Form 9 Normative Survey 1

Consent & Complete Item Bank for

D

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.

aily Activities & Learning and Applying Knowledge FAB (Survey 1-Normative)

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.

Initial Demographic Questions

Item	Response options
Age
Gender	Male Female Refuse
Are you of Hispanic or Latino Origin:	Yes No Refuse
Race	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Unknown Refuse
What is your current relationship status:	Never married Married Living with a partner in a committed relationship Separated Divorced Widowed Refused
Education	Less than high school diploma High school diploma (or a GED) Associate's degree Vocational Training Some college – no degree College or more Refused
Zip code
What is your primary means of communication	Verbal Written/pictorial Sign/fingerspell Gesture/body movements Communication board Computer/electronic
What is your primary means of written work	Writing by hand Dictation Computer Braille writer other (specify)
Do you use any of the following?	Communication board Communication book Mouth stick Headwand Choice/scanning program Hearing aides Magnifier Eyeglasses (including specialized lenses) Reading machine/device Microphone/voice amplifier Interpreter Braille Memory Book Recorder Calendars and/or planner To-do lists Electronic device (palm pilot, Smartphone, paging system, etc.) Other (specify)

Health-Work Status questions

Item	Response options
In general, compared to other people of your age, would you say that your health is excellent, very good, good, fair, or poor?	Excellent Very good Good Fair Poor Refused Don’t know
In general, would you say your mental health is excellent, very good, good, fair, or poor?	Excellent Very good Good Fair Poor Refused Don’t know
How long has it been since you worked at a full time job for pay? (Full time means 30 hours or more per week.)	Less than 6 months Between 6 months and 1 year Between 1 year and 18 months Longer than 18 months Never have worked for pay
How long has it been since you worked at a part time job for pay? ( Part time means less than 30 hours per week.)	Less than 6 months Between 6 months and 1 year Between 1 year and 18 months Longer than 18 months Does not apply
How long has it been since you worked at a temporary job (seasonal or short term) or did odd jobs for pay?	Less than 6 months Between 6 months and 1 year Between 1 year and 18 months Longer than 18 months Does not apply
NORMATIVE SAMPLE QUESTIONS ONLY
Have you ever held a job or worked at a business?	Yes No Don't know Refuse
What kind of business or industry was this?	• Accounting / Finance / Insurance • Administrative / Clerical • Banking / Real Estate / Mortgage Professionals • Biotech / R&D / Science • Building Construction / Skilled Trades • Business / Strategic Management • Creative / Design • Customer Support / Client Care • Editorial / Writing • Education / Training • Engineering • Food Services / Hospitality • Human Resources • IT / Software Development • Installation / Maintenance / Repair • Legal • Logistics / Transportation • Manufacturing / Production / Operations • Marketing / Product • Medical / Health • Project / Program Management • Quality Assurance / Safety • Sales / Retail / Business Development • Security / Protective Service • Other (please specify
Please indicate what kind of work you were doing? (For example: farming, mail clerk, computer specialist.)	free text
Briefly specify what were your most important activities on this job or business? (For example: sells cars, keeps account books, operates printing press.)	free text

Self-Administer Comorbidity

Instructions: The following is a list of common problems. Please indicate if you currently have the problem in the first column, If you do not have the problem, skip to the next problem. If you do have the problem, please indicate in the second column if you receive medications or some other type of treatment for the problem. In the third column indicate if the problem limits any of your activities. Finally, indicate all medical conditions that are not listed under "other medical problems" at the end of the page.	Do you have the problem?		Do you receive treatment for it?		Does it limit your activities?
	No (0)	Yes ---> (1)	No (0)	Yes (1)	No (0)	Yes (1)
Problem
Heart Disease
High blood pressure
Lung disease
Diabetes
Ulcer of stomach disease
Kidney disease
Liver disease
Anemia or other blood disease
Cancer
Depression
Osteoarthritis, degenerative arthritis
Back pain
Rheumatoid arthritis
Other medical problems (please write in)

