Routing for UAS660
surveyversion := '2'
main_intro
Thank you for taking the time to complete this survey. This survey asks about your health and how it affects your ability to carry out daily activities which may include work activities. Please focus on what you are able to do, regardless of whether you would prefer to do it or not. If an ability varies from day to day, please indicate your level of ability on your worst days.
mental_intro
The following questions ask about your thinking abilities.
For each question in this section, the first option represents what most people would be capable of doing.
For each question in this section, the first option represents what most people would be capable of doing.
m001 (how long can focus attention in everyday life)
For how long can you focus your attention in your everyday life?
1 If I need to, I can focus my attention on a single source of information (an item, person, or event) for at least 30 minutes
2 I can at most focus on a single source of information (an item, person, or event) for longer than 5 minutes, but less than 30 minutes
3 I can focus on a single source of information (an item, person, or event) for no more than 5 minutes
2 I can at most focus on a single source of information (an item, person, or event) for longer than 5 minutes, but less than 30 minutes
3 I can focus on a single source of information (an item, person, or event) for no more than 5 minutes
m002 (ability to process and react to new information in everyday life)
How would you describe your ability to process and react to new information in your everyday life?
1 I have no trouble taking in new information around me and responding appropriately (for example, I can drive a car in busy traffic)
2 I can only take in and respond to small amounts of new information (for example, I cannot drive in busy traffic, but I can travel by bus in an urban area)
3 I usually cannot take in and respond to new information
2 I can only take in and respond to small amounts of new information (for example, I cannot drive in busy traffic, but I can travel by bus in an urban area)
3 I usually cannot take in and respond to new information
m003 (describe memory in everyday life)
How would you describe your memory in your everyday life?
1 I can usually remember things; sometimes I use lists or reminders to help
2 I can only remember things by using lists or reminders
3 I cannot remember information I need for my everyday life, even if I use lists or reminders
2 I can only remember things by using lists or reminders
3 I cannot remember information I need for my everyday life, even if I use lists or reminders
m004 (how well can estimate abilities and limitations in everyday life)
How would you describe how well you can estimate your abilities and limitations in everyday life?
1 I am usually aware of my abilities and limitations, or only moderately over- or underestimate what I can do
2 I often greatly overestimate what I can do
3 I often greatly underestimate what I can do
2 I often greatly overestimate what I can do
3 I often greatly underestimate what I can do
Group of questions presented on the same screen
m005_intro
Do you agree or disagree with the following statements about how efficiently you are able to do everyday activities, such as getting dressed and eating a meal?
Subgroup of questions
m005a (I usually start activities in time to reach a given goal )
I usually start activities in time to reach a given goal
1 Agree
2 Disagree
2 Disagree
m005b (I usually do activities in a logical order )
I usually do activities in a logical order
1 Agree
2 Disagree
2 Disagree
m005c (I usually monitor the progress of my activities )
I usually monitor the progress of my activities
1 Agree
2 Disagree
2 Disagree
m005d (I usually stop activities when I am done or when I can't finish them )
I usually stop activities when I am done or when I can't finish them
1 Agree
2 Disagree
2 Disagree
End of subgroup of questions
End of group of questions
Group of questions presented on the same screen
m006_intro
Do you agree or disagree with the following statements about your ability to do everyday activities, such as getting dressed and eating a meal, without help from others?
Subgroup of questions
m006a (I usually start activities myself)
I usually start activities myself
1 Agree
2 Disagree
2 Disagree
m006b (I usually set goals for myself)
I usually set goals for myself
1 Agree
2 Disagree
2 Disagree
m006c (After deciding I want to do something, I usually can think of ways to do it )
After deciding I want to do something, I usually can think of ways to do it
1 Agree
2 Disagree
2 Disagree
m006d (After deciding I want to do something, I usually can decide the best way to do it)
After deciding I want to do something, I usually can decide the best way to do it
1 Agree
2 Disagree
2 Disagree
m006e (After choosing a way to do something, I usually recognize when my way of doing it is not working)
After choosing a way to do something, I usually recognize when my way of doing it is not working
1 Agree
2 Disagree
2 Disagree
m006f (When I realize I've chosen the wrong way to do something, I usually choose a different way to do it or adjust my goal)
When I realize I've chosen the wrong way to do something, I usually choose a different way to do it or adjust my goal
1 Agree
2 Disagree
2 Disagree
m006g (After deciding I want to do something, I usually keep going until the job is done )
After deciding I want to do something, I usually keep going until the job is done
1 Agree
2 Disagree
2 Disagree
m006h (When I need help, I usually ask for it in time)
When I need help, I usually ask for it in time
1 Agree
2 Disagree
2 Disagree
End of subgroup of questions
End of group of questions
m007 (pace at which do everyday activities)
Which of the following best describes the pace at which you do everyday activities?
1 I can do everyday activities at a similar or faster pace as most people
2 The pace at which I do everyday activities is slower than most people
2 The pace at which I do everyday activities is slower than most people
m008 (working conditions require to work at job)
What working conditions do you require to work at a job? Check all that apply.
1 I do not require any of the working conditions listed below
2 Few or no distractions from others
3 Predictable work environment and/or tasks
4 Few or no disturbances and interruptions
5 Few or no deadlines, and/or few or no times when I must work harder than usual
6 Steady and manageable pace
7 Safe work environment with no physical risk (for example, working near heavy machinery or traffic), because I have difficulty recognizing or protecting myself from hazards
2 Few or no distractions from others
3 Predictable work environment and/or tasks
4 Few or no disturbances and interruptions
5 Few or no deadlines, and/or few or no times when I must work harder than usual
6 Steady and manageable pace
7 Safe work environment with no physical risk (for example, working near heavy machinery or traffic), because I have difficulty recognizing or protecting myself from hazards
m009 (extent need tasks at work to be planned out)
To what extent would you need tasks at work to be planned out for you?
