Adult Disability Questions

NCHS Questionnaire Design Research Laboratory

0920-0222 Attachment 1a - Adult Disability Questions 0106 2014

Adult and Child Disability Questions

OMB: 0920-0222

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Attachment 1a- Adult Disability Questions to be cognitively tested


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 for statistical purposes 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 55 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



Section 3000: FUNCTIONING


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

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

COMMUNICATION


1

Not at all

2

Yes, a little

3

Yes, a lot

4

Cannot do at all


8

Don’t Know


Using you usual language, do you have difficulty communicating, for example understanding or being understood?

1

2

3

4


8

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


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 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

Almost 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

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

Somewhere in between



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

Somewhere in between



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

5

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

Somewhere in between



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

Somewhere in between



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?

1

2

3

4


8

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



The following problems may arise because of a health condition or because of the environment you live in. They may also arise because of the attitudes or behaviours of people.

GETTING AROUND


1

Not at all

2

Yes, a little

3

Yes, a lot

4

Cannot do at all


8

Don’t Know

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

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

CARING FOR OTHERS


1

Not at all

2

Yes, a little

3

Yes, a lot

4

Cannot do at all


8

Don’t Know

9

Not applicable

I3043

Does providing care or support for others pose a problem for you?

1

2

3

4


8

9

WORK & SCHOOLING


1

Not at all

2

Yes, a little

3

Yes, a lot

4

Cannot do at all


8

Don’t Know

9

Not applicable

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



RECREATION, LEISURE, & COMMUNITY PARTICIPATION


1

Not at all

2

Yes, a little

3

Yes, a lot

4

Cannot do at all


8

Don’t Know

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


1

Not at all

2

Yes, a little

3

Yes, a lot

4

Cannot do at all


8

Don’t Know

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




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