Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Date. Enter the numbers representing today's date (the date of the activity or service) in these boxes. Enter the month as a number from 01 to 12 corresponding to January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "96" for 1996). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure that each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Client Gender. Darken the circle next to the response that indicates the person's gender.

How will this questionnaire be completed? We strongly recommend doing this as an interview where the questions are read to the client. However, the questionnaire could be completed by the client with or without guidance. If the client is to fill out the questionnaire him/herself, darken the circle next to "Self-Administered"; if you will help the client fill out the questionnaire, darken the circle next to "Self-Administered with help"; if you will fill out the questionnaire for the client in person, darken the circle next to "Face-to-face interview," and if you will fill out the questionnaire for the client during a phone interview with him/her, darken the circle next to "Phone interview."

Questions to be Asked of the Respondent Begin Here

1. In general, would you say your health is: Fill in the circle next to the client’s assessment of his/her health. Choose only one answer to this question.
2. How would you rate your overall health? On the provided scale of 0 to 10 (0 corresponding to the worst possible health, 5 to the midpoint, and 10 to the best possible health), darken the circle next to the number that best describes the person’s overall health. Choose only one answer to this question.
3. During the past 4 weeks, has your health kept you from working at a job, doing work around the house, or going to school? Darken the circle next to the response that best describes how much the person’s health has kept him/her from doing activities related to work, home, or school during the past 4 weeks. Choose only one answer to this question.
4. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors or groups? Darken the circle next to the response that best describes how much the person’s physical health or emotional problems has kept him/her from engaging in his/her normal social activities in the past 4 weeks. Choose only one answer to this question.
5. During the past 4 weeks, have you been unable to do certain kinds or amounts of work, housework, or schoolwork because of your health? Darken the circle next to the response that best describes how much of the time the person’s health has affected the types or amounts of work that he/she could do over the past 4 weeks. Choose only one answer to this question.
6. During the past 4 weeks, how much did bodily pain interfere with normal work (including work outside the house and housework)? Darken the circle next to the response that best describes how much bodily pain as experienced by the person kept him/her from engaging in his/her normal work, including work inside and outside the house, in the past 4 weeks. Choose only one answer to this question.
7. Please indicate the extent to which the following statements are true or false for you: Item 7 contains two parts, "A" and "B." For each part, darken the circle next to "Definitely True" if the statement is true all of the time, "Mostly True" if the statement is true most of the time, "Not Sure" if the respondent does not know or is unsure, "Mostly False" if the statement is false most of the time, or "Definitely False" if the statement is false all of the time.

7-A. My health is excellent. Darken the circle next to the response that best describes how true this statement is as applied to the person. Choose only one answer to this question.

7-B. I have been feeling bad lately. Darken the circle next to the response that best describes how true this statement is as applied to the person. Choose only one answer to this question.

 

8. How much, if at all, does your health limit you in each of the following activities? How much does your health limit: Item 8 contains four parts, "A," "B," "C," and "D." For each part, respond by darkening the circle next to "Limited a Lot" if the person’s health seriously limits the activity, "Limited a Little" if it slightly limits the activity, or "Not Limited at All" if the person’s health does not limit the activity at all.

 

8-A. The kinds or amounts of vigorous activities you can do, like lifting heavy objects, running, or participating in strenuous sports? Based on the instructions for Item 8 above darken the circle next to the response that best describes how limited the person feels in doing this type of activity. Choose only one answer to this question.

 

8-B. The kinds or amounts of moderate activities you can do, like moving a table or carrying groceries? Based on the instructions for Item 8 above darken the circle next to the response that best describes how limited the person feels in doing this type of activity. Choose only one answer to this question.

 

8-C. Walking uphill or climbing a few flights of stairs? Based on the instructions for Item 8 above darken the circle next to the response that best describes how limited the person feels in doing this type of activity. Choose only one answer to this question.

 

8-D. Eating, dressing, bathing, or using the toilet? Based on the instructions for Item 8 above darken the circle next to the response that best describes how limited the person feels in doing this type of activity. Choose only one answer to this question.

