Form 10 Normative Survey 2

Consent & Replenishment Item Bank &

Short Form Version of

Physical Function & Behavioral Health FAB (Survey 2-Normative)

OMB No.: 0925-XXXX

Expiration Date: XX/XX/2017

Public reporting burden for this collection of information is estimated to be 45 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 aspects 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-XXXX). Do not return the completed form to this address.

This screenshot would be the format the respondent would see 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.

Every individual will indicate consent before beginning the survey. This is one contact and burden is calculated for both the consent and the survey to total 60 minutes.

Normative Sample IRB-Approved Consent

Background

Boston University Health and Disability Research Institute and YouGov are doing a research study. This study will test a series of questions that ask about your health and functioning.

Purpose

The purpose of this study is to ask you about your health and functioning across several different areas.

What Happens In This Research Study

You will be one of approximately 2,000 subjects to be asked to participate in this study.

This research study will be conducted by YouGov on behalf of Boston University Health and Disability Research Institute.

As a study participant you will be asked to answer questions about your functioning in daily life. You will be asked to complete the survey on your own using the internet. You will be asked to complete two surveys about 10 days apart. The first survey should take about 40 minutes of your time and the second should take about 30 minutes. The information we collect is for research purposes only.

Risks and Discomforts

We expect that your participation will not cause you any discomfort. There may be unknown risks/discomforts involved. Study staff will update you in a timely way on any new information that may affect your health, welfare, or decision to stay in this study. There may be the potential for a small loss of confidentiality of the information you provide as part of this study; however, all measures possible will be taken to prevent this loss. Your name will not be used in any research publications and the information you provide will only be linked to you by a study identification number.

Potential Benefits

You will receive no direct benefit from your participation in this study. However, your participation may help the investigators improve upon the questions they are asking about daily life functioning of adults.

Alternatives

Your alternative is to not participate in the study.

Subject Costs and Payments

There are no costs to you for participating in this research study. As part of the YouGov panel you will be given 1000 points to complete the first survey and 2000 points to complete the second.

Confidentiality

Information from this study may be reviewed by the Office of Human Research Protection as and the Institutional Review Board of Boston University Medical Center. Information from this study be used for research purposes and may be published; however, your name will not be used in any publications.

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Subject's Rights

By consenting to participate in this study you do not waive any of your legal rights. Giving consent means that you have heard or read the information about this study and that you agree to participate. You will be given a copy of this form to keep.

If at any time you withdraw from this study you will not suffer any penalty or lose any benefits to which you are entitled.

You may obtain further information about your rights as a research subject by calling the Office of the Institutional Review Board of Boston University Medical Center at 617-638-7207. If this study is being done outside the United States, you can ask the investigator for contact information for the local Ethics Board.

The investigator or a member of the research team will try to answer all of your questions. If you have questions or concerns at any time, contact Kara Bogusz at 617-638-1995.

Right to Refuse or Withdraw

Taking part in this study is voluntary. You have the right to refuse to take part in this study. If you decide to be in the study and then change your mind, you can withdraw from the research. Your participation is completely up to you. Your decision will not affect your being able to get health care at this institution or payment for your health care. It will not affect your enrollment in any health plan or benefits you can get.

If you choose to take part, you have the right to stop at any time. If there are any new findings during the study that may affect whether you want to continue to take part, you will be told about them as soon as possible.

The investigator may decide to discontinue your participation without your permission because he/she may decide that staying in the study will be bad for you, or the sponsor may stop the study.

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

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