Self Care

Primary Domain	Subdomain	Item Stem	Item Content	Item Response Scale
self-care	dressing	Are you able	to get dressed in the morning?	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
self-care	dressing	Are you able	to get dressed to go to an appointment? For example a doctor's visit.	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
self-care	dressing	Please specify your level of agreement:	It takes me a long time to get dressed to go to an appointment. For example a doctor's visit.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
self-care	dressing	Please specify your level of agreement:	It takes me a long time to get dressed in the morning.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
self-care	eating	Are you able	to eat meals at home?	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
self-care	eating	Are you able	to eat meals outside of the home? For example at restaurant or friend's house.	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
self-care	eating	Please specify your level of agreement:	I have trouble eating meals in a short amount of time. For example during a lunch break.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
self-care	toileting	Are you able	to use the toilet at home? This includes wiping yourself, getting on and off the toilet and putting clothes back on.	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
self-care	toileting	Are you able	to use a toilet in a public bathroom? This includes wiping yourself, getting on and off the toilet and putting clothes back on.	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
self-care	toileting	Please specify your level of agreement:	It takes me a long time to use the toilet in a public bathroom. This includes wiping yourself, getting on and off the toilet and putting clothes back on.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
self-care	bathing	Are you able	to take a shower or bath?	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
self-care	bathing	Please specify your level of agreement:	It takes me a long time to take a shower or bath.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
self-care	grooming/ hygiene	Are you able	to get cleaned up in the morning? For example brushing teeth and combing 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
self-care	hygiene/ grooming	Please specify your level of agreement:	It takes me a long time to get cleaned up in the morning. For example brushing teeth and combing hair.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know

Domestic

Primary Domain	Subdomain	Item Stem	Item Content	Item Response Scale
domestic	shopping	Are you able	to do your grocery shopping?	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
domestic	shopping	Please specify your level of agreement:	Grocery shopping takes me longer than I think it should.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
domestic	shopping	Are you able	to run errands? For example going to the bank or drugstore.	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
domestic	shopping	Please specify your level of agreement:	It takes me a long time to run errands. For example going to the bank or drugstore.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
domestic	housework	Are you able	to do heavy housework? For example scrubbing floors, washing windows, moving furniture 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
domestic	housework	Please specify your level of agreement:	It takes me a long time to do heavy housework. For example scrubbing floors, washing windows and moving furniture to clean.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
domestic	housework	Are you able	to do light housework? For example dusting or sweeping.	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
domestic	housework	Please specify your level of agreement:	It takes me a long time to do light housework. For example dusting or sweeping.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
domestic	preparing meals	Are you able	to prepare light meals? For example make a sandwich.	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
domestic	preparing meals	Please specify your level of agreement:	It takes me a long time to prepare light meals. For example make a sandwich.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
domestic	preparing meals	Are you able	to prepare a meal for several people?	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
domestic	preparing meals	Please specify your level of agreement:	It takes me a long time to prepare a meal for several people.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
domestic	health maintenance	Are you able	to take your medications correctly?	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
domestic	health maintenance	Are you able	to follow your doctor's orders or instructions?	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
domestic	health maintenance	Are you able	to keep your medical appointments?	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

Social Appropriateness

Primary Domain	Subdomain	Item Stem	Item Content	Item Response Scale
Social Appropriateness	attire	Please specify your level of agreement:	I often feel over or under dressed.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social appropriateness	attire	Please specify your level of agreement:	People have told me I need to dress better.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Appropriateness	hygiene	Please specify your level of agreement:	I have trouble taking a shower or bath often enough.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Appropriateness	hygiene	Please specify your level of agreement:	People have told me I need to take a shower or bath more often.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Appropriateness	grooming	Please specify your level of agreement:	I have trouble getting cleaned up often enough. For example brushing teeth and combing hair.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Appropriateness	grooming	Please specify your level of agreement:	People have told me that I need to do a better job getting cleaned up. For example brushing teeth and combing hair.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Appropriateness	grooming	Please specify your level of agreement:	I have trouble keeping my hair clean and neat.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Appropriateness	monitoring appearance	Please specify your level of agreement:	I make sure I change my clothes regularly.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Appropriateness	monitoring appearance	Please specify your level of agreement:	I make sure I look clean and neat.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know

