Adult Disability Topical Module

-ADQ1-

These next few questions are about your health. Would you say your health in general is excellent, very good, good, fair, or poor?

(1) Excellent

(2) Very Good

(3) Good

(4) Fair

(5) Poor

-ADQ2-

MARK BY OBSERVATION IF APPARENT.

Do you use any of the following aids?

(1) Yes (2) No

a. A cane, crutches, or a walker?

b. A wheelchair, electric scooter, or similar aid for getting around?

c. A hearing aid?

-ADQ3-

Have you used a cane, crutches, or a walker for six months or longer?

(1) Yes

(2) No

-ADQ4-

Do you have difficulty seeing the words and letters in ordinary newspaper print even when wearing glasses or contact lenses if you usually wear them?

(1) Yes

(2) No

(3) Person is Blind

-ADQ5-

Are you able to see the words and letters in ordinary newspaper print at all?

(1) Yes

(2) No

-ADQ6-

Do you have difficulty hearing what is said in a normal conversation with another person even when wearing your hearing aid?

(1) Yes

(2) No

(3) Person is deaf

-ADQ7-

Are you able to hear what is said in a normal conversation at all?

(1) Yes

(2) No

-ADQ8-

Do you have difficulty having your speech understood?

FR NOTE: DO NOT enter "1" for "Yes" if the person has trouble simply because they speak a language other than English.

(1) Yes

(2) No

-ADQ9-

In general, are people able to understand your speech at all?

(1) Yes

(2) No

-ADQ10-

Do you have any difficulty lifting and carrying something as heavy as 10 pounds - such as a bag of groceries?

(1) Yes

(2) No

-ADQ11-

Are you able to lift and carry a 10 pound bag of groceries at all?

(1) Yes

(2) No

-ADQ12-

Would you have any difficulty lifting and carrying a 25 pound bag of pet food?

(1) Yes

(2) No

-ADQ13-

Would you be able to lift and carry a 25 pound bag of pet food at all?

(1) Yes

(2) No

-ADQ14-

Do you have any difficulty pushing or pulling large objects such as a living room chair?

(1) Yes

(2) No

-ADQ15-

Are you able to push or pull such large objects at all?

(1) Yes

(2) No

-ADQ16-

Do you have any difficulty -

(1) Yes (2) No

a. Standing or being on your feet for one hour?

b. Sitting for one hour?

c. Stooping, crouching, or kneeling?

d. Reaching over your head?

-ADQ17-

Do you have difficulty using your hands and fingers to do things such as picking up a glass or grasping a pencil?

(1) Yes

(2) No

-ADQ18-

Are you able to use your hands and fingers to grasp and handle at all?

(1) Yes

(2) No

-ADQ19-

Do you have any difficulty walking up a flight of 10 stairs?

(1) Yes

(2) No

-ADQ20-

Are you able to walk up a flight of 10 stairs at all?

(1) Yes

(2) No

-ADQ21-

Do you have any difficulty walking a quarter of a mile - about 3 city blocks?

(1) Yes

(2) No

-ADQ22-

Are you able to walk a quarter of a mile at all?

(1) Yes

(2) No

-ADQ23-

Do you have any difficulty using an ordinary telephone?

(1) Yes

(2) No

-ADQ24-

Are you able to use an ordinary telephone at all?

(1) Yes

(2) No

-ADQ25-

Because of a physical or mental health condition, do you have difficulty doing any of the following by yourself?

FR NOTE: EXCLUDE THE EFFECTS OF TEMPORARY CONDITIONS - IF AN AID IS USED, ASK WHETHER THE PERSON HAS DIFFICULTY WHEN USING THE AID.

(1) Yes (2) No

a. Getting around INSIDE the home?

b. Going OUTSIDE the home, for example, to shop or visit a doctor's office?

c. Getting in and out of bed or a chair?

d. Taking a bath or shower?

e. Dressing?

f. Walking?

g. Eating?

h. Using or getting to the toilet?

i. Keeping track of money or bills?

j. Preparing meals?

k. Doing light housework such as washing dishes or sweeping a floor?

l. Taking the right amount of prescribed medicine at the right time?

-ADQ26-

Do you need the help of another person with :

FR NOTE: Read activity listed

(1) Yes (2) No

a. Getting around INSIDE the home?

b. Going OUTSIDE the home, for example, to shop or visit a doctor's office?

c. Getting in and out of bed or a chair?

d. Taking a bath or shower?

e. Dressing?

f. Walking?

g. Eating?

h. Using or getting to the toilet?

i. Keeping track of money and bills?

j. Preparing meals?

k. Doing light housework such as washing dishes or sweeping a floor?

l. Taking the right amount of prescribed medicine at the right time?

-AD27A-

You have said you need the help of another person with one or more activities. Who generally helps you with these activities?

Mark only one.

First Helper:

RELATIVE

(1) Son

(2) Daughter

(3) Spouse

(4) Parent

(5) Other relative

NONRELATIVE

(6) Friend or Neighbor

(7) Paid help

(8) Other nonrelative

Did not receive help

(9) Did not receive help

-AD27B-

ASK OR VERIFY : THIS PERSON MUST BE 15 YEARS OF AGE OR OLDER

Is the person who generally helps you with these activities a member of this household?

Enter line number of person, or N if not a household member

-AD27C-

Does anyone else help you with these activities?

Mark only one.

NO ONE ELSE HELPED:

(1) No one else helped

RELATIVE:

(2) Son

(3) Daughter

(4) Spouse

(5) Parent

(6) Other relative

NONRELATIVE:

(7) Friend or Neighbor

(8) Paid help

(9) Other nonrelative

-AD27D-

ASK OR VERIFY : THIS PERSON MUST BE 15 YEARS OF AGE OR OLDER

Is this person a member of this household?