1 I can do work where I need to figure out which tasks to do and how to do them by myself
2 I can only do work where set tasks are simple and assigned to me, and the way to do these tasks is mostly planned out for me
3 I can only do work where set tasks are simple and assigned to me, and the way to do these tasks is completely planned out for me
2 I can only do work where set tasks are simple and assigned to me, and the way to do these tasks is mostly planned out for me
3 I can only do work where set tasks are simple and assigned to me, and the way to do these tasks is completely planned out for me
se_intro
The following questions ask about your senses and communication skills.
se001 (have any vision problems that limit daily functioning)
Do you have any vision problems that limit your daily functioning that cannot be corrected by wearing glasses or contact lenses?
1 (YES) Yes
2 (NO) No
2 (NO) No
se002 (have any hearing problems that affect daily functioning)
Do you have any hearing problems that affect your daily functioning that cannot be corrected with a hearing aid?
1 (YES) Yes
2 (NO) No
2 (NO) No
se003 (have any trouble speaking that limits daily functioning)
Do you have any trouble speaking that limits your daily functioning (e.g. stuttering, slow speech, problems making clear sounds, problems finding the right words to express your thoughts)?
1 (YES) Yes
2 (NO) No
2 (NO) No
se004 (have any trouble with handwriting)
Do you have any trouble with handwriting (such as difficulty moving your hand)?
1 (YES) Yes
2 (NO) No
2 (NO) No
se005 (have any problems with reading large amounts of material at a regular pace)
Do you have any problems with reading large amounts of material at a regular pace?
1 (YES) Yes
2 (NO) No
2 (NO) No
soc_intro
The following questions ask about interactions with other people.
For each question in this section, the first option represents what most people would be capable of doing.
For each question in this section, the first option represents what most people would be capable of doing.
soc001_v2 ( how you usually handle other peoples emotions)
Which of the following best describes how you usually handle other peoples' emotions?
1 I can relate to others' emotions, and they do not strongly affect me or how I behave
2 I am strongly affected by others' emotions, but they do not affect how I behave
3 I cannot relate to others' emotions, but I can respond appropriately
4 I am strongly affected by others' emotions, and they do affect how I behave
5 I cannot relate to others' emotions, and I cannot respond appropriately
2 I am strongly affected by others' emotions, but they do not affect how I behave
3 I cannot relate to others' emotions, but I can respond appropriately
4 I am strongly affected by others' emotions, and they do affect how I behave
5 I cannot relate to others' emotions, and I cannot respond appropriately
soc002 (how express feelings to others)
Which of the following best describes how you express your feelings to others?
1 I usually express my feelings in a way that is clear and acceptable to others
2 I usually cannot express what I am feeling to others
3 I usually express my feelings in unclear, unpredictable, or unconventional ways, which confuses others
4 I have very little control over how I express my feelings
2 I usually cannot express what I am feeling to others
3 I usually express my feelings in unclear, unpredictable, or unconventional ways, which confuses others
4 I have very little control over how I express my feelings
soc003 (ability to cope with conflict with other people)
Which of the following best describes your ability to cope with conflict with other people?
1 I usually handle conflict as well as most other people
2 I can only handle conflicts over the phone or through written communication but not in person
3 I usually cannot handle conflict
2 I can only handle conflicts over the phone or through written communication but not in person
3 I usually cannot handle conflict
soc004 (ability to work with others)
Which of the following best describes your ability to work with others?
1 I communicate and collaborate with people that I work with like most other people
2 I can work with others, but only if my tasks are clearly mine
3 I am unable to work with others
2 I can work with others, but only if my tasks are clearly mine
3 I am unable to work with others
soc005 (travel to and from places by yourself)
In your everyday activities can you travel to and from places by yourself?
1 I can travel by myself
2 I cannot travel by myself
2 I cannot travel by myself
soc006 (operate a vehicle at work with training)
If you received training, could you operate a vehicle at work (such as a car, truck, bus, tractor, crane, etc.)?
1 Yes, if I received training I could operate a vehicle at work
2 No, even if I received training I could not operate a vehicle at work
2 No, even if I received training I could not operate a vehicle at work
soc007 (working conditions require to work at job)
What working conditions do you require to work at a job? Check all that apply.
1 I do not require any of the working conditions listed below
2 Little to no contact with customers or clients (such as some service professions)
3 No (or limited) interaction with patients or those in need of help (such as some professions in healthcare or social services)
4 Access to help from colleagues or managers if I need it
5 No direct contact with colleagues
6 No managing of other people
2 Little to no contact with customers or clients (such as some service professions)
3 No (or limited) interaction with patients or those in need of help (such as some professions in healthcare or social services)
4 Access to help from colleagues or managers if I need it
5 No direct contact with colleagues
6 No managing of other people
ph_intro
The following questions ask about your ability to tolerate different physical environments.
For each question in this section, the first option represents what most people would be capable of doing.
For each question in this section, the first option represents what most people would be capable of doing.
ph001 (be exposed to temperatures greater than 95 degrees Fahrenheit)
Can you be exposed to temperatures greater than 95 degrees Fahrenheit for at least 5 minutes at a time, while wearing appropriate clothing?
1 Yes
2 No, I cannot be exposed to temperatures greater than 95 degrees Fahrenheit, even while wearing appropriate clothing
2 No, I cannot be exposed to temperatures greater than 95 degrees Fahrenheit, even while wearing appropriate clothing
ph002 (be exposed to temperatures lower than 5 degrees Fahrenheit)
Can you be exposed to temperatures lower than 5 degrees Fahrenheit (for example, a freezer room) for at least 5 minutes at a time, while wearing appropriate clothing?
1 Yes
2 No, I cannot be exposed to temperatures lower than 5 degrees Fahrenheit, even while wearing appropriate clothing
2 No, I cannot be exposed to temperatures lower than 5 degrees Fahrenheit, even while wearing appropriate clothing
ph003 (be exposed to strong sudden air movements)
Can you be exposed to strong sudden air movements, while wearing appropriate clothing?
1 Yes
2 No, I cannot be exposed to strong sudden air movements
2 No, I cannot be exposed to strong sudden air movements
ph004 (be exposed to substances that make your skin wet or dirty, or that might cause skin irritation)
Can you be exposed to substances that make your skin wet or dirty, or that might cause skin irritation (for example, working on a car, or as a hairdresser)?
