SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 25: INSTRUMENTAL ACTIVITIES OF DAILY LIVING FORM INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 25: Activities of Daily Living Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Source Citations: Adapted from work by Lawton and Brody, 1969 and Katz et al.; Lawton, M. P., and Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 9(3), 179-86; Katz, S., Downs, T. D., Cash, H. R., and Grotz, R. C. (1970). Progress in development of the index of ADL. Gerontologist, 10(1), 20-30; Akpom, C. A., Katz, S., and Densen, P. M. (1973). Methods of classifying disability and severity of illness in ambulatory care patients. Medical Care, 11(2): Suppl: 125-31.

This form must be completed by project staff.

It is not intended to be filled out by the client.

Use a black pen to complete this form. Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Specific Parts of the Module 25: Instrumental Activities of Daily Living Form

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 the unique identifier for this client, 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. 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 of the service provider agency doing the activity. Provider codes can be up to three letters.

Date. Enter the numbers representing today's date (the date of the activity) in these boxes. Enter the month as a number from 01 to 12 for 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, "95" for 1995). 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. Use your observations to determine if client is male or female. If the client is biologically male, darken the circle next to "Male." If the client is biologically female, darken the circle next to "Female." Ask him or her if necessary.

Note: This module is intended to be administered as a semi-structured interview. A semi-structured interview is one in which you are guided by question formats. However, you need not use the question format in a verbatim or absolutely standardized fashion, only as a guide to elicit a valid response. You should use your best judgment in using a combination of direct observation, informal conversation, and direct questions in eliciting responses to items 1 through 14 in Module 25.

Items 1 through 14. Read the following statement: "Now I’d like to ask you about some of the activities of daily living, things that we all need to do as a part of our daily lives. I would like to know if you can do these activities without any help at all."

Can you use the telephone...
Determine to what extent the client can use the telephone by himself or herself and darken the circle next to the response which best describes the client’s ability to use the telephone. Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Can you get to places out of walking distance...
Determine to what extent the client can get to places that are out of walking distance from his or her home and darken the circle next to the response which best describes the client’s ability to get to places out of walking distance. Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Can you go shopping for groceries or clothes (assuming client has transportation)...
Determine to what extent the client can go shopping for groceries by himself or herself and darken the circle next to the response which best describes the client’s ability to do his or her own shopping. Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Can you prepare your own meals...
Determine to what extent the client can prepare meals by himself or herself and darken the circle next to the response which best describes the client’s ability to prepare meals. Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Can you do housework...
Determine to what extent the client can do housework by himself or herself and darken the circle next to the response which best describes the client’s ability to do housework. Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Can you take your own medicine...
Determine to what extent the client can use the telephone by himself or herself and darken the circle next to the response which best describes the client’s ability to use the telephone. Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Can you handle your own money...
Determine to what extent the client can handle money by himself or herself and darken the circle next to the response which best describes the client’s ability handle money. Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Can you eat...
Determine to what extent the client can eat by himself or herself and darken the circle next to the response which best describes the client’s ability ear. Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Can you dress and undress yourself...
Determine to what extent the client can dress and undress by himself or herself and darken the circle next to the response which best describes the client’s ability to dress. Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Can you take care of your own appearance, for example combing your hair and (for men) shaving...
Determine to what extent the client can take care of his or her own appearance and darken the circle next to the response which best describes the client’s ability to take care of his or her own appearance. Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Can you walk...
Determine to what extent the client can use walk by himself or herself and darken the circle next to the response which best describes the client’s ability to walk. Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Can you get in and out of bed...
Determine to what extent the client can get in and out of bed by himself or herself and darken the circle next to the response which best describes the client’s ability to get in and out of bed. Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Can you take a bath or shower...
Determine to what extent the client can take a bath or shower by himself or herself and darken the circle next to the response which best describes the client’s ability to . Darken the circle next to "Refused" if the client refuses to answer. Darken the circle next to "Don’t know" if the client does not know. If the question in not applicable to the client, darken the circle next to "Not applicable."

Do you ever have trouble getting to the bathroom on time...
Determine to what extent the client has trouble getting to the bathroom on time. Darken the circle next to "No," if the client does not have trouble getting to the bathroom on time. Darken the circle next to "Yes," if the client does have problems getting to the bathroom on time. Darken the circle next to "Have a catheter or colostomy," if the client has a catheter or colostomy.