Form 8 Survey 2 Replinishment Items and Short Forms

Calibration II & Predictive Validity Testing of Item Response Theory – Computer Adaptive Testing Tools (IRT-CAT)

Attachment 5 Replinishment Items and Short Forms_Survey 2

Claimant Survey 2

OMB: 0925-0704

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Replenishment Item Bank &

Short Form Version of

Physical Function & Behavioral Health FAB (Survey 2)


Shape1

OMB No.: 0925-XXXX

Expiration Date: XX/XX/2017

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The following items represent a comprehensive list of every question for Survey #2 (Both for Calibration with SSDI Claimants and the Normative Sample).


This screenshot would be the format the respondent would see (if choosing to self administer, i.e. not request the answers entered by a telephone interviewer) for each selected question. If granted OMB clearance, the OMB Control number, expiration date and required language will be written into the software so that it appears on the introductory screen for every respondent. For those participants opting for telephone interviewer administration, they will be read the contents of the OMB control box during the pre-screening for each survey.






Physical Function Replenishment Items

Primary Domain

Item Stem

Item Content

Item Response Scale

changing and maintaining body position

Are you able

to stand in the shower to wash your hair?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

changing and maintaining body position

Are you able

to get in and out of the bathtub?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

Changing and maintaining body position

Are you able

to reach into a cabinet from a step ladder or stool?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

changing and maintaining body position

Are you able

to bend down to use a dust pan?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

changing and maintaining body position

Are you able

to lean forward to brush your teeth over a sink?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

changing and maintaining body position

Are you able

to look over your shoulder to back up in a car?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

changing and maintaining body position

Are you able

to look under your bed or couch?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

changing and maintaining body position

Are you able

to unload a washing machine?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

changing and maintaining body position

Are you able

to kneel down to tie a shoe?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

changing and maintaining body position

Are you able

to bend to look under a car?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

changing and maintaining body position

Are you able

to sit in a car for more than 2 hours?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

changing and maintaining body position

Are you able

to crawl under a table to pick up something you dropped?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

Upper Body Function

Are you able

to clean a floor using a mop?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to pull open a dresser drawer?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

Upper body function

Are you able

to pull open a low cabinet door?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

Upper Body function

Are you able

to push your chair back to get up from sitting at a table?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

pull a small suitcase by the handle?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to lift a 2 liter soda bottle from the floor to a high shelf? A soda bottle=3.5lbs/1.5kg

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to clean out a closet?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to lift a heavy box from the floor to table height?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to carry your jacket?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to lift a package weighing 10 lbs?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to carry a full kitchen trash bag outside?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to lift a 12 pack of soda cans from a grocery shelf to a grocery cart?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to lift a full, small (carry-on size) suitcase from the floor to a high shelf?
A full carry-on suitcase weighs 20 pounds/8 kg.

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to lift a large heavy box from the floor to a high shelf?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

Upper Body Function

Are you able

to unload a full grocery cart into a car?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to unload the dishwasher?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to move a sofa to clean under it?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to wipe down a kitchen counter?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to reach into a mailbox?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper body function

Are you able

to make a bed?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

Upper extremity fine motor

Are you able

to grip the steering wheel during a long drive? For example a couple of hours.

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to change a light bulb overhead?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

Upper extremity fine motor

Are you able

to chop or slice vegetables for a large meal?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to hold an umbrella?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to use tweezers?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to use a nut cracker?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to remove a dollar bill from your wallet?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to put coins into a slot? For example a vending machine.

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to push the correct buttons on a remote control?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to type a text message on a cell/mobile phone?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to use a mouse to select what you need on a computer screen?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to close a zip lock bag?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to close a twist tie on a bag of bread?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to peel the sticker off something you bought?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to open a bottle of soda?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to insert a plug into an electric outlet?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to use a chip clip to close a bag?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to turn a dial? For example on a stove.

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to use the trigger on a spray bottle?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to type an email?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to button your shirt?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

upper extremity fine motor

Are you able

to put on a watch or bracelet?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

Whole body mobility

Are you able

to walk a short distance? For example from a parking lot into a grocery store.

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

Whole body mobility

Are you able

to walk a short distance using your walking aid? For example from a parking lot into a grocery store.

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

whole body mobility

Are you able

to walk the aisles of a grocery store using a shopping cart?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

Whole body mobility

Are you able

to walk from store to store while shopping ? For example in a shopping mall.

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

Whole body mobility

Are you able

to walk from store to while shopping using your walking aid? For example in a shopping mall.