1 Yes
2 No, I cannot be exposed to any of these substances
2 No, I cannot be exposed to any of these substances
ph005 (able to wear protective gear if necessary)
Are you able to wear protective gear if necessary (such as a helmet, mask, eye and face protection, headphones, gloves, reinforced shoes, etc.)?
1 Yes
2 No, I am not able to wear some types of protective gear
2 No, I am not able to wear some types of protective gear
ph006 (be exposed to dust, smoke, gas or steam)
Can you be exposed to dust, smoke, gas or steam (for example, working in a garage, working outside on a busy road, working in a factory)?
1 Yes
2 No, I cannot be exposed to dust, smoke, gas or steam
2 No, I cannot be exposed to dust, smoke, gas or steam
ph007 (be exposed to noise levels so high that cannot have conversation)
Can you be exposed to noise levels so high that you cannot have a conversation with someone 3 feet away without raising your voice?
1 Yes
2 No, I cannot be exposed to such noise levels
2 No, I cannot be exposed to such noise levels
ph008 (be exposed to vibrations or jolts)
Can you be exposed to vibrations or jolts (for example, sitting in a tractor)?
1 Yes
2 No, I cannot be exposed to vibrations or jolts
2 No, I cannot be exposed to vibrations or jolts
ph009 (conditions that limit how well can tolerate different physical environments)
Do you have any of the following conditions that limit how well you can tolerate different physical environments? Check all that apply.
1 No
2 Allergies (respiratory and other)
3 I am at higher risk of getting infections (for example due to lung disease or chemotherapy)
4 Weakened skin (for example due to lymphedema or eczema)
2 Allergies (respiratory and other)
3 I am at higher risk of getting infections (for example due to lung disease or chemotherapy)
4 Weakened skin (for example due to lymphedema or eczema)
mv_intro
The following questions ask about movement.
mv001 (hand preference)
What is your hand preference or "handedness"?
1 I am right handed
2 I am left handed
3 I have no hand preference
2 I am left handed
3 I have no hand preference
mv_intro2
For all remaining questions in this section, the first option represents what most people would be capable of doing.
mv002 (limited functioning in arms, hands, legs or feet)
Do you have limited functioning in your arms, hands, legs or feet on either side of your body?
1 No
2 Right side
3 Left side
4 Both sides
2 Right side
3 Left side
4 Both sides
mv003 (any difficulties using hands and fingers in everyday life)
Do you have any of the following difficulties using your hands and fingers in everyday life? Check all that apply. Check the first option if none of the other options apply to you.
1 No, I do not have any of the difficulties using my hands and fingers listed below (select this option if none of the following options apply to you)
2 I have difficulty grasping round objects (such as a door knob)
3 I have difficulty handling objects between the tips of 2 fingers and my thumb (for example, holding a pen)
4 I have difficulty handling objects between the top of my index finger and my thumb (pincer grasp)
5 I have limited grip strength with my fingers and thumb (for example, holding and turning a key)
6 I have limited grip strength in my hand (for example, squeezing objects)
7 I have difficulty handling rod-shaped objects (for example, carrying a suitcase by its handle, using a hammer)
8 I have difficulty making accurate, fine movements with my fingers and hands (for example, inserting a key into a lock, pulling a thread through the eye of a needle)
9 I have difficulty making repetitive movements with my fingers and hands (such as typing)
10 I have difficulty with movements that are required to operate a keyboard and a mouse
2 I have difficulty grasping round objects (such as a door knob)
3 I have difficulty handling objects between the tips of 2 fingers and my thumb (for example, holding a pen)
4 I have difficulty handling objects between the top of my index finger and my thumb (pincer grasp)
5 I have limited grip strength with my fingers and thumb (for example, holding and turning a key)
6 I have limited grip strength in my hand (for example, squeezing objects)
7 I have difficulty handling rod-shaped objects (for example, carrying a suitcase by its handle, using a hammer)
8 I have difficulty making accurate, fine movements with my fingers and hands (for example, inserting a key into a lock, pulling a thread through the eye of a needle)
9 I have difficulty making repetitive movements with my fingers and hands (such as typing)
10 I have difficulty with movements that are required to operate a keyboard and a mouse
mv004 (how long can use keyboard and/or mouse)
How long can you use a keyboard and/or a mouse?
If your ability level falls between two answer choices, select the answer corresponding to the lower level of ability.
If your ability level falls between two answer choices, select the answer corresponding to the lower level of ability.
1 I can use a keyboard and/or a mouse for most of the workday
2 I can use a keyboard and/or a mouse for about 4 hours per workday
3 I can use a keyboard and/or a mouse for about 1 hour per workday
4 I can use a keyboard and/or a mouse for about 30 minutes per workday
5 I cannot use a keyboard and/or a mouse for 30 minutes per workday
2 I can use a keyboard and/or a mouse for about 4 hours per workday
3 I can use a keyboard and/or a mouse for about 1 hour per workday
4 I can use a keyboard and/or a mouse for about 30 minutes per workday
5 I cannot use a keyboard and/or a mouse for 30 minutes per workday
mv005 (any limitations in sense of touch which negatively affect everyday life)
Do you have any limitations in your sense of touch which negatively affect your everyday life? For example, you might have trouble turning a page without looking, feeling the grain of wood, or recognizing objects by touch only.
1 No, I do not have limitations in my sense of touch which negatively affect my everyday life
2 Yes, I do have limitations in my sense of touch which negatively affect my everyday life
2 Yes, I do have limitations in my sense of touch which negatively affect my everyday life
mv006 (make twisting movements with hands or arms)
Can you make twisting movements with your hands or arms (for example, using a screwdriver, wringing out wet towels)?
1 Yes, I can make twisting movements with my hands or arms
2 No, I cannot make twisting movements with my hands or arms
2 No, I cannot make twisting movements with my hands or arms
mv_intro3
For the next set of questions, if your ability level falls between two answer choices, select the answer corresponding to the lower level of ability.
mv007 (furthest distance can hold hand away from body)
Using your best arm, what is the furthest distance you can hold your hand away from your body?
