Form 1 PDE-Participant Disability Screen Eng

Public reporting burden for this collection of information is estimated to average 04
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 (0925-0584). Do not return the completed form to this address.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL Visit 2 Participant Disability Screening Form
ID
NUMBER:

FORM CODE: PDE
VERSION: 1, 06/03/2014

Contact
Occasion

0

2

SEQ #

0

1

ADMINISTRATIVE INFORMATION

/

0a. Completion Date (mm/dd/yyyy):

/

0b. Staff ID:

Instructions: This disability screening form must be completed after informed consent administration and before the
participant has their examination. Positive responses to Questions 1 – 6 should be noted on the Exam Itinerary
Checklist for routing purposes during the visit.

Introductory Script for staff: Now I would like to ask you about difficulties you may have in usual

activities of daily living:
A. Disability Status
1. Are you deaf or do you have serious difficulty hearing?
No

0

Yes 1
2. Are you blind or do you have serous difficulty seeing, even when wearing glasses?
No

0

Yes 1
3. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating,
remembering, or making decisions?
No

0

Yes 1
4. Do you have serious difficulty walking or climbing stairs?
No

0

Yes

1

5. Do you have difficulty walking one half mile (approximately 1 kilometer)?
No

0

Yes

1

6. Do you have difficulty climbing 10 stairs?
No

0

Yes

1

PDE-Participant Disability Screen_06-03-14-English mod

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FORM CODE: PDE
VERSION: 1, 6/03/2014

ID NUMBER:

Contact
Occasion

0

2

SEQ #

7. Do you have difficulty dressing or bathing?
No

0

Yes 1
8. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as
visiting a doctor’s office or shopping ?
No

0

Yes 1

PDE-Participant Disability Screen_06-03-14-English mod

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