Form unnumbered Disability testing form

Attachment 2- Testing Instrument/Physical & Social Barriers of Mobility-Impaired Persons

OMB #0920-0222; Expiration Date: 02/28/10

Notice - Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

Assurances of Confidentiality – All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Note: The following questions are from the 1994-1995 National Health Interview Survey on Disability

[Physical Barriers]

The first set of questions are about the place you live.

1. Because of a physical impairment, do you have any difficulty –

a) Entering or leaving your home? Yes No

b) Opening or closing any of the doors in your home? Yes No

c) Reaching or opening cabinets in your home? Yes No

d) Using the bathroom in your home? Yes No

2. Some residencies have special features to assist persons who have physical impairments or health problems. Whether you use them or not, does your residence have any of these features?

1. Widened doorways or hallways? Yes No

2. Ramps or street level entrances? Yes No

3. Railings? Yes No

4. Automatic or easy to open doors? Yes No

5. Accessible parking or drop-off site? Yes No

6. Bathroom modifications? Yes No

7. Kitchen modifications? Yes No

8. Elevator, chair lift, or stair glide? Yes No

9. Alerting devices? Yes No

10. Any other special features? Yes No

If Yes to all items in Q2 skip to Q4. Otherwise ask Q3 for items marked “No” in Q2.

3. Which special features do you NEED to get around your home, but do not have?

1. Widened doorways or hallways? Yes No

2. Ramps or street level entrances? Yes No

3. Railings? Yes No

4. Automatic or easy to open doors? Yes No

5. Accessible parking or drop-off site? Yes No

6. Bathroom modifications? Yes No

7. Kitchen modifications? Yes No

8. Elevator, chair lift, or stair glide? Yes No

9. Alerting devices? Yes No

10. Any other special features? Yes No

[Transportation]

The next questions are about getting around outside your home.

4. Some communities have special bus, cab or van services for people who have difficulty using the regular public transportation service. When using this special service, people can call ahead and ask to be picked up. Is such a service available in your area?

Yes

No (skip to Q7)

5. Have you used this special service in the past 12 months?

Yes (skip to Q7)

No

6. Why haven’t you used this service in the past 12 months?

1. Don’t know how to use

2. Need help from another person

3. Can’t use alone

4. Can’t use phone

5. Don’t have phone

6. Can’t read

7. Illness

8. Can’t get reservation for service

9. Hours of service inadequate

10. Pickup unreliable/inconvenient

11. Cost

12. Denied use of service

13. Service not needed/wanted

14. Other reason

7. During the past 12 months, have you used local public transportation, such as a regular bus line, rapid transit, subway or street car?

1. No public system available (Skip to 11)

2. Yes (Skip to Q9)

3. No (Go to Q8)

8. Does an impairment or health problem prevent or limit your use of the public transportation services?

1. No public system available (Skip to Q11)

2. Yes (Go to Q9)

3. No (Skip to Q11)

9. Because of an impairment or health problem, during the past 12 months, did you have any difficulty using the local public transportation service?

Yes

No

10. What types of difficulties did/would you have using the public transportation service?

(DO NOT READ)

1. Cognitive/mental problems (remembering where to go/knowing how to avoid trouble)

2. Fear

3. Vision

4. Hearing

5. Weather

6. Difficulty walking/can’t walk

7. Wheelchair/scooter/access problems

8. Problems with other medical/assistive devices

9. Need help from another person

10. Hours inadequate

11. Cost

12. Other

13. DK

[General Physical Barriers Outside the Home]

11) Do you have any (other) problems getting around outside your home due to an impairment or health problem?

Yes

No (Skip to Q13)
DK

12) What (other) problems do you have getting around outside your home?

(DO NOT READ)

1. Cognitive/mental problems (remembering where to go/knowing how to avoid trouble)

2. Fear

3. Vision

4. Hearing

5. Weather

6. Difficulty walking/can’t walk

7. Wheelchair/scooter/access problems

8. Problems with other medical/assistive devices

9. Need help from another person

10. Hours inadequate

11. Cost

12. Other

13. DK

Anything else?

[Work Barriers]

These next questions are about working for pay or profit.

13. Do you now work at a job or business? Yes No DK

If “Yes” ask Q14-17, If “No” skip to Q18

13. In order to work, do you NEED any of these special features at your worksite, regardless of whether or not you actually have them:

Handrails or ramps?	Yes No DK
Accessible parking or an accessible transportation stop close to the building?	Yes No DK
An elevator	Yes No DK
An elevator designed for persons with special needs?	Yes No DK
A work station specially adapted for your use?	Yes No DK
A restroom designed for persons with special needs?	Yes No DK
An automatic door?	Yes No DK

Ask for each “yes” response in question 14

13. Do you have (feature) at work?

Handrails or ramps?	Yes No DK
Accessible parking or an accessible transportation stop close to the building?	Yes No DK
An elevator	Yes No DK
An elevator designed for persons with special needs?	Yes No DK
A work station specially adapted for your use?	Yes No DK
A restroom designed for persons with special needs?	Yes No DK
An automatic door?	Yes No DK

13. IN THE PAST FIVE YEARS, have you been fired from a job, laid off, or told to resign because of an ongoing health problem, impairment, or disability?

Yes

No

Not Sure

DK

13. IN THE PAST FIVE YEARS, because of an ongoing health problem, impairment, or disability, have you been –

Refused employment?	Yes No DK
Refused a promotion	Yes No DK
Refused a transfer?	Yes No DK
Refused access to training programs?	Yes No DK

Skip to question 21

13. [If no to Q13, ask]. In order to work, would you NEED any of these special features at your worksite?

Handrails or ramps?	Yes No DK
Accessible parking or an accessible transportation stop close to the building?	Yes No DK
An elevator	Yes No DK
An elevator designed for persons with special needs?	Yes No DK
A work station specially adapted for your use?	Yes No DK
A restroom designed for persons with special needs?	Yes No DK
An automatic door?	Yes No DK

13. IN THE PAST FIVE YEARS, have you been fired from a job, laid off, or told to resign because of an ongoing health problem, impairment, or disability?

Yes

No

Not Sure

DK

13. IN THE PAST FIVE YEARS, because of an ongoing health problem, impairment, or disability, have you been –

Refused employment?	Yes No DK
Refused a promotion	Yes No DK
Refused a transfer?	Yes No DK
Refused access to training programs?	Yes No DK

[Social Activities]

The next questions are about various activities you may have participated in.

21) DURING THE PAST 2 WEEKS, did you –

Get together socially with friends or neighbors?	Yes No DK
Talk with friends or neighbors on the telephone?	Yes No DK
Get together with ANY relatives not including those living with you?	Yes No DK
Talk with ANY relatives on the telephone not including those living with you?	Yes No DK
Go to church, temple, or another place or worship for services or other activities?	Yes No DK
Go to a show or movie, sports event, club meeting, class, or other group event?	Yes No DK
Go out to eat at a restaurant?	Yes No DK

22. Regarding your present social activities, do you feel that you are doing about enough, too much, or would you like to be doing more?

1. Doing about enough

2. Doing too much

3. Would like to be doing more

[Identity]

23) Do you consider yourself to be disabled? (Yes/No)

24. Would other people consider you to have a disability? (Yes/No)

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