1 I can fully extend my arm to shoulder height
2 I can almost extend my arm to shoulder height
3 I can extend my arm only a little bit (i.e. I fall short of full extension by more than 4 inches)
2 I can almost extend my arm to shoulder height
3 I can extend my arm only a little bit (i.e. I fall short of full extension by more than 4 inches)
mv008 (how many times reach distance per hour for each hour of a workday)
In the previous question, you responded with your maximum reaching distance of your best arm. How many times can you reach this distance per hour for each hour of a workday?
1 I can reach my maximum reaching distance once every 3 seconds for most of the workday, with a break every hour
2 I can reach my maximum reaching distance once every 6 seconds for most of the workday, with a break every hour
3 I can reach my maximum reaching distance once every 12 seconds for most of the workday, with a break every hour
4 I cannot reach my maximum reaching distance once every 12 seconds for most of the workday, with a break every hour
2 I can reach my maximum reaching distance once every 6 seconds for most of the workday, with a break every hour
3 I can reach my maximum reaching distance once every 12 seconds for most of the workday, with a break every hour
4 I cannot reach my maximum reaching distance once every 12 seconds for most of the workday, with a break every hour
mv009 (how far can bend forward)
How far can you bend forward?
1 I can bend forward 90 degrees
2 I can bend forward 60 degrees
3 I can bend forward 45 degrees
4 I cannot bend forward 45 degrees
2 I can bend forward 60 degrees
3 I can bend forward 45 degrees
4 I cannot bend forward 45 degrees
mv010 (how many times can bend forward for each hour of a workday)
In the previous question you told us how far you can bend forward. How many times can you bend forward to this extent in an hour, for the number of hours that you are capable of working in a day?
1 Once every 6 seconds
2 Once every 12 seconds
3 Once every 24 seconds
4 Once every 72 seconds
5 Less than once every 72 seconds
2 Once every 12 seconds
3 Once every 24 seconds
4 Once every 72 seconds
5 Less than once every 72 seconds
mv011 (when sitting, how far can turn to side)
When sitting, how far can you turn to the side?
1 I can turn 45 degrees to the side
2 I can turn 30 degrees to the side
3 I cannot turn 30 degrees to the side
2 I can turn 30 degrees to the side
3 I cannot turn 30 degrees to the side
mv012 (most weight can push or pull)
What is the most weight you can push or pull?
1 I can push or pull about 55 lbs (the weight of a large bag of dog food)
2 I can push or pull about 33 lbs (the weight of a 3 year old child)
3 I can push or pull about 22 lbs (the weight of an average car tire)
4 I cannot push or pull 22 lbs
2 I can push or pull about 33 lbs (the weight of a 3 year old child)
3 I can push or pull about 22 lbs (the weight of an average car tire)
4 I cannot push or pull 22 lbs
mv013 (most weight can lift)
What is the most weight you can lift?
1 I can lift about 30 lbs (the weight of a case of bottled water)
2 I can lift about 20 lbs (the weight of an average watermelon)
3 I can lift about 10 lbs (the weight of a gallon of paint)
4 I can lift about 4 lbs (the weight of a bag of sugar)
5 I cannot lift 4 lbs
2 I can lift about 20 lbs (the weight of an average watermelon)
3 I can lift about 10 lbs (the weight of a gallon of paint)
4 I can lift about 4 lbs (the weight of a bag of sugar)
5 I cannot lift 4 lbs
mv014 (most weight can carry)
What is the most weight you can carry?
By carrying we mean holding an object for at least 10 seconds, or moving at least 3 feet while holding the object.
By carrying we mean holding an object for at least 10 seconds, or moving at least 3 feet while holding the object.
1 I can lift about 30 lbs (the weight of a case of bottled water)
2 I can lift about 20 lbs (the weight of an average watermelon)
3 I can lift about 10 lbs (the weight of a gallon of paint)
4 I can lift about 4 lbs (the weight of a bag of sugar)
5 I cannot lift 4 lbs
2 I can lift about 20 lbs (the weight of an average watermelon)
3 I can lift about 10 lbs (the weight of a gallon of paint)
4 I can lift about 4 lbs (the weight of a bag of sugar)
5 I cannot lift 4 lbs
mv015 (any difficulty can you moving head)
Do you have any difficulty moving your head? Check all that apply. Check the first option if none of the other options apply to you.
1 No difficulties; I can look both up and down by at least 45 degrees, I can tilt my head to the side by at least 45 degrees, and I can rotate my head sideways by at least 60 degrees
2 I cannot look both up and down at least 45 degrees
3 I cannot tilt my head to the side at least 45 degrees
4 I cannot rotate my head sideways at least 60 degrees
2 I cannot look both up and down at least 45 degrees
3 I cannot tilt my head to the side at least 45 degrees
4 I cannot rotate my head sideways at least 60 degrees
mv016 (How get around)
How do you get around?
1 I usually walk without an aid
2 I usually walk with a cane or walker
3 I usually use a wheelchair without help from others
4 I usually need help from others to get around
2 I usually walk with a cane or walker
3 I usually use a wheelchair without help from others
4 I usually need help from others to get around
if mv016 != 4 then
if mv016 = 3 then
mv017b (how long can use wheelchair without stopping)
How long you can use a wheelchair without stopping?
1 I can use a wheelchair for more than 1 hour without stopping
2 I can use a wheelchair for 30 minutes without stopping
3 I can use a wheelchair for 15 minutes without stopping
4 I can use a wheelchair for 5 minutes without stopping
5 I cannot use a wheelchair for 5 minutes without stopping
2 I can use a wheelchair for 30 minutes without stopping
3 I can use a wheelchair for 15 minutes without stopping
4 I can use a wheelchair for 5 minutes without stopping
5 I cannot use a wheelchair for 5 minutes without stopping
mv018b (how long can use a wheelchair over 8-hour working day)
How long can you use a wheelchair over an 8-hour working day (not at one time, but over the course of the day)?
