Validation Measure Questions

ATTACHMENT 4- Validation Measure Selected Questions from Legacy Instruments

Participation Measure for Post-Acute CARE (PM-PAC) Community Mobility Scale

1. Think about how you go places, using any help or means of transportation available. How much are you currently limited in getting around?

2. How much are you currently limited in . . .

2a. getting around your home?

2b. getting around offices, stores, or public buildings?

2c. getting around your neighborhood or town?

2d. traveling outside of your town?

3. During the past week, how much of the time . . .

3a. did your means of transportation allow you to travel whenever you wanted?

3b. did your means of transportation allow you to get to all the places you wanted to go?

4. During the past week, how many days did you go away from your home for at least part of the day?

Independent Living Skills Survey Subscales

Appearance and Clothing

(Yes/No/Not Apply)

In the last 30 days, did you

1 .* Wash your clothes by hand or machine using the proper amount of detergent?

2.* Dry your clothes in a dryer or on a clothes line?

3.* Fold, hang up, and store your clothes after they were washed and dried?

4.* Store your dirty clothes separate from your clean clothes?

5.* Change your underwear at least twice a week?

6.* Buy your own clothes the last time you needed some?

Personal Hygiene

In the last 30 days, did you

1 .* Bathe or shower using soap at least twice a week?

2.* Shampoo your hair at least twice a week (once a week for females)?

3.* Use deodorant daily?

4.* Brush or comb your hair daily?

5.* Brush your teeth (or dentures) using toothpaste at least once a day?

6. Regularly clean your nails?

VR PF-10 The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

	YES, LIMITED A LOT	YES, LIMITED A LITTLE	NO, NOT LIMITED AT ALL
a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports?			
b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?			
c. Lifting or carrying groceries?			
d. Climbing several flights of stairs?			
e. Climbing one flight of stairs?			
f. Bending, kneeling, or stooping?			
g. Walking more than a mile?			
h. Walking several blocks?			
i. Walking one block?			
j. Bathing or dressing yourself?			

La Trobe Communication Questionnaire

Question:

When talking to other do you:

1. Leave out important details?

2. Use a lot of vague or empty words such as 'you know what I mean' instead of the right word?

3. Go over and over the same ground in conversation?

4. Switch to a different topic of conversation too quickly?

5. Need a long time to think before answering the other person?

6. Find it hard to look at the other speaker?

7. Have difficulty thinking of the particular word you want?

8. Speak too slowly

9. Say or do things others might consider rude or embarrassing?

10. Hesitate, pause or repeat yourself?

11. Know when to talk and when to listen?

12. Get 'side-tracked' by irrelevant parts of the conversation?

13. Find it difficult to follow group conversations?

14. Need the other person to repeat what they have said before being able to answer?

15. Give people information that is not correct?

16. Make a few false starts before getting your message across?

17. Have trouble using your tone of voice to get the message across?

18. Have difficulty getting the conversation started?

19. Keep track of the main details of conversations?

20. Give answers that are not connected to the question?

21. Find it easy to change your speech style (e.g., tone of voice, choice of words) according to the situation you are in?

22. Speak too quickly?

23. Put ideas together in a logical way?

24. Allow people to assume wrong impressions from your conversations?

25. Carry on talking about things for too long in your conversations?

26. Have difficulty thinking of things to say to keep the conversation going?

27. Answer without taking time to think about what the other person has said?

28. Give information that is completely accurate?

29. Lose track of conversations in noisy places?

30. Have difficulty bringing the conversation to a close?

Never or Rarely (1) Sometimes (2) Often (3) Usually or always (4)

General Self-Efficacy Scale

Rating Scale

1 = Not at all true 2 = Hardly true 3 = Moderately true 4 = Exactly true

Items:

1. I can always manage to solve difficult problems if I try hard enough.

2. If someone opposes me, I can find the means and ways to get what I want.

3. It is easy for me to stick to my aims and accomplish my goals.

4. I am confident that I could deal efficiently with unexpected events.

5. Thanks to my resourcefulness, I know how to handle unforeseen situations.

6. I can solve most problems if I invest the necessary effort.

7. I can remain calm when facing difficulties because I can rely on my coping abilities.

8. When I am confronted with a problem, I can usually find several solutions.

9. If I am in trouble, I can usually think of a solution.

10. I can usually handle whatever comes my way.

Scoring:

Add up all responses to a sum score. The range is from 10 to 40 points.

BASIS 24 (20)

During the PAST WEEK, how much difficulty did you have…

1. Managing your day to day life?

2. Coping with Problems in your life?

3. Concentrating?

No difficulty, A little difficulty, Moderate difficulty, Quite a bit of difficulty, Extreme difficulty

During the PAST WEEK, how much of the time did you…

4. Get along with people in your family?

5. Get along with people outside your family?

6. 6. Get along well in social situations

7. Feel close to another person?

8. Feel like you had someone to turn to if you needed help?

9. Feel confident in yourself?

None of the time, A little of the time, Half of the time, Most of the time, All of the time

During the PAST WEEK, how much of the time did you….

10. Feel sad or depressed?

11. Think about ending your life?

12. Feel nervous?

None of the time, A little of the time, Half of the time, Most of the time, All of the time

During the PAST WEEK, how much of the time did you….

13. Have thoughts racing through your head?

14. Think you had special powers?

15. Hear voices or see things?

16. Think people were watching you?

17. Think people were against you?

Never, Rarely, Sometimes, Often, Always

During the PAST WEEK, how much of the time did you….

18. Have mood swings?

19. Feel short-tempered?

20. Think about hurting yourself?

Never, Rarely, Sometimes, Often, Always

Activity Measure for Post-Acute Care (AM-PAC) Applied Cognition short form

Getting to know new people

Managing your time to do most of your daily activities

Carrying on a conversation with a familiar person in a noisy environment (e.g., a large social group)

Remembering to take medications at the appropriate time

Following/understanding a 10- to 15-min speech or presentation (e.g., lesson at a place of worship, guest lecture at a senior center)

Remembering where things were placed or put away (e.g., keys)

Planning for and keeping appointments that are not part of your weekly routine (e.g., a therapy, doctor appointment, or a social gathering with friends and family)

Checking the accuracy of financial documents, (e.g., bills, checkbook or bank statements)

Reading and following complex instructions (e.g., directions to operate a new appliance or for a new medication)

Following a recipe to make a new dish (e.g., a new pie or soup recipe)

Using a local street map to locate a new store or doctor’s office

Reading a long book (more than 100 pages) over a number of days

Filling out a long form (e.g., insurance forms or an application for services)

Doing calculations in your head while shopping (e.g., 30% off, etc.)

Remembering a list of 4 or 5 errands without writing it down