1 Questionnaire

Attachment 1: 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 60 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 Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

Form Approved OMB #0920-0222; Expiration Date: 07/31/2018

1. For at least the past six months, to what extent have you been limited because of a health problem in activities people usually do?

1. Severely limited (go to Q2)

2. Limited but not severely (go to Q2)

3. Not limited at all

Have you been limited for at least the past 6 months? Yes No What is your current working status?
Working for pay at a job or business With a job or business but not at work Looking for work Working, but not for pay, at a family-owned job or business Not working at a job or business and not looking for work

DISABILITY IDENTIFICATION [For all household members aged 18 to 65 years]

VIS_1 [Do/Does] [you/he/she] have difficulty seeing, even when wearing [your/his/her] glasses]? Would you say… [Read response categories]

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

5. Refused

6. Don’t know

HEAR_1 [Do/Does] [you/he/she] have difficulty hearing, even when using a hearing aid(s)]? Would you say… [Read response categories]

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

5. Refused

6. Don’t know

MOB_1 [Do/Does] [you/he/she] have difficulty walking or climbing steps? Would you say… [Read response categories]

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

5. Refused

6. Don’t know

COM_1 Using [your/his/her] usual language, [do/does] [you/he/she] have difficulty communicating, for example understanding or being understood? Would you say… [Read response categories]

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

5. Refused

6. Don’t know

COG_1 [Do/does] [you/he/she] have difficulty remembering or concentrating? Would you say… [Read response categories]

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

5. Refused

6. Don’t know

SC_1 [Do/does] [you/he/she] have difficulty with self-care, such as washing all over or dressing? Would you say… [Read response categories]

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

5. Refused

6. Don’t know

UB_1 [Do/Does] [you/he/she] have difficulty raising a 2 liter bottle of water or soda from waist to eye level? Would you say… [Read response categories]

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

7. Refused

9. Don’t know

UB_2 [Do/Does] [you/he/she] have difficulty using [your/his/her] hands and fingers, such as picking up small objects, for example, a button or pencil, or opening or closing containers or bottles? Would you say… [Read response categories]

1. No difficulty

2. Some difficulty

3. A lot of difficulty

4. Cannot do at all / Unable to do

7. Refused

9. Don’t know

ANX_1 How often [do/does] [you/he/she] feel worried, nervous or anxious? Would you say… [Read response categories]

1. Daily

2. Weekly

3. Monthly

4. A few times a year

5. Never

7. Refused

9. Don’t know

ANX_2 Thinking about the last time [you/he/she] felt worried, nervous or anxious, how would [you/he/she] describe the level of these feelings? Would [you/he/she] say… [Read response categories]

1. A little

2. A lot

3. Somewhere in between a little and a lot

7. Refused

9. Don’t know

DEP_1 How often [do/does] [you/he/she] feel depressed? Would [you/he/she] say… [Read response categories]

1. Daily

2. Weekly

3. Monthly

4. A few times a year

5. Never

7. Refused

9. Don’t know

DEP_2 Thinking about the last time [you/he/she] felt depressed, how depressed did [you/he/she] feel? Would you say… [Read response categories]

1. A little

2. A lot

3. Somewhere in between a little and a lot

7. Refused

9. Don’t know

DISABILITY ONSET [For all with at least “a lot of difficulty]

ONS_1 [You/He/She] mentioned having a lot of difficulties doing some things. When did the first of these difficulties start?

1. At birth

2. Between the birth and the age of 15

3. Between the ages of 15 and 29

4. Between the ages of 30 and 65

5. After age 65

6. Refused

7. Don’t know

EMPLOYMENT STATUS [For all aged 18 to 65 years]

EM_1a What was [your/his/her] employment status last week?

1. Employed (worked for pay or profit)

2. Unemployed (i.e. not in employment, carried out activities to seek employment and were available to take up employment given a job opportunity)

3. Inactive (Not employed and not looking for work)

4. Refused

5. Don’t know

BARRIERS [For all who are inactive and have at least “a lot of difficulty”]

EW_1a Which of the following, if any, would make it more likely for [you/him/her] to seek employment. Check all that apply.

1. Training to qualify for available jobs

2. Transportation from my home to available jobs

3. Help in locating available jobs

4. Greater belief that someone will hire me

5. Assistive devices or technology to help me do the job

6. A work place that accommodates people with disabilities

7. Other: Please specify _________________

8. Refused

9. Don’t know

ATT_3 How supportive would [your/his/her] family members be if you decide to work?

1. Very supportive

2. Somewhat supportive

3. Not supportive

4. Refused

5. Don’t Know

ACCOMMODATIONS [For all who are employed and who have ‘a lot of difficulty’]

WA_1 Has [your/his/her] workplace been set up in a way to account for difficulties you have in doing certain activities?

1. Yes (go to WA_1a)

2. No (go to WA_1b)

3. Refuse

4. Don’t Know

WA_1a Would more modifications be needed?

1. Yes

2. No

3. Refuse

4. Don’t know

(Go to WA_2)

WA_1b Would you need any modification?

1. Yes

2. No

3. Refuse

4. Don’t know

WA_2 Is [your/his/her] work schedule arranged to account for difficulties you have in doing certain activities?

1. Yes (go to WA_2a)

2. No (go to WA_2b)

3. Refuse

4. Don’t Know

(Go to WA_3)

WA_2a Would you need any other arrangement of your work schedule?

1. Yes

2. No

3. Refuse

4. Don’t know

WA_2b Would you need your work schedule to be changed?

1. Yes

2. No

3. Refuse

4. Don’t know

WA_3 Are [your/his/her] work tasks arranged to account for difficulties you have in doing certain activities?

1. Yes (go to WA_3a)

2. No (go to WA_3b)

3. Refuse

4. Don’t Know

WA_3a Would you need any other arrangement of your tasks?

1. Yes

2. No

3. Refuse

4. Don’t know

WA_3b Would you need your tasks to be changed?

1. Yes

2. No

3. Refuse

4. Don’t know

SOCIAL PROTECTION

[For those with ‘a lot of difficulty’ and being employed]

SP_1 Do you receive any cash benefits from the government linked to your disability?

1. Yes

2. No (go to ATT_1)

3. Refused

4. Don’t know

SP_1a Do you know if the amount of the benefit will change if your salary increases?

1. Yes

2. No

3. Don’t know

4. Refuse

(For those with “a lot of difficulty” and unemployed or inactive)

SP_2 Do you receive any cash benefits from the government linked to your disability?

1. Yes

2. No (go to ATT_1)

3. Refused

4. Don’t know

SP_2a Will you keep the benefit if you find a paid job?

1. Yes

2. Yes, but the amount will decrease

3. No

4. Don’t know

5. Refuse

ATTITUDES [For all aged 18 to 65 years]

ATT_1 How willing are employers to hire people with disabilities?

1. Unwilling

2. Somewhat willing

3. Very willing

4. Refused

5. Don’t Know

ATT_2 How willing are people to work alongside people with disabilities?

1. Unwilling

2. Somewhat willing

3. Very willing

4. Refused

5. Don’t Know

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