1 I can use a wheelchair for most of an 8-hour working day
2 I can use a wheelchair for a total of 4 hours per day
3 I can use a wheelchair for a total of 1 hour per day
4 I can use a wheelchair for a total of less than 30 minutes per day
5 I cannot use a wheelchair for 30 minutes per day
2 I can use a wheelchair for a total of 4 hours per day
3 I can use a wheelchair for a total of 1 hour per day
4 I can use a wheelchair for a total of less than 30 minutes per day
5 I cannot use a wheelchair for 30 minutes per day
Else
mv017a (how long can walk without stopping)
How long you can walk without stopping?
1 I can walk for more than 1 hour without stopping
2 I can walk for 30 minutes without stopping
3 I can walk for 15 minutes without stopping
4 I can walk for 5 minutes without stopping
5 I cannot walk for 5 minutes without stopping
2 I can walk for 30 minutes without stopping
3 I can walk for 15 minutes without stopping
4 I can walk for 5 minutes without stopping
5 I cannot walk for 5 minutes without stopping
mv018a (how long can walk over 8-hour working day)
How long can you walk over an 8-hour working day (not at one time, but over the course of the day)?
1 I can walk for most of an 8-hour working day
2 I can walk for a total of 4 hours per day
3 I can walk for a total of 1 hour per day
4 I can walk for a total of less than 30 minutes per day
5 I cannot walk for 30 minutes per day
2 I can walk for a total of 4 hours per day
3 I can walk for a total of 1 hour per day
4 I can walk for a total of less than 30 minutes per day
5 I cannot walk for 30 minutes per day
mv019 (can go up and down stairs)
Can you go up and down stairs?
1 I can go up and down at least 2 flights of stairs (30 steps up and 30 steps down) in one go, at least 4 times per hour
2 I can go up and down at least 1 flight of stairs in one go (15 steps up and 15 steps down), at least 4 times per hour
3 I can either go up or go down at least 1 flight of stairs in one go (either 15 steps up or 15 steps down but not both), at least 4 times per hour
4 I can only go up or down a few stairs at most in one go, at least 4 times per hour
5 I cannot go up or down stairs
2 I can go up and down at least 1 flight of stairs in one go (15 steps up and 15 steps down), at least 4 times per hour
3 I can either go up or go down at least 1 flight of stairs in one go (either 15 steps up or 15 steps down but not both), at least 4 times per hour
4 I can only go up or down a few stairs at most in one go, at least 4 times per hour
5 I cannot go up or down stairs
mv020 (can climb stepladder)
Can you climb a stepladder?
1 I can go up and down a tall ladder (15 feet tall), at least 4 times per hour
2 I can go up and down a stepladder (10 feet tall), at least 4 times per hour
3 I can go up and down a single step or stepstool, at least 4 times per hour
4 I cannot go up or down a single step
2 I can go up and down a stepladder (10 feet tall), at least 4 times per hour
3 I can go up and down a single step or stepstool, at least 4 times per hour
4 I cannot go up or down a single step
mv021 (can kneel or squat)
Can you kneel or squat?
1 I can reach the floor with my hands, kneeling or squatting
2 I can reach the floor with my hands, kneeling or squatting, but not more than 5 times in a single hour
3 I can reach the floor with my hands, kneeling or squatting, but not more than 2 times in a single hour
4 I can barely or cannot reach the floor with my hands, kneeling or squatting
2 I can reach the floor with my hands, kneeling or squatting, but not more than 5 times in a single hour
3 I can reach the floor with my hands, kneeling or squatting, but not more than 2 times in a single hour
4 I can barely or cannot reach the floor with my hands, kneeling or squatting
End of if
End of if
st_intro
The following questions ask about your ability to hold certain positions.
For each question in this section, the first option represents what most people would be capable of doing.
If your ability level falls between two answer choices, select the answer corresponding to the lower level of ability.
For each question in this section, the first option represents what most people would be capable of doing.
If your ability level falls between two answer choices, select the answer corresponding to the lower level of ability.
st001 (how long can sit in chair without needing to get up)
How long you can sit in a chair without needing to get up?
1 I can sit for 2 hours without needing to get up
2 I can sit for 1 hour without needing to get up
3 I can sit for 30 minutes without needing to get up
4 I can sit for 15 minutes without needing to get up
5 I cannot sit for 15 minutes without needing to get up
2 I can sit for 1 hour without needing to get up
3 I can sit for 30 minutes without needing to get up
4 I can sit for 15 minutes without needing to get up
5 I cannot sit for 15 minutes without needing to get up
st002 (how long can sit over 8-hour working day)
How long can you sit over an 8-hour working day (not at one time, but over the course of the day)?
1 I can sit for more than 8 hours
2 I can sit for more than 6 hours
3 I can sit for more than 4 hours
4 I can sit for more than 1 hour
5 I cannot sit for 1 hour
2 I can sit for more than 6 hours
3 I can sit for more than 4 hours
4 I can sit for more than 1 hour
5 I cannot sit for 1 hour
st003 (how long can stand at one time)
How long you can stand at one time?
1 I can stand for 1 hour without resting
2 I can stand for 30 minutes without resting
3 I can stand for 15 minutes without resting
4 I can stand for 5 minutes without resting
5 I can stand for less than 5 minutes without resting
6 I cannot stand
2 I can stand for 30 minutes without resting
3 I can stand for 15 minutes without resting
4 I can stand for 5 minutes without resting
5 I can stand for less than 5 minutes without resting
6 I cannot stand
if st003 != 6 then
st004 (how long can stand over 8-hour working day)
How long can you stand over an 8-hour work day (not at one time, but over the course of the day)?
1 I can stand for over 8 hours
2 I can stand for over 6 hours
3 I can stand for over 4 hours
4 I can stand for over 1 hour
5 I can stand for over 30 minutes
6 I can stand for less than 30 minutes
2 I can stand for over 6 hours
3 I can stand for over 4 hours
4 I can stand for over 1 hour
5 I can stand for over 30 minutes
6 I can stand for less than 30 minutes
End of if
if mv021 != 4 then
st005 (how long can be active in a kneeling or squatting position at one time)
How long can you be active in a kneeling or squatting position at one time, twice an hour (for example, while gardening)?