Transportation

Primary Domain	Subdomain	Item Stem	Item Content	Item Response Scale
Do you currently drive a car?		Yes (go to DA051-DA067)   No
Do you currently use a bus, train or subway to get around?		Yes (go to DA051, DA052, DA068-DA074)   No
transportation	global	Are you able to get where you need to go each day?		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
transportation	global	Are you able to get a ride to where you need to go?		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
transportation	driving	Please specify your level of agreement:	I can drive to a local store and back home on my own.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
transportation	driving	Are you able	to drive in the rain?	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
transportation	driving	Are you able	to drive at night?	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
transportation	driving	Are you able	to drive in heavy traffic?	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
transportation	driving	Are you able to	to park your car in a parking lot?	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
transportation	driving	Are you able	to stay within your lane while driving?	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
transportation	driving	Please specify your level of agreement:	I am only comfortable driving short distances.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
transportation	driving	Please specify your level of agreement:	I am limited in driving long distances.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
transportation	driving	Are you able	to merge onto a busy road?	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
transportation	driving	Are you able	to drive in your own neighborhood?	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
transportation	driving	Are you able	to back out of a driveway?	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
transportation	public	Please specify your level of agreement:	I can usually get to the bus or train station on time.	Yes, without difficulty   Yes, with a litte difficulty   Yes, with some difficulty   Yes, with a lot of difficulty  Unable to do  I don't know
transportation	public	Please specify your level of agreement:	I have trouble using tickets, cash or a fare card to get on a bus or train.	Yes, without difficulty   Yes, with a litte difficulty   Yes, with some difficulty   Yes, with a lot of difficulty  Unable to do  I don't know
transportation	public	Are you able	to use a bus or train schedule to get to familiar places?	Yes, without difficulty   Yes, with a litte difficulty   Yes, with some difficulty   Yes, with a lot of difficulty  Unable to do  I don't know
transportation	public	Are you able	to use a bus or train schedule to get to unfamiliar places?	Yes, without difficulty   Yes, with a litte difficulty   Yes, with some difficulty   Yes, with a lot of difficulty  Unable to do  I don't know
transportation	public	Are you able	to get on the right bus or train?	Yes, without difficulty   Yes, with a litte difficulty   Yes, with some difficulty   Yes, with a lot of difficulty  Unable to do  I don't know
transportation	public	Are you able	to get on to a bus or train?	Yes, without difficulty   Yes, with a litte difficulty   Yes, with some difficulty   Yes, with a lot of difficulty  Unable to do  I don't know
transportation	public	Are you able	to get off the bus or train before the doors close?	Yes, without difficulty   Yes, with a litte difficulty   Yes, with some difficulty   Yes, with a lot of difficulty  Unable to do  I don't know

Social Language

Primary Domain	Subdomain	Item Stem	Item Content	Item Response Scale
Social Language	Conversation skills	Are you able	to discuss your ideas with others?	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
Social Language	Conversation skills	Please specify your level of agreement:	I can keep up a conversation.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Language	Conversation skills	Please specify your level of agreement:	People tell me I stand too close when I am talking to them.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Language	Conversation skills	Please specify your level of agreement:	I show interest when other people are talking to me.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Language	Conversation skills	Are you able	to get your point across when talking with someone?	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
Social Language	Conversation skills	Are you able	to have a conversation with family and friends?	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
Social Language	Conversation skills	Please specify your level of agreement:	I nod and smile to make people comfortable talking to me.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Language	Conversation skills	Are you able	to wait your turn to speak?	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
Social Language	Conversation skills	Are you able	to make small talk?	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
Social Language	Figurative language	Are you able	to figure out why a joke is funny?	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
Social Language	Figurative language	Are you able	to use body language and facial expressions when talking to people?	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
Social Language	Understanding others perspective	Please specify your level of agreement:	I can relate to other people's feelings.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Language	Understanding others perspective	Please specify your level of agreement:	I say "I am sorry" when I make a mistake.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Language	Understanding others perspective	Please specify your level of agreement:	I can tell when people are upset at me.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Language	Understanding others perspective	Please specify your level of agreement:	I can see both sides of an argument.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Language	Understanding others perspective	Please specify your level of agreement:	When there is a problem I am able to work things out with other people.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Social Language	Understanding others perspective	Please specify your level of agreement:	I can tell when people don't feel like talking to me.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know