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

whole body mobility

Are you able

walk up a flight of stairs without a handrail?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

whole body mobility

Are you able

to walk to the bathroom?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know

whole body mobility

Are you able

to walk to the bathroom using your walking aid?

  Yes, without difficulty
  Yes, with a little difficulty
  Yes, with some difficulty
  Yes, with a lot of difficulty
  Unable to do
  I don't know









Behavioral Health Replenishment Items

Primary Domain

Item Stem

Item Content

Item Response Scale

Mood & Emotions

Please specify your level of agreement:

I worry a lot about my health.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Mood & Emotions

Please specify your level of agreement:

I often think that something is really wrong with my health.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Mood & Emotions

Please specify your level of agreement:

I seem to worry about my health a lot.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Mood & Emotions

Please specify your level of agreement:

People say I show no emotion

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I often get upset with the people around me.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

It doesn’t take much to set me off

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

People often tell me my behavior is inappropriate.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behaviroal Control

Please specify your level of agreement:

I often get angry when I'm told how to do something.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I can handle stressful situations.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

Usually, I can do no wrong.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

Even when I do something very carefully I feel that it is not quite right.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I can see things that others can't.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I can hear things that others can't.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I do whatever I want, no matter what others think.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I have difficulty following the rules.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I find that I have a hard time sitting still when I need to.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I tend to do things very slowly.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I am always watching or on guard for threats.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I often get angry when I'm told what to do.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

When I am stressed, I find myself losing control.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I am often overly alert.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

Sometimes I do things to hurt myself.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

Often my thoughts go a mile a minute.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

Sometimes I feel on top of the world for no reason.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I like to be the center of attention.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I have difficulty calming down.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

People tell me that I am too energetic.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I often feel that I have been given special powers.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

My mind is always racing.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I get behind in my work or daily activities because I do things over and over again.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

The same thoughts keep running through my head

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self-Efficacy

Please specify your level of agreement:

I am the person most responsible for my own well being.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self-Efficacy

Please specify your level of agreement:

I am able to get the emotional support I need.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self-Efficacy

Please specify your level of agreement:

I usually accomplish what I set out to do.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self-Efficacy

Please specify your level of agreement:

I ask for help when I need to.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self-Efficacy

Please specify your level of agreement:

I have a desire to succeed.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self-Efficacy

Please specify your level of agreement:

I have goals in life that I want to reach

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self-Efficacy

Please specify your level of agreement:

Doing things well is very important to me.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self-Efficacy

Please specify your level of agreement:

I am confident that I can get things done in my day-to-day life.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self-Efficacy

Please specify your level of agreement:

I don’t mind when people give me advice.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I make an effort to get to know other people.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I always try to get along with others.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I work well in a group.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I often have difficulty dealing with people.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I respect other people.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

People have told me that sometimes I act strange.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I don't feel the same things that others around me feel.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I am polite to others.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I often avoid going to crowded places.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I feel distant or cut off from people.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I don't have much interest in being with other people.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I am afraid of being with other people.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I am able to adjust to other people's ways.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I respect other people's privacy.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I respect other people's space.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I respect other people's property.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I have a hard time accepting criticism.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I often say things that upset others.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

Please specify your level of agreement:

I difficulty letting people know how I feel.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know




Short Form Version, Physical Function

Changing and Maintaing Body Position

Are you able

to get in and out of bed?
Base response on the most difficult part of the activity.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Changing and Maintaing Body Position

Are you able

to get into and out of a car?
Please base your response on the most difficult part of this activity.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Changing and Maintaing Body Position

Are you able

to sit on a stool without back support?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Changing and Maintaing Body Position

Are you able

to get up off the floor from lying on your back?
You can use a chair or other object to get up.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Changing and Maintaing Body Position

Are you able

to get down on the floor? For example moving from standing or your wheelchair to kneel or sit on the floor

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Changing and Maintaing Body Position

Are you able

to get into and out of a kneeling position? Please base your response on the most difficult part of the activity.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Changing and Maintaing Body Position

Are you able

to get in and out of a squatting position? Please base your response on the most difficult part of the activity.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Changing and Maintaing Body Position

Are you able

to climb 2 or 3 steps up a step ladder?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Changing and Maintaing Body Position

Are you able

to work at floor level? For example changing the face plate on an electric outlet.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Changing and Maintaing Body Position

Are you able

to bend over to pick up coins that are scattered on the floor?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Changing and Maintaing Body Position

Are you able

to stand up from a low, soft couch?
Without holding on to anything.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Changing and Maintaing Body Position

Are you able

to kneel on the floor for a long time? For example when cleaning the bathtub or playing with kids or pet.
3-5 minutes

