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.

 

 

Specific Parts of Module 18 (Page 2): Brief Health and Functioning Questionnaire

Please note that Module 18 is two pages long. Before beginning Page 2 of Module 18, Page 1 should be completed.

Some information that is requested on Page 1 of Module 18 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

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.

 

Module 18: Abbreviated Health and Functioning Questionnaire:

Response Card

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 18

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