Communication

Primary Domain	Subdomain	Item Stem	Item Content	Item Response Scale
Communication	Comprehending messages: hearing impairment	Please specify your level of agreement:	I can follow what is being said when a group of people are talking.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Communication	Comprehending messages: hearing impairment	Please specify your level of agreement:	I can follow what is being said when talking with someone I don't know.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Communication	Comprehending messages: hearing impairment	Please specify your level of agreement:	I can follow what is being said when talking with family and friends.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Communication	Comprehending messages:	Please specify your level of agreement:	I can understand simple instructions.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Communication	Comprehending messages: nonverbal	Are you able	to understand body language and facial expressions when talking to people?	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
Communication	Comprehending messages: verbal	Are you able	to understand what you hear on 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
Communication	Comprehending messages: verbal	Are you able	to understand people on the 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
Communication	Comprehending messages: verbal	Are you able	to understand people in noisy places?	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
Communication	Fluency	Please specify your level of agreement:	People can understand me when I talk.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Communication	Fluency	Are you able	to speak clearly?	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
Communication	Fluency	Please specify your level of agreement:	I have to talk very slowly to make myself understood.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Communication	Producing verbal messages	Are you able	to get information you need when talking with people?	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
Communication	Producing verbal messages	Are you able	to get your point across when speaking with other people?	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
Communication	Producing verbal messages	Please specify your level of agreement:	I have trouble finding the right word when talking with people.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Communication	Producing verbal messages	Please specify your level of agreement:	I am uncomfortable talking in a group.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Communication	Producing verbal messages	Are you able	to organize what you want to say?	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
Communication	Producing verbal messages	Are you able	to give directions to another person?	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
Communication	Producing verbal messages	Are you able	to get your point across when you are upset?	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
Communication	Producing verbal messages	Are you able	to tell a doctor about a health problem?	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
Communication	Producing verbal messages	Are you able	to tell others your needs? For example when you're tired and need to rest.	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
Communication	Using communication device	Are you able	to make an appointment over the phone? For example a haircut or dentist.	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
Communication	Using communication device	Are you able	to use a computer to get in touch with someone?	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
Communication	Using communication device	Are you able	to use a computer to get information you need?	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
Communication	Using communication device	Are you able	to hear people over the 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
Communication	Using communication device	Are you able	to talk to people over the 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
Communication	Using communication device	Are you able	to write reminder notes to yourself?	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
Communication	Writing	Are you able	to write a short email to someone?	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
Communication	Writing	Please specify your level of agreement:	I often make mistakes when writing down numbers. For example a phone number, checkbook entry.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Communication	Writing	Please specify your level of agreement:	I often misspell words.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Communication	Writing	Are you able	to fill out applications?	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
Communication	Writing	Are you able	to write your signature?	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

