0920-0222 Questions to be Cognitively Tested

Attachment 1: Questions to be Cognitively Tested

Form Approved

OMB No. 0920-0222

Exp. Date: 01/31/2026

Notice - CDC estimates the average public reporting burden for this collection of information as 55 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).

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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