1 I can be active in a kneeling or squatting position for 5 minutes at a time
2 I can be active in a kneeling or squatting position for more than 1 minute at a time
3 I can be active in a kneeling or squatting position for 1 minute at a time
4 I cannot be active in a kneeling or squatting position for even 1 minute at a time
2 I can be active in a kneeling or squatting position for more than 1 minute at a time
3 I can be active in a kneeling or squatting position for 1 minute at a time
4 I cannot be active in a kneeling or squatting position for even 1 minute at a time
End of if
if mv009 in [1,2] then
st006 (how long can be active in position upper body is bent forward or twisted)
How long can you be active in a position where your upper body is either bent forward or twisted to the side (for example, sweeping the floor)?
1 I can be active in a position where my upper body is either bent forward or twisted to the side for at least 5 minutes at a time, twice an hour
2 I can be active in a position where my upper body is either bent forward or twisted to the side for at least 2 minutes at a time, twice an hour
3 I can be active in a position where my upper body is either bent forward or twisted to the side for less than 2 minutes at a time, twice an hour
4 I cannot be active in a position where my upper body is either bent forward or twisted to the side
2 I can be active in a position where my upper body is either bent forward or twisted to the side for at least 2 minutes at a time, twice an hour
3 I can be active in a position where my upper body is either bent forward or twisted to the side for less than 2 minutes at a time, twice an hour
4 I cannot be active in a position where my upper body is either bent forward or twisted to the side
End of if
st007 (how long can keep best arm lifted above shoulder height)
How long can you keep your best arm lifted above shoulder height (for example, while hanging up curtains, changing a light bulb)?
1 I can lift my best arm above shoulder height for at least 2 minutes, 10 times an hour
2 I can lift my best arm above shoulder height for about 1 minute, 10 times an hour
3 I can barely or cannot lift my best arm above shoulder height
2 I can lift my best arm above shoulder height for about 1 minute, 10 times an hour
3 I can barely or cannot lift my best arm above shoulder height
st008 (have any difficulties with holding head in specific position)
Do you have any difficulties with holding your head in a specific position (either tilted up/down/sideways by at least 15 degrees, or rotated to the side by 30 degrees)? Please tell us the total amount of time in an 8-hour work day you can spend in this position, allowing for breaks.
1 I can keep my head in a specific position for more than 4 hours
2 I can keep my head in a specific position for about 4 hours
3 I can keep my head in a specific position for about 1 hour
4 I can only keep my head in a specific position for less than 30 minutes or not at all
2 I can keep my head in a specific position for about 4 hours
3 I can keep my head in a specific position for about 1 hour
4 I can only keep my head in a specific position for less than 30 minutes or not at all
wh_intro
The following questions ask about what hours you are capable of working, and whether you would need any accommodations due to an injury, illness, or condition.
wh001 (illness, injury or condition prevent from working evenings or nights)
Does an illness, injury or condition prevent you from working evenings or nights? Check all that apply.
1 No, I can work any time of day, including evenings or nights if needed
2 Yes, I cannot work evenings between 6:00pm -12:00 midnight due to an injury, illness, or condition
3 Yes, I cannot work nights between 12:00 midnight and 6:00am due to an injury, illness, or condition
2 Yes, I cannot work evenings between 6:00pm -12:00 midnight due to an injury, illness, or condition
3 Yes, I cannot work nights between 12:00 midnight and 6:00am due to an injury, illness, or condition
wh002 (illness, injury or condition limit number of hours could work in day)
Does an illness, injury or condition limit the number of hours you could work in a day?
1 I can usually work more than 8 hours a day
2 I can usually work for about 8 hours a day
3 I can usually work for about 6 hours a day
4 I can usually work for about 4 hours a day
5 I can work for at most 2 hours a day
2 I can usually work for about 8 hours a day
3 I can usually work for about 6 hours a day
4 I can usually work for about 4 hours a day
5 I can work for at most 2 hours a day
wh003 (illness, injury or condition limit number of hours could work in week)
Does an illness, injury or condition limit the number of hours you could work in a week?
1 I can usually work more than 40 hours a week
2 I can usually work for about 40 hours a week
3 I can usually work for about 30 hours a week
4 I can usually work for about 20 hours a week
5 I can usually work for about 10 hours a week
6 I cannot work for 10 hours a week
2 I can usually work for about 40 hours a week
3 I can usually work for about 30 hours a week
4 I can usually work for about 20 hours a week
5 I can usually work for about 10 hours a week
6 I cannot work for 10 hours a week
ba_intro
The next part of this survey asks a little more detail about your education, skills and work experience.
if education = empty then
education (R HIGHEST LEVEL OF EDUCATION)
What is the highest level of school that you have completed or the highest degree you have received?
1 Less than 1st grade
2 Up to 4th grade
3 5th or 6th grade
4 7th or 8th grade
5 9th grade
6 10th grade
7 11th grade
8 12th grade-no diploma
9 High school graduate or GED
10 Some college-no degree
11 Assoc. college degree-occ/voc program
12 Assoc. college degree-academic program
13 Bachelor's degree
14 Master's degree
15 Professional school degree
16 Doctorate degree
2 Up to 4th grade
3 5th or 6th grade
4 7th or 8th grade
5 9th grade
6 10th grade
7 11th grade
8 12th grade-no diploma
9 High school graduate or GED
10 Some college-no degree
11 Assoc. college degree-occ/voc program
12 Assoc. college degree-academic program
13 Bachelor's degree
14 Master's degree
15 Professional school degree
16 Doctorate degree
End of if
if education > 10 then
ba001 (degree(s) specialize in any fields)
Do your degree(s) specialize in any of the fields below? Check all that apply.
Please note that this list is not intended to be exhaustive - if your specialization does not appear or you are not sure which field to select, select "None of the above".
Please note that this list is not intended to be exhaustive - if your specialization does not appear or you are not sure which field to select, select "None of the above".