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Changing and Maintaing Body Position

Are you able

to go down one flight of stairs using a handrail?
A flight of stairs is 12-15 steps.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

to carry a full paper grocery bag for 30 feet?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

to lift a full small (carry-on size) suitcase from the floor to table height?
A full carry-on suitcase weighs 20 pounds/8 kg.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

to push a vacuum?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

to pick up a kitchen chair and move it, in order to clean?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

to push a full grocery cart?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

to carry a full laundry basket for 30 feet?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

to work overhead for 20 minutes? For example organizing a high shelf in a closet.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

to lift a full 2 liter soda bottle from table height to a high shelf?
A 2 liter soda bottle= 3.5 lbs/1.5 kg.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

to lift a full large (check-in size) suitcase from the floor to table height?
A full large suitcase weighs 40-50 pounds/18-23 kg

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

to pull open a heavy door?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

to carry a full small (carry-on size) suitcase for 30 feet?
A full carry-on suitcase weighs 20 pounds/8 kg.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

to carry a full laundry basket up a flight of stairs?
A flight of stairs is 12-15 steps.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Body Function

Are you able

do yard work for 2 hours? For example plant shrubs or a garden.
With occasional rest but continuous work.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to buckle a strap
For example on a bicycle helmet, child's car seat or backpack.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to write for 20 minutes?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to tighten screws by hand with a screwdriver?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to turn a key in a door lock?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to put batteries in a flashlight, or remote control for your television?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to turn faucets on and off?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to remove wrappings from small objects? For example like removing the packaging from a pack of batteries.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to reach behind you to get your seatbelt?
A shoulder harness seatbelt.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to pick up coins from a table top?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to open childproof medicine bottles or jars?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to a can with a hand can opener?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to use a hammer to pound a nail?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to pick out one key from group of keys?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Upper Extremity Fine Motor

Are you able

to open previously opened jars?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Please select the response that best describes how you usually get around:

 

I usually use a walking aid (cane, crutches, or walker):

All the time
Sometimes
Never

I usually use a manual wheelchair or power wheelchair to get around:

All the time; I never walk
Sometimes
Never

Whole Body Mobility

Are you able

to stand on your feet for one hour?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to stand on your feet for one hour using your walking aid?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to walk a mile without resting?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to walk a mile without resting using your walking aid?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to walk up a steep slope? For example on a hill.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to walk up a steep slope using your walking aid? For example on a hill.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to walk on uneven surfaces? For example on grass, dirt road or sidewalk.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

walk on uneven surfaces using your walking aid? For example on grass, dirt road or sidewalk.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to walk quickly indoors? For example to answer the telephone or the front door.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to run a short distance, such as to catch a bus? A short distance is roughly half a block or about 15-20 yards.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to walk at least 15 minutes?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to walk at least 15 minutes using your walking aid?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to remain on your feet for at least 20 minutes?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to remain on your feet for at least 20 minutes using your walking aid?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to cross the road at a 4-lane traffic light with curbs using your walking aid?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to walk around one floor of your home without tripping or losing your balance?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Whole Body Mobility

Are you able

to run fast for 2 minutes?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Wheelchair

Are you able

to get in and out of your wheelchair?
Please base your response on the most difficult part of this activity.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Wheelchair

Are you able

to move around one floor of your home in your wheelchair without bumping into things?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Wheelchair

Are you able

to move your wheelchair for at least 15 minutes?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Wheelchair

Are you able

to move around in the bathroom, including getting on and off the toilet from your wheelchair?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Wheelchair

Are you able

to cross the street at a traffic light in your wheelchair?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Wheelchair

Are you able

to get in and out of a car from your wheelchair?
Please consider a sedan sized car when considering your answer.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Wheelchair

Are you able

to get into and out of a truck, bus, shuttle van, or sport utility vehicle from your wheelchair?

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know

Wheelchair

Are you able

to move your wheelchair up and down curbs?
Please base your response on the most difficult part of this activity.

Yes, without difficulty
Yes, with a little difficulty
Yes, with some difficulty
Yes, with a lot of difficulty
Unable to do
I don't know



Short Form Version, Behavioral Health

Primary Domain

Item Stem

Item Content

Item Response Scale

Social Interactions

In the past 7 days,

I could keep up with my family responsibilities.

Never
Rarely
Sometimes
Often
Always

Social Interactions

In the past 7 days,

I was able to do all the family activities that I was expected to do.

Never
Rarely
Sometimes
Often
Always

Social Interactions

In the past 7 days,

I could keep up with my social commitments. Social commitments meaning plans you’ve made with others.