 

9. For each of the following questions, please darken the circle next to the answer that comes closest to the way you have been feeling during the past 4 weeks.

How much of the time during the past 4 weeks: Item 9 contains nine parts, identified as "9-A" through "9-I." ‘For each of these parts, show the respondent CARD 17a, and have him/her indicate the extent of time to which he/she experienced the characteristic mentioned.

 

9-A. Has your physical health or emotional problems limited your social activities (like visiting with friends or close relatives)? Darken the circle next to the response that best describes the extent to which physical or emotional problems limited the person’s social activities, such as visiting with friends or close relatives in the past 4 weeks. Choose only one answer to this question.

 

9-B. Did you have trouble keeping your attention on an activity for long? Darken the circle next to the response that best describes how much trouble the person experienced in the past 4 weeks in keeping his/her attention on an activity for a sustained period of time. Choose only one answer to this question.

 

9-C. Did you have difficulty reasoning and solving problems? Darken the circle next to the response that best describes how much difficulty the person experienced in the past 4 weeks in thinking through and solving problems. Choose only one answer to this question.

 

9-D. Have you felt calm and peaceful? Darken the circle next to the response that best describes how often the person felt calm and peaceful in the past 4 weeks. Choose only one answer to this question.

 

9-E. Have you felt downhearted and blue? Darken the circle next to the response that best describes how often the person felt sad, downhearted, blue, or depressed in the past 4 weeks. Choose only one answer to this question.

 

9-F. Did you feel tired? Darken the circle next to the response that best describes how often the person felt tired in the past 4 weeks. Choose only one answer to this question.

 

9-G. Did you have enough energy to do the things you wanted to do? Darken the circle next to the response that best describes how often the person has had enough energy (physical, emotional, and/or mental) to do the things he/she wanted to do in the past 4 weeks. Choose only one answer to this question.

 

9-H. Have you been happy? Darken the circle next to the response that best describes how often the person felt happy in the past 4 weeks. Choose only one answer to this question.

 

9-I. Did you forget things that have happened? Darken the circle next to the response that best describes how often, in the past 4 weeks, the person forgot things that have happened either in the immediate present or from the past. Choose only one answer to this question.

 

10. How much bodily pain have you had during the past 4 weeks? Darken the circle next to the response that best describes how much bodily or physical pain the person has experienced in the past 4 weeks. Choose only one answer to this question.

 

Specific Parts of Module 17 (Page 2): Brief Health and Functioning Questionnaire

Please note that Module 17 is two pages long. Before beginning Page 2 of Module 17, Page 1 should be completed.

Some information that is requested on Page 1 of Module 17 is requested also on Page 2. The following information, designated here in these instructions by a vertical line on the left, must be included on both pages so that the responses given on Pages 1 and 2 of this module can be matched.

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. If it has not been already entered on the form, look up your code in the table below. Site codes are 3 letters.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Date. Enter the numbers representing today's date (the date of the activity or service) in these boxes. Enter the month as a number from 01 to 12 corresponding to January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "96" for 1996). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure than each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Client Gender. Darken the circle next to the response that indicates the person's gender.

Resume Asking Questions of the Respondent Here

11. How many days during the past 4 weeks did your own illness, treatment or a personal problem (like feeling depressed) cause you to do any of the following things? Item 11 contains 3 parts, "A," "B," and "C." For each part, indicate the extent of time in the past 4 weeks (28 days) that the respondent did or did not do the activity mentioned. By marking the first alternative, it is indicated that the respondent DID NOT do the activity mentioned. The remaining alternatives indicate the number of days (from 1 to 28) that the respondent DID do the activity mentioned.

 

11-A. Cut down on your usual activities (such as housework, school, leisure) for 1/2 day or more? Darken the circle next to the response that best describes how many days, in the past 4 weeks, the person has had to cut down his/her usual activities for a 1/2 day or more due to illness, treatment, or a personal problem like feeling depressed. Choose only one answer to this question.