Enter line number of person, or N if not a household member

-ADQ29-

For how long have you needed help of another person?

(1) Less than 6 months

(2) 6 to 11 month

(3) 1 to 2 years

(4) 3 to 5 years

(5) More than 5 years

-ADQ30-

During the past month, did you or your family pay for any of the help that you received?

(1) Yes

(2) No

-ADQ31-

How much was paid for such help?

Enter ($0-$999999) or (N) for none

-ADQ32-

SHOW FLASHCARD BB FOR PERSONAL VISIT INTERVIEWS.

I have recorded that you have difficulty with certain activities. Which condition or conditions cause these difficulties?

Any Others?

Enter (N) for None or no more.

Enter (H) for list of health conditions.

FR NOTE: If the person reports more than three conditions enter the appropriate code for the first three conditions the respondent identified.

-ADQ33-

I have recorded that your health is fair. Which condition or conditions cause your health problems?

SHOW FLASHCARD BB FOR PERSONAL VISIT INTERVIEWS.

Any Others?

Enter (H) for list of health conditions.

FR NOTE: If the person reports more than three conditions enter the appropriate code for the first three conditions the respondent identified.

Mark all that apply; Enter (N) for None or no more

-ADQ34-

Are any of these conditions the result of a motor vehicle accident?

(1) Yes

(2) No

-ADQ35-

Which of the conditions that you mentioned do you consider to be the main reason for your difficulties?

PRESS (H) TO SEE A LIST OF CONDITIONS

Main condition

-ADQ36-

When did (name of condition or main condition) first begin to bother you?

(S) Since birth

____ Year

-ADQ36B-

Do you know what month?

-ADQ37-

Have you had this condition for at least 5 months?

(1) Yes

(2) No

-ADQ38-

Is this condition expected to last for at least 12 more months?

(1) Yes

(2) No

-ADQ39-

Do you have -

(1) Yes (2) No

a. A learning disability such as dyslexia?

b. Mental retardation?

c. A developmental disability such as autism or cerebral palsy?

d. Alzheimer's disease or any other serious problem with confusion or forgetfulness?

e. Any other mental or emotional condition?

-ADQ40-

Are you frequently depressed or anxious?

(1) Yes

(2) No

-ADQ41-

Do you have -

(1) Yes (2) No

a. A lot of trouble getting along with other people and making and keeping friendships?

b. A lot of trouble concentrating long enough to finish everyday tasks?

c. A lot of trouble coping with day-to-day stresses?

-ADQ42-

During the past 12 months, did the problems just mentioned seriously interfere with your ability to manage everyday activities?

(1) Yes

(2) No

-ADQ43-

Do you have a long-lasting physical or mental condition that has made it difficult to remain employed or to find a job?

(1) Yes

(2) No

-ADQ44-

Does your health or condition prevent you from working at a job or business?

(1) Yes

(2) No

-ADQ45-

Do you have a physical, mental, or other health condition that limits the kind or amount of work you can do around the house?

(1) Yes

(2) No

-ADQ46-

Does your health or condition completely prevent you from doing work around the house?

(1) Yes

(2) No

-ADQ47-

SHOW FLASHCARD BB FOR PERSONAL VISIT INTERVIEWS.

I have recorded that you have a limitation in working. Which condition or conditions cause this limitation?

Enter (H) for list of health conditions

Enter (N) for None or no more

FR NOTE: If the person reports more than three conditions enter the appropriate code for the first three conditions the respondent identified.

Any Others?

-ADQ48-

Which of the conditions that you mentioned do you consider to be the main reason for your limitation?

PRESS (H) TO SEE A LIST OF CONDITIONS

-ADQ49-

In the last 12 months, have you applied for social security disability benefits for yourself?

(1) Yes

(2) No

-ADQ50-

These next few questions are about computer usage. Is there a computer or laptop in your household?

(1) Yes

(2) No

-ADQ51-

Do you use a computer at home?

(1) Yes

(2) No

-ADQ52-

Do you use a computer as a part of your (MAIN) job?

(1) Yes

(2) No

-ADQ53-

Do you use a computer at school?

(1) Yes

(2) No

-ADQ54-

Do you use the internet from any location?

(1) Yes

(2) No

-ADQ55-

Do you connect to the internet at home?

(1) Yes

(2) No

-ADQ56-

At work, do you connect to the internet?

(1) Yes

(2) No

-ADQ57-

Do you use the internet at school?

(1) Yes

(2) No

-ADQ58-

Do you use the internet at-

(1) a public library?

(2) a community Center?

(3) someone else's house?

(4) some other place/specify______________

-ADQ59-

READ: Now we're going to talk about how you may have used the internet this year.

This year, have you used the internet to take a course online?

(1) Yes

(2) No

-ADQ60-

This year, have you used the internet to search for information about health services or practices?

(1) Yes

(2) No

-ADQ61-

This year, have you used the internet to search for information about government services or agencies?

(1) Yes

(2) No

-ADQ62-

This year, have you used the internet to search for a job?

(1) Yes

(2) No

-ONLINE-

Would you be willing to respond to future SIPP interviews over the Internet?

(1) Yes

(2) No

-INTSTILL-

If the SIPP questionnaire was available through the Internet, we expect it would work like this:

- you could answer the questionnaire at your convenience;

- an interviewer would not directly administer the questionnaire;

- it might take longer to complete the questionnaire than the current practice;

- everyone in the household would be asked to fill in parts of the questionnaire for themselves.

Under these conditions, would your household be willing to respond to future SIPP interviews over the Internet?

(1) Yes

(2) No

End of the Adult Disability Topical Module

Page Last Modified: May 12, 2006

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