Never
Rarely
Sometimes
Often
Always

Social Interactions

In the past 7 days,

I look forward with enjoyment to upcoming events.

Never
Rarely
Sometimes
Often
Always

Social Interaction

Please specify your level of agreement:

I feel that I'm an important part of the community where I live.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Social Interactions

In the past 7 days,

I was able to do all of my usual work (including work at home).

Never
Rarely
Sometimes
Often
Always

Mood and Emotions

In the past 7 days,

it was hard to keep up enthusiasm to get things done.

Never
Rarely
Sometimes
Often
Always

Mood and Emotions

In the past 7 days,

I felt that nothing was interesting.

Never
Rarely
Sometimes
Often
Always

Mood and Emotions

In the past 7 days,

I was preoccupied with my worries.

Never
Rarely
Sometimes
Often
Always

Mood and Emotions

In the past 7 days,

I had sudden feelings of panic.

Never
Rarely
Sometimes
Often
Always

Mood and Emotions

In the past 7 days,

I felt nervous when my normal routine was disturbed.

Never
Rarely
Sometimes
Often
Always

Mood and Emotions

In the past 7 days,

I felt that nothing could cheer me up.

Never
Rarely
Sometimes
Often
Always

Mood and Emotions

In the past 7 days,

I was afraid of what the future holds for me.

Never
Rarely
Sometimes
Often
Always

Mood and Emotions

In the past 7 days,

I had trouble paying attention.

Never
Rarely
Sometimes
Often
Always

Mood and Emotions

In the past 7 days,

it was hard to adjust to unexpected changes.

Never
Rarely
Sometimes
Often
Always

Mood and Emotions

Please specify your level of agreement:

I feel good about myself.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Mood and Emotions

In the past 7 days,

many situations made me worry.

Never
Rarely
Sometimes
Often
Always

Mood and Emotions

Please specify your level of agreement:

When I'm stressed, I can't figure out what to do.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Mood and Emotions

In the past 7 days,

I suddenly became emotional for no reason.

Never
Rarely
Sometimes
Often
Always

Behavioral Control

Please specify your level of agreement:

I get very loud when I do not get what I want.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I sometimes get physical when I'm angry.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

Sometimes I shout or yell for no reason.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

People know that I get angry easily.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

It's easy to do what people in authority ask me to do.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

Please specify your level of agreement:

I can't stop myself from doing the same thing over and over.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Behavioral Control

In the past 7 days,

I was stubborn with others.

Never
Rarely
Sometimes
Often
Always

Behavioral Control

In the past 7 days,

I was in conflict with others.

Never
Rarely
Sometimes
Often
Always

Behavioral Control

In the past 7 days,

I was resentful when I didn't get my way.

Never
Rarely
Sometimes
Often
Always

Behavioral Control

In the past 7 days,

I threatened violence toward people or property .

Never
Rarely
Sometimes
Often
Always

Behavioral Control

In the past 7 days,

I tried to get even when I was angry at someone.

Never
Rarely
Sometimes
Often
Always

Behavioral Control

In the past 7 days,

I held grudges toward others.

Never
Rarely
Sometimes
Often
Always

Behavioral Control

In the past 7 days,

I had trouble controlling my temper.

Never
Rarely
Sometimes
Often
Always

Behavioral Control

In the past 7 days,

people told me that I talked in a loud or excessive manner.

Never
Rarely
Sometimes
Often
Always

Behavioral Control

In the past 7 days,

I said or did things that other people probably thought were inappropriate.

Never
Rarely
Sometimes
Often
Always

Self Efficacy

Please specify your level of agreement:

I get along well with people outside my family.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I feel people are against me.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I feel that there are people I can turn to.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I am good at making new friends.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I can easily begin talking with others.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I'm comfortable trying different ways to do things.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

Trying new things is fun.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

When I'm asked to do a really difficult task, I keep at it until I get it done.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

If I make a mistake, I know I can deal with it.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I think people trust me.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I look at both sides of an issue.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I am willing to accept help from others.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I am comfortable making eye contact with others.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I like large family gatherings.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

Most people like what I have to say.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I'm usually able to help solve other people's problems.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I'm comfortable just seeing what the day brings.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I look for the good in difficult situations.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I learn from my mistakes.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I believe that things end up alright most of the time.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I respect other people's point of view.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

I can get back on track when I am distracted.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know

Self Efficacy

Please specify your level of agreement:

People tell me I'm flexible and agreeable.

Strongly agree
Agree
Disagree
Strongly disagree
I don't know


45


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AuthorHobbs, Daniel (NIH/CC/RMD) [C]
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File Created2021-01-27

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