 

11-B. Stay in bed for a half day or more? Darken the circle next to the response that best describes how many days, in the past 4 weeks, the person has had to stay in bed for a half day or more due to illness, treatment, or a personal problem like feeling depressed. Choose only one answer to this question.

 

11-C. Miss work for a half day or more? Darken the circle next to the response that best describes how many days, in the past 4 weeks, the person has had to miss work for a half day or more due to illness, treatment, or a personal problem like feeling depressed. Choose only one answer to this question.

 

12. Last week, were you: Item 12 identifies the respondents work status over the previous week. This item contains eight options, however, choose only ONE answer to this question. If more than one answer seems to be applicable, select the one that indicates the highest degree of work activity. For example, if the respondent was a student and working part time, darken the bubble corresponding to "Working part time." If the respondent was keeping house as well as working full time, darken the bubble corresponding to "Working full time." If the respondent was working full time and then was laid off, choose "Working full time."

Working full time. Fill in the circle next to "Working full time" if the person was working 35 hours or more last week.

Working part time. Fill in the circle next to "Working part time" if the person was working less than 35 hours last week.

With a job, but not at work because of illness, vacation, or strike. Fill in the circle next to this statement if the person has a job, but did not work at all last week due to illness, vacation, or strike.

Unemployed, laid off, or looking for work. Fill in the circle next to this statement if the person was unemployed, laid off, or looking for work last week.

Retired, disabled, or no longer working. Fill in the circle next to this statement if the person was has retired, was disabled, or was no longer working last week.

In school. Fill in the circle next to this statement if the person was in school last week.

Keeping house. Fill in the circle next to this statement if the person was a homemaker last week.

None of the above. Fill in the circle next to this statement if none of the above descriptions apply.

 

13. How many hours did you work last week, at all jobs? Darken the circle that indicates the number of hours that the respondent worked at all of his/her jobs in total. Most responses are listed in terms of a range of hours. If the respondent identifies a number that falls between two alternatives, round the response to the nearest whole number. For example, if the respondent notes that he/she worked 20.5 hours, round this to 21 and darken the bubble corresponding to the alternative 21-35 hours; if he/she worked 45.25, round this to 45 and darken the bubble corresponding to the alternative 36-45 hours. If his/her response is "More than 60 hours", darken the bubble corresponding to "More than 60 hours," and write the exact number of hours in the boxes located next to "How Many?." If the exact number of hours is less than three digits, place 0s before the number. For example, if the person worked 61 hours, fill in 061, if they worked 80 hours, fill in 080, if they worked 101 hours, fill in 101. Choose only one answer to this question.

 

14. Approximately what was your own personal income from all sources before taxes last month? Darken the circle that indicates the range of how much income, in total, the person received last month. Most responses are listed in terms of a range of dollars. If the respondent identifies an amount that falls between two alternatives, round the response to the nearest whole dollar. If the respondent replies that he/she made more than $4,001.00, in the boxes next to "How Much?", write the exact amount of income. For example if the exact amount of income was $4,100.50, you would write in 04101 (this incorporates rounding to the nearest whole dollar), if it was $10,000, you would write 10000, if it was $5,525.40, you would 05525. Do not write in decimal points or commas in the boxes. Choose only one answer to this question.

 

15. In the past 4 weeks, how many visits have you made to doctors, nurses, or other health professionals you saw at a private office, a clinic, or hospital emergency room? Darken the circle that indicates the number of times in the past 4 weeks the person visited doctors, nurses, or other health professionals at a private office, a clinic, or hospital emergency room. Choose only one answer to this question.

 

16. During the past 4 weeks, how many visits have you had from a doctor, nurse, or other paid health professional who came to your home or where you live now? Darken the circle that indicates the number of times in the past 4 weeks the person was visited by doctors, nurses, or other health professionals who came to the person’s home or to where he/she currently lives (e.g., how many "house calls" the person received). Note that this item identifies visits made NOT ONLY by doctors, but ANY paid health professional. Choose only one answer to this question.