1 Administration (such as office administration, accounting, secretarial work)
2 Agriculture (such as agriculture, forestry, fishing)
3 Art and culture (such as literature, fine arts, performing arts, visual arts)
4 Commercial (such as marketing, advertising, banking, insurance)
5 Health care (such as medicine, dentistry, nursing, social work)
6 Services (such as education, hospitality, sports and recreation, tourism)
7 Technical (such as engineering and technology, electronics, construction)
8 None of the above
2 Agriculture (such as agriculture, forestry, fishing)
3 Art and culture (such as literature, fine arts, performing arts, visual arts)
4 Commercial (such as marketing, advertising, banking, insurance)
5 Health care (such as medicine, dentistry, nursing, social work)
6 Services (such as education, hospitality, sports and recreation, tourism)
7 Technical (such as engineering and technology, electronics, construction)
8 None of the above
End of if
ba002 (have active professional certification, or state industry license)
Do you have an active professional certification, or a state industry license (such as a real estate license, medical assistant certification, teaching certification, IT certification, etc.)? Do not include business licenses, such as a liquor or vending license
1 (YES) Yes
2 (NO) No
2 (NO) No
if ba002 = 1 then
ba003 (certificate/license specialize in any fields)
Does your certificate/license specialize in any of the fields below? Check all that apply.
Please note that this list is not intended to be exhaustive - if your specialization does not appear or you are not sure which field to select, select "None of the above".
Please note that this list is not intended to be exhaustive - if your specialization does not appear or you are not sure which field to select, select "None of the above".
1 Administration (such as office administration, accounting, secretarial work)
2 Agriculture (such as agriculture, forestry, fishing)
3 Art and culture (such as literature, fine arts, performing arts, visual arts)
4 Commercial (such as marketing, advertising, banking, insurance)
5 Health care (such as medicine, dentistry, nursing, social work)
6 Services (such as education, hospitality, sports and recreation, tourism)
7 Technical (such as engineering and technology, electronics, construction)
8 None of the above
2 Agriculture (such as agriculture, forestry, fishing)
3 Art and culture (such as literature, fine arts, performing arts, visual arts)
4 Commercial (such as marketing, advertising, banking, insurance)
5 Health care (such as medicine, dentistry, nursing, social work)
6 Services (such as education, hospitality, sports and recreation, tourism)
7 Technical (such as engineering and technology, electronics, construction)
8 None of the above
End of if
ba004 (have active driver's license)
Do you have an active driver's license?
1 (YES) Yes
2 (NO) No
2 (NO) No
calcage:= calcAge(dateofbirth_year,dateofbirth_month,dateofbirth_day)
if calcage = empty then
calcage (calculated age)
What is your current age?
End of if
if calcage = response then
ba005_max := calcage - 18
Else
ba005_max := empty
End of if
Fill code of question 'FL_ba005' executed
ba005 (years of work experiencesince turned 18 years old)
Since you turned 18 years old, how many years of work experience have you acquired, excluding any time spent in higher education?
[
Because of your age, the most you could have worked if you stopped school at 18 is ^ba005_max years.]
RANGE 0..99Because of your age, the most you could have worked if you stopped school at 18 is ^ba005_max years.]
ba006 (currently working for pay)
Are you currently working for pay?
1 (YES) Yes
2 (NO) No
2 (NO) No
if ba006 = 2 then
ba007 (last time worked for pay)
When was the last time you worked for pay?
1 Less than 1 year ago
2 1-2 years ago
3 3-5 years ago
4 Over 5 years ago
2 1-2 years ago
3 3-5 years ago
4 Over 5 years ago
ba008 (possible would return to paid employment or self-employed if opportunity)
Is it possible you would return to paid employment or become self-employed in the future if you had the right opportunity?
1 (YES) Yes
2 (NO) No
2 (NO) No
Else
ba009 (how many hours currently work in typical work week)
How many hours do you currently work in a typical work week across all jobs you may have?
RANGE 0..168ba010 (how many weeks per year usually work)
How many weeks per year do you usually work? Do not count vacation weeks.
RANGE 0..52ba011 (total earnings over 12 months)
Which category represents the total amount of money you expect to earn from working over 12 months, before taxes?
1 Less than $5,000
2 $5,000 to $7,499
3 $7,500 to $9,999
4 $10,000 to $12,499
5 $12,500 to $14,999
6 $15,000 to $19,999
7 $20,000 to $24,999
8 $25,000 to $29,999
9 $30,000 to $34,999
10 $35,000 to $39,999
11 $40,000 to $49,999
12 $50,000 to $59,999
13 $60,000 to $74,999
14 $75,000 to $99,999
15 $100,000 to $124,999
16 $125,000 to $199,999
17 $200,000 or more
2 $5,000 to $7,499
3 $7,500 to $9,999
4 $10,000 to $12,499
5 $12,500 to $14,999
6 $15,000 to $19,999
7 $20,000 to $24,999
8 $25,000 to $29,999
9 $30,000 to $34,999
10 $35,000 to $39,999
11 $40,000 to $49,999
12 $50,000 to $59,999
13 $60,000 to $74,999
14 $75,000 to $99,999
15 $100,000 to $124,999
16 $125,000 to $199,999
17 $200,000 or more
End of if
Group of questions presented on the same screen
ba012 (how would pay for emergency expense that costs $400)
Based on your current financial situation, how would you pay for an emergency expense that costs $400? If you would use more than one method, please check all that apply.
1 Put it on my credit card and pay it off in full at the next statement
2 Put it on my credit card and pay it off over time
3 Use the money currently in my bank account, or with cash
4 Use money from a loan or other line of credit
5 Borrow money from a friend or family member
6 Use a payday loan, deposit advance, or overdraft
7 Sell something
8 Other, please specify:
9 I would not be able to pay for the expense right now
2 Put it on my credit card and pay it off over time
3 Use the money currently in my bank account, or with cash
4 Use money from a loan or other line of credit
5 Borrow money from a friend or family member
6 Use a payday loan, deposit advance, or overdraft
7 Sell something
8 Other, please specify:
9 I would not be able to pay for the expense right now
ba012_other (other how would pay for emergency expense that costs $400)
STRINGEnd of group of questions
hi_intro
The final part of this survey asks about your health and what health and disability benefits you have applied for and/or are receiving.
he001 (health conditions)
Please indicate which if any of the following statements apply to you. Check all that apply.
