The Veterans Rand 12-Item Health Survey (VR-12)

Attach 6E_VR12 Legacy Instrument.docx

Questionnaire Cognitive Interviewing and Pretesting (NCI)

The Veterans Rand 12-Item Health Survey (VR-12)

OMB: 0925-0589

Document [docx]
Download: docx | pdf

OMB 0925-0589

Expiration Date: xx/xx/20xx


Shape1 Public reporting burden for this collection of information is estimated to be 5 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 (0925-0589). Do not return the completed form to this address.



THE VETERANS RAND 12-ITEM HEALTH SURVEY (VR-12)



This study is a collaboration between the Social Security Administration and the National Institutes of Health to develop a new method of asking questions related to disability (i.e., computer adaptive tests) and new questions to ask about your daily physical and behavioral activities.


The following questions ask for your views about your health—how you feel and how well you are able to do your usual activities. All kinds of people across the country are being asked these same questions. Their answers and yours will help to improve health care for everyone. There are no right or wrong answers; please choose the answer that best fits your life right now.


Answer each question by marking an X next to the best response. For example:


What is your gender?

Male

Shape2 Female




Q1. In general, would you say your health is:


Excellent

Very good

Good

Fair

Poor



Q2. The following questions are about activities you might do during a typical day. Does

your health now limit you in these activities? If so, how much?



a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf?


Yes, limited a lot

Yes, limited a little

No, not limited at all



b. Climbing several flights of stairs?


Yes, limited a lot

Yes, limited a little

No, not limited at all



Q3. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?



a. Accomplished less than you would like.


No, none of the time

Yes, a little of the time

Yes, some of the time

Yes, most of the time

Yes, all of the time



b. Were limited in the kind of work or other activities.


No, none of the time

Yes, a little of the time

Yes, some of the time

Yes, most of the time

Yes, all of the time




Q4. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?



a. Accomplished less than you would like.


No, none of the time

Yes, a little of the time

Yes, some of the time

Yes, most of the time

Yes, all of the time



b. Didnt do work or other activities as carefully as usual.


No, none of the time

Yes, a little of the time

Yes, some of the time

Yes, most of the time

Yes, all of the time



Continue to next page




Q5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?


Not at all

A little bit

Moderately

Quite a bit

Extremely



These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.



Q6a. How much of the time during the past 4 weeks:


Have you felt calm and peaceful?


All of the time

Most of the time

A good bit of the time

Some of the time

A little of the time

None of the time



Q6b. How much of the time during the past 4 weeks:


Did you have a lot of energy?


All of the time

Most of the time

A good bit of the time

Some of the time

A little of the time

None of the time



Q6c. How much of the time during the past 4 weeks:


Have you felt downhearted and blue?


All of the time

Most of the time

A good bit of the time

Some of the time

A little of the time

None of the time



Continue to next page





Q7. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?


All of the time

Most of the time

Some of the time

A little of the time

None of the time



Now, wed like to ask you some questions about how your health may have changed.



Q8. Compared to one year ago, how would you rate your physical health in general now?


Much better

Slightly better

About the same

Slightly worse

Much worse



Q9. Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) now?


Much better

Slightly better

About the same

Slightly worse

Much worse






Your answers are important!


Thank you for completing this questionnaire!






6

Shape3

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleDkdkdkdk
AuthorAndersen
File Modified0000-00-00
File Created2021-01-27

© 2024 OMB.report | Privacy Policy