 

17. During the past 4 weeks, how many telephone contacts have you had with a doctor, nurse, or other health professional about your own health care? Do not count contacts that were only for making or changing appointments. Darken the circle that indicates the number of phone contacts the person made in the past 4 weeks to doctors, nurses, or other health professionals about the person’s health care. Do not include contacts that were made solely for making, changing, or canceling appointments. Choose only one answer to this question.

 

18. In the past 4 weeks, how many nights did you stay overnight or longer in a hospital? Darken the circle that indicates the number of nights in total the person stayed in a hospital in the past 4 weeks. Note that what is being counted here are actual nights. If the person was discharged during the day, the day that he/she was discharged does not count in the total. Choose only one answer to this question.

 

19. Item 19 is set up as a grid. Item 19 consists of 13 parts identified as "19-a" through "19-m." The point of this item is to assess the extent to which the respondent experienced a number of predominantly physical symptoms. Each of the 13 parts itself consists of two sections corresponding to columns in the grid. The first establishes whether or not the respondent had any of the symptoms in question: Have you had any of the following symptoms in the past 4 weeks? If the respondent did not have any of the symptoms mentioned, darken the bubble corresponding to "I did not have it at all," and go on to the next part (row) of Item 19. If the respondent DID have any of the symptoms mentioned, DO NOT darken that bubble. Instead, move to the next column and section: FOR EACH SYMPTOM YOU HAD: How much did it interfere with your normal activity in the past 4 weeks? (4 weeks = 28 days) I HAD IT AND IT INTERFERED: Show the respondent Card 17b and have him/her indicate the extent to which the symptoms interfered with his/her normal activity.

 

19-a. Trouble with thinking, concentrating, or memory. Darken the circle next to the response that best describes the extent to which any of these symptoms interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

19-b. Depressed or sad; trouble sleeping. Darken the circle next to the response that best describes the extent to which any of these symptoms interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

19-c. Aches, fatigue, lightheadedness, weak-all-over. Darken the circle next to the response that best describes the extent to which any of these symptoms interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

19-d. Fevers, chills, sweats. Darken the circle next to the response that best describes the extent to which any of these symptoms interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

19-e. Poor appetite, weight loss. Darken the circle next to the response that best describes the extent to which any of these symptoms interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

19-f. Trouble with eyes or ears. Darken the circle next to the response that best describes the extent to which any of these symptoms interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

19-g. Trouble with nose or sinuses; headache. Darken the circle next to the response that best describes the extent to which any of these symptoms interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

19-h. Trouble with mouth or swallowing. Darken the circle next to the response that best describes the extent to which any of these symptoms interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

19-i. Nausea, vomiting, diarrhea, abdominal pain. Darken the circle next to the response that best describes the extent to which any of these symptoms interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

19-j. Coughing, wheezing, or chest pain; trouble breathing. Darken the circle next to the response that best describes the extent to which any of these symptoms interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

19-k. Rash, itch, herpes, or other skin trouble. Darken the circle next to the response that best describes the extent to which any of these symptoms interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

19-l. Numbness, tingling, or pain in an arm or leg. Darken the circle next to the response that best describes the extent to which any of these symptoms interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

19-m. Other symptoms. Ask the person if there were any other symptoms that he/she had in the past 4 weeks. If the person did experience any other symptoms, write in the first symptom they mention in the boxes provided next to "Which?" Then, darken the circle next to the response that best describes the extent to which this symptom interfered over the past 4 weeks with the person’s normal activities. Choose only one answer to this question.

 

Module 17: Brief Health and Functioning Questionnaire:

Response Card 17a

How much of the time during the past 4 weeks...

All of the Time

Most of the Time

A Good Bit of the Time

Some of the Time

A Little of the Time

None of the Time

Module 17: Brief Health and Functioning Questionnaire:

Response Card 17b

Have you had any of the following symptoms in the past 4 weeks?

For each symptom you had: How much did it interfere with your normal activity in the past 4 weeks?

Did not have it (the symptom) at all

Not at all

Very little

Moderately

Quite a bit

Extremely

Module 17

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