot		4 Cannot do at all				8 Don’t Know
RECREATION, LEISURE, & COMMUNITY PARTICIPATION
I3046	Is doing things for relaxation or pleasure a problem for you?			1		2		3		4				8
I3047	Is joining in community activities, such as festivities, religious or other activities a problem for you?			1		2		3		4				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				8
I3049	Do you participate in local and community affairs?			1		2		3		4				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				8
I3051	Does living with dignity pose a problem to you?			1		2		3		4				8
I3052	Generally, do you exercise your right of voting?			1		2		3		4				8

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

Have you looked into purchasing health insurance coverage through the [health insurance marketplace/name of state exchange program in R’s state]?

1. Yes

2. No

3. Don’t Know

E3 [SKIP if E1=k or l]

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

4. Yes

5. No

6. Don’t Know

E4 [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

Non-Disability Questions

N1

About how long has it been since you last saw or talked to a doctor or other health care professional about your own health? Never LT 1 Year 1-2 Years 2-5 Years 5 Years Were you including dentists when you were thinking about this question? Were you including mental health professionals, like psychologists or therapists, when you were thinking about this question?

N2

During the past 12 months, that is since [FILL 12 MONTH REF DATE], about how days many did you miss work at a job or business because of illness or injury, not including maternity leave? ______Days Don’t Know How did you come up with your answer?

N3

How much do you agree or disagree with the following statement about your neighborhood. People in my neighborhood can be trusted. Agree Disagree Don’t Know What do you think of as your neighborhood? How long have you lived in your current home? What do you think trusted means in this context?

N4

Please tell me how much confidence you, yourself, have that The US Census Bureau protects information they may have about you – a great deal, quite a lot, some or very little? A great deal Quite a lot Some Very little Why do you say that you have _____ confidence in the Census Bureau to protect information about you? What type of information does the Census Bureau have about you?

N5

The last question I will ask you is about your sexual history. In your lifetime, with how many individuals have you had any kind of sex? ___ Individuals Don’t Know How did you come up with your answer? How difficult is it for you to come up with an answer to this question?

25