1 I have a mental health or neurological condition which means I cannot live independently
2 I am receiving intensive medical treatment which will continue for the foreseeable future
3 I am currently confined to a bed
4 A doctor has told me that I will probably not live for more than 1 year
5 I need help getting dressed and undressed
6 I need help getting in and out of bed
7 I need help sitting down and standing up
8 I need help washing my face and hands
9 I need help bathing and drying off
10 I need help using the restroom
11 I need help eating and drinking
12 I need help to getting around the house
13 None of these apply to me
2 I am receiving intensive medical treatment which will continue for the foreseeable future
3 I am currently confined to a bed
4 A doctor has told me that I will probably not live for more than 1 year
5 I need help getting dressed and undressed
6 I need help getting in and out of bed
7 I need help sitting down and standing up
8 I need help washing my face and hands
9 I need help bathing and drying off
10 I need help using the restroom
11 I need help eating and drinking
12 I need help to getting around the house
13 None of these apply to me
he002 (medical conditions)
Did you experience any of the following medical conditions in the past 12 months? Check all that apply.
1 Glaucoma
2 Macular degeneration
3 Need for hearing aid
4 High blood pressure or hypertension
5 Diabetes or high blood sugar
6 Cancer or a malignant tumor, excluding minor skin cancer
7 Chronic lung disease such as chronic bronchitis or emphysema (do not include asthma)
8 Heart attack, coronary heart disease, angina, heart failure, atrial fibrillation, or other heart problems
9 Stroke
10 Emotional, nervous or psychiatric problems
11 Arthritis or rheumatism
12 Broken hip
13 Cataracts
14 Depression
15 Memory disease, Alzheimer's/dementia or other serious memory impairment
16 Osteoporosis
17 Sleep disorder
18 Weakened immune system
19 None of the above
2 Macular degeneration
3 Need for hearing aid
4 High blood pressure or hypertension
5 Diabetes or high blood sugar
6 Cancer or a malignant tumor, excluding minor skin cancer
7 Chronic lung disease such as chronic bronchitis or emphysema (do not include asthma)
8 Heart attack, coronary heart disease, angina, heart failure, atrial fibrillation, or other heart problems
9 Stroke
10 Emotional, nervous or psychiatric problems
11 Arthritis or rheumatism
12 Broken hip
13 Cataracts
14 Depression
15 Memory disease, Alzheimer's/dementia or other serious memory impairment
16 Osteoporosis
17 Sleep disorder
18 Weakened immune system
19 None of the above
Group of questions presented on the same screen
hi001 (current source of health insurance)
What is your current source of health insurance? Check all that apply.
1 Private insurance through my employer or union
2 Private insurance through a family member’s employer or union
3 Private insurance, not through any employer or union
4 Medicare
5 Medicaid
6 Veterans Affairs (VA) Health Care
7 TRICARE
8 Other, please specify:
9 I do not have health insurance
2 Private insurance through a family member’s employer or union
3 Private insurance, not through any employer or union
4 Medicare
5 Medicaid
6 Veterans Affairs (VA) Health Care
7 TRICARE
8 Other, please specify:
9 I do not have health insurance
hi001_other (other current source of health insurance)
STRINGEnd of group of questions
Group of questions presented on the same screen
hi002 (currently receiving types of disability benefits)
Are you currently receiving any of the following types of disability benefits? Check all that apply.
1 Social Security Disability Insurance (SSDI)
2 Supplemental Security Income (SSI)
3 Veterans' disability compensation
4 Military disability benefits
5 Disability payments from your employer
6 Disability payments from private insurance
7 Disability benefits from other source, please specify:
8 I am not currently receiving disability benefits
2 Supplemental Security Income (SSI)
3 Veterans' disability compensation
4 Military disability benefits
5 Disability payments from your employer
6 Disability payments from private insurance
7 Disability benefits from other source, please specify:
8 I am not currently receiving disability benefits
hi002_other (other currently receiving types of disability benefits)
STRINGEnd of group of questions
Group of questions presented on the same screen
hi003 (applied types of disability benefits)
In the past 12 months, have you applied for disability benefits through any of the following programs? Check all that apply.
1 Social Security Disability Insurance (SSDI)
2 Supplemental Security Income (SSI)
3 Veterans' disability compensation
4 Military disability benefits
5 Disability payments from your employer
6 Disability payments from private insurance
7 Disability benefits from other source, please specify:
8 I have not applied for disability benefits in the past 12 months
2 Supplemental Security Income (SSI)
3 Veterans' disability compensation
4 Military disability benefits
5 Disability payments from your employer
6 Disability payments from private insurance
7 Disability benefits from other source, please specify:
8 I have not applied for disability benefits in the past 12 months
hi003_other (other applied types of disability benefits)
STRINGEnd of group of questions
if hi003 != 8 and hi003 = response then
Fill code of question 'FL_hi004' executed
Loop from 1 to 7
if FL_hi004[tempcnt] = response then
hi004 (status benefit application)
What is the status of your application to the [Social Security Disability Insurance (SSDI)/Supplemental Security Income (SSI)/Veterans’ disability compensation/Military disability benefits/Disability payments from your employer/Disability payments from private insurance/Disability benefits from other source (^hi003_other)] program?
1 Awaiting decision
2 Rejected, planning to appeal
3 Rejected, not planning to appeal
4 Awarded benefits
2 Rejected, planning to appeal
3 Rejected, not planning to appeal
4 Awarded benefits
End of if
End of loop
End of if
endq
Thank you for taking the time to complete this survey!
CS_001 (HOW PLEASANT INTERVIEW)
Could you tell us how interesting or uninteresting you found the questions in this survey?
1 Very interesting
2 Interesting
3 Neither interesting nor uninteresting
4 Uninteresting
5 Very uninteresting
2 Interesting
3 Neither interesting nor uninteresting
4 Uninteresting
5 Very uninteresting
CS_003 (comments)
Do you have any other comments on the survey? Please type these in the box below. (If you have no comments, please click next to complete this survey.)
STRING