Cognition

Primary Domain	Subdomain	Item Stem	Item Content	Item Response Scale
Cognition	Carrying out tasks: completion	Are you able	to finish things that you start?	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
Cognition	Carrying out tasks: completion	Are you able	to finish things within a reasonable amount of time?	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
Cognition	Carrying out tasks: initiation	Please specify your level of agreement:	When I have something hard to do, I have trouble getting started.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Carrying out tasks: initiation	Please specify your level of agreement:	When I have something easy to do, I have trouble getting started.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Carrying out tasks: multitask	Please specify your level of agreement:	I am able to do many things at once.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Carrying out tasks: multitask	Are you able	to follow instructions given over the 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
Cognition	Concept formation	Are you able	to think quickly?	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
Cognition	Concept formation	Please specify your level of agreement:	I am able to think clearly	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Concept formation	Please specify your level of agreement:	I have trouble putting my thoughts together	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Acquiring skills	Are you able	to learn to do new 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
Cognition	Adapting	Please specify your level of agreement:	If I can't do something one way, I will find another way to do it.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Adapting	Are you able	to do two things at once?	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
Cognition	Adapting	Are you able	adjust to a new situation or change?	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
Cognition	Attention to detail	Please specify your level of agreement:	I am able to do my work carefully.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Attention to detail	Please specify your level of agreement:	People often tell me I make mistakes in my work.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Attention to detail	Please specify your level of agreement:	I notice my mistakes when they happen.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Attention to detail	Are you able	to check that your bills are correct?	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
Cognition	Attention to detail	Please specify your level of agreement:	I have to work really hard to focus so I don't make a mistake.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Calculating	Are you able	figure out the correct price for something that is on sale? For example 25% 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
Cognition	Calculating	Please specify your level of agreement:	I am able to add and subtract numbers in my head.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Focusing attention	Please specify your level of agreement:	I am easily confused when in a busy or noisy environment.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Focusing attention	Please specify your level of agreement:	I am easily distracted in a busy or noisy environment	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Focusing attention	Please specify your level of agreement:	I have trouble keeping my mind on what I am doing.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Focusing attention	Are you able	to pay attention when someone is talking to you for a long time?	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
Cognition	Focusing attention	Are you able	to pay attention when someone is talking to you for a short time?	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
Cognition	Focusing attention	Are you able	to pay attention for a long period of time?	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
Cognition	Handling responsibilities	Please specify your level of agreement:	I am good at following through with plans I make.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Handling responsibilities	Are you able	to work hard on tasks you don't like?	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
Cognition	Handling responsibilities	Are you able	to use bank cards and automatic teller machines (ATMs)?	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
Cognition	Handling responsibilities	Are you able	to keep track of what you need to do each day?	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
Cognition	Handling responsibilities	Are you able	to do your regular chores?	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
Cognition	Making decisions	Are you able	to make everyday decisions? For example what to wear, what to eat or what time 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
Cognition	Making decisions	Please specify your level of agreement:	I am able to make important decisions in my life.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Making decisions	Are you able	to think things through before making a decision?	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
Cognition	Memory	Are you able	to remember important numbers? For example a phone number.	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
Cognition	Memory	Please specify your level of agreement:	I often have trouble keeping track of time.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Memory	Are you able	to remember things for a short time?	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
Cognition	Memory	Are you able	to remember the name of people you know when you see them?	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
Cognition	Memory	Are you able	to recall information that you have always known?	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
Cognition	Memory	Are you able	remember something you read or heard earlier in the day?	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
Cognition	Memory	Please specify your level of agreement:	I have trouble remembering important events. For example birthdays.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Memory	Are you able	remember a list of 4 or 5 errands without writing it down?	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
Cognition	Memory	Please specify your level of agreement:	I often forget where I put things. For example like your keys or wallet.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Memory	Please specify your level of agreement:	I often forget whether or not I did important things, like take medications.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Orientation	Are you able	to keep track of the day of the week?	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
Cognition	Orientation	Are you able	to find your way around in unfamiliar places?	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
Cognition	Orientation	Are you able	to find your way around in familiar places?	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
Cognition	Planning/organizing	Are you able	to manage your time each day?	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
Cognition	Planning/organizing	Please specify your level of agreement:	I am able to plan ahead for things that I want to do.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Planning/organizing	Are you able	to stay organized?	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
Cognition	Planning/organizing	Are you able	to keep important papers organized? For example bills, insurance documents and tax forms.	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
Cognition	Planning/organizing	Are you able	to get to places on time?	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
Cognition	Problem Solving	Please specify your level of agreement:	I am able to correct my mistakes when they happen.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Problem Solving	Please specify your level of agreement:	I am able to solve problems on my own.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Problem Solving	Are you able	to ask for help from others when difficult problems come 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
Cognition	Reading	Are you able	to understand written instructions?	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
Cognition	Reading	Please specify your level of agreement:	I have to read something several times to understand it.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Safety	Please specify your level of agreement:	Others have told me that I do things that put me at risk.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Safety	Please specify your level of agreement:	I recognize danger when I see it.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Safety	Please specify your level of agreement:	I know what to do in case of an emergency.	Strongly agree   Agree   Disagree   Strongly disagree   I don't know
Cognition	Safety	Are you able	to follow public signs? For example Stop, Do Not Enter, Exit.	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
Cognition	Safety	Are you able	to keep yourself safe at home?	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

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