0920-0222 Questions to be Cognitively Tested

[NCHS] Collaborating Center for Questionnaire Design and Evaluation Research

Attachment 1 Questions CD

CCQDER - Questions on Subjective Cognitive Decline

OMB: 0920-0222

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Attachment 1: Questions to be Cognitively Tested


Form Approved

OMB No. 0920-0222

Exp. Date: 01/31/2026


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Proposed Questions:

Five question module (2023 revision)

Intro1: The next few questions ask about difficulties in thinking or memory that can make a big difference in everyday activities. We want to know how these difficulties may have impacted you.

Q1. During the past 12 months, have you experienced difficulties with thinking or memory that are happening more often or are getting worse?

  1. Yes

  2. No [go to next module]

  3. Don’t know [go to next module]

  4. Refused [go to next module]





Q2. Are you worried about these difficulties with thinking or memory?

  1. Yes

  2. No

  3. Don’t know

  4. Refused





Q3. Have you or anyone else discussed your difficulties with thinking or memory with a health care provider?

  1. Yes

  2. No

  3. Don’t know

  4. Refused



Q4. During the past 12 months, have your difficulties with thinking or memory interfered with day-to-day activities, such as managing medications, paying bills, or keeping track of appointments?

  1. Yes

  2. No

  3. Don’t know

  4. Refused



Q5. During the past 12 months, have your difficulties with thinking or memory interfered with your ability to work or volunteer?

  1. Yes

  2. No

  3. Don’t know

  4. Refused





Additional questions


Q1. Over the past 12 months, how have your memory and thinking abilities compared with that of your peers (i.e., friends or acquaintances of a similar age)?

  1. Better than

  2. The same

  3. Worse than

  4. Don’t know

  5. Refused



Q2. During the past 12 months, have you become concerned about your memory loss and thinking?

1. Yes

2. No

3. Don’t know

4. Refused



Six question module (pre-2023)


Intro2: The next few questions ask about difficulties in thinking or remembering that can make a big difference in everyday activities. This does not refer to occasionally forgetting your keys or the name of someone you recently met, which is normal. This refers to confusion or memory loss that is happening more often or getting worse, such as forgetting how to do things you’ve always done or forgetting things that you would normally know. We want to know how these difficulties impact you.


1. During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse?

  1. Yes [Go to Q2]

  2. No [Go to next module]

  3. Don’t Know [Go to Q2]

  4. Refused [Go to next module]



2. During the past 12 months, as a result of confusion or memory loss, how often have you given up day-to-day household activities or chores you used to do, such as cooking, cleaning, taking medications, driving, or paying bills?

  1. Always

  2. Usually

  3. Sometimes

  4. Rarely

  5. Never

  6. Don’t Know

  7. Refused



3. As a result of confusion or memory loss, how often do you need assistance with these day-to-day activities?

  1. Always

  2. Usually

  3. Sometimes

  4. Rarely [Go to Q5]

  5. Never [Go to Q5]

  6. Don’t Know[Go to Q5]

  7. Refused [Go to Q5]



4. When you need help with these day-to-day activities, how often are you able to get the help that you need?

  1. Always

  2. Usually

  3. Sometimes

  4. Rarely

  5. Never

  6. Don’t Know

  7. Refused



5. During the past 12 months, how often has confusion or memory loss interfered with your ability to work, volunteer, or engage in social activities outside the home?

  1. Always

  2. Usually

  3. Sometimes

  4. Rarely

  5. Never

  6. Don’t Know

  7. Refused





6. Have you or anyone else discussed your confusion or memory loss with a health care professional?

    1. Yes

    2. No

    3. Don’t Know

    4. Refused


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMassey, Meredith (CDC/DDPHSS/NCHS/DRM)
File Modified0000-00-00
File Created2025-05-19

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