List of all Physical Function CAT items

Attachment B: List of All Physical Function CAT Items

OMB No.: 0925-0589

Expiration Date: xx/xx/20xx

Public reporting burden for this collection of information is estimated to range from 5 to 15 minutes per response, including the 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 this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0589). Do not return the completed form to this address.

Below is a list of all the questions that could potentially be asked by the interviewer to the respondent. Because of the adaptive nature of the application, a respondent may be asked to respond to anywhere from 5 to 30 questions to assess the nature of their current functional status for physical and behavioral aspects. This application will take into account the person’s previous response to choose the next question and number of remaining questions necessary to develop a Functional Assessment Profile.

Scale Code for the Physical Function CAT Instrument

BP = Changing and Maintaining Body Position

UBF = Upper Body Function

UEFM = Upper Extremity Fine Motor

WBM = Whole Body Mobility

WC = Wheelchair

Introduction:

This study is a collaboration between the Social Security Administration and the National Institutes of Health to develop a new method of asking questions about disability (i.e., computer adaptive tests) and new questions to ask about your daily physical and behavioral activities.

The functional assessment profile is intended to measure self-reported functioning in the areas of physical health. These questions will not be used in your application for benefits and your answers to these questions will not affect your current or any future application.  It is up to you whether you want to answer these questions or not. You can skip any questions that you do not want to answer. Some of these questions may be similar to other questions you may have answered already or may come up during the application process.  Is it okay if I ask you these additional questions?

Choose one response to these questions:

Strongly Agree, Agree, Disagree, Strongly Disagree, or Does not apply.

Scale	Content
BP	Are you able to get into and out of a car? Hint: Please base your response on the most difficult part of this activity.
BP	Are you able to get up off the floor from lying on your back? Hint: You can use a chair or other object to get up.
BP	Are you able to stand up from an armless, straight chair? Hint: Without holding on to anything.
BP	Are you able to move from lying on your back to sitting on the edge of your bed?
BP	Are you able to get in and out of bed? Hint: Base response on the most difficult part of the activity.
BP	Are you able to sit on a stool without back support?
BP	Are you able to move around on your hands and knees in a crawling position?
BP	Are you able to go up three flights of stairs using a handrail? Hint: A flight of stairs is 12-15 steps.
BP	Are you able to go up one flight of stairs using a handrail? Hint: A flight of stairs is 12-15 steps.
BP	Are you able to get moving after you've been lying down on a couch? For example: Get to the sitting position, then walk or use your wheelchair.
BP	Are you able to get down on the floor? For example: Moving from standing or your wheelchair to kneel or sit on the floor
BP	Are you able to get in and out of a squatting position? Hint: Please base your response on the most difficult part of the activity.
BP	Are you able to get into and out of a kneeling position? Hint: Please base your response on the most difficult part of the activity.
BP	Are you able to stand up from a low, soft couch? Hint: Without holding on to anything.
BP	Are you able to bend down to pick up clothing from the floor?
BP	Are you able to bend over to pick up coins that are scattered on the floor?
BP	Are you able to work at floor level (e.g. changing the face plate on an electric outlet)?
BP	How long are you able to squat?
BP	Are you able to kneel on the floor for a long time (e.g. when cleaning the bathtub or playing with kids or pets)? For example: 3-5 minutes
BP	How long are you able to kneel?
BP	Are you able to climb 2 or 3 steps up a step ladder?
BP	Are you able to go down one flight of stairs using a handrail? Hint: A flight of stairs is 12-15 steps.
BP	Are you able to bend over from a sitting position to pick up an object you dropped on the floor?
BP	Are you able to get into and out of a car? Hint: Please base your response on the most difficult part of this activity.
BP	Are you able to get up off the floor from lying on your back? Hint: You can use a chair or other object to get up.
BP	Are you able to stand up from an armless, straight chair? Hint: Without holding on to anything.
UBF	Are you able to pull open a heavy door?
UBF	Are you able to push open a heavy door?
UBF	Are you able to push a vacuum?
UBF	Are you able to push a full wheelbarrow?
UBF	Are you able to pick up a kitchen chair and move it, in order to clean?
UBF	Are you able to carry a full laundry basket up a flight of stairs? Hint: A flight of stairs is 12-15 steps.
UBF	Are you able to push a full grocery cart?
UBF	Are you able to pull a cord on a lawn mower, chain saw, generator or boat motor?
UBF	Are you able to reach overhead into a high cabinet?
UBF	Are you able to work overhead for 20 minutes (e.g. organizing a high shelf in a closet)?
UBF	Are you able to carry a full plastic shopping bag for 30 feet?
UBF	Are you able to carry a full laundry basket for 30 feet?
UBF	Are you able to carry a full paper grocery bag for 30 feet?
UBF	Are you able to lift a full 2 liter soda bottle from table height to a high shelf? Hint: 2 liter soda bottle= 3.5 lbs/1.5 kg.
UBF	Are you able to do yard work (e.g. plant shrubs or a garden) for 2 hours? For example: With occasional rest but continuous work.
UBF	Are you able to lift a full small (carry-on size) suitcase from the floor to table height? Hint: A full carry-on suitcase weighs 20 pounds/8 kg.
UBF	Are you able to lift a full small (carry-on size) suitcase from table height to a high shelf? Hint: A full carry-on suitcase weighs 20 pounds/8 kg.
UBF	Are you able to lift a full large (check-in size) suitcase from the floor to table height? Hint: A full large suitcase weighs 40-50 pounds/18-23 kg.
UBF	Are you able to lift a full large (check-in size) suitcase from table height to a high shelf? Hint: A full large suitcase weighs 40-50 pounds/18-23 kg.
UBF	Are you able to carry a full large (check-in size) suitcase for 30 feet? Hint: A full large suitcase weighs 40-50 pounds/18-23 kg.
UBF	Are you able to trim a tree with long handle saw?
UEFM	Are you able to pick up and put down a pen or pencil?
UEFM	Are you able to use a hammer to pound a nail?
UEFM	Are you able to open previously opened jars?
UEFM	Are you able to open a can with a hand can opener?
UEFM	Are you able to use a lever handle to open a door? Hint: A lever handle is a handle that you push down to open a door.
UEFM	Are you able to open childproof medicine bottles or jars?
UEFM	Are you able to hold a full glass of water in one hand?
UEFM	Are you able to cut a piece of paper with scissors?
UEFM	Are you able to turn faucets on and off?
UEFM	Are you able to address an envelope with a pen?
UEFM	Are you able to remove wrappings from small objects? For example: Like removing the packaging from a pack of batteries.
UEFM	Are you able to pick out one key from group of keys?
UEFM	Are you able to pick out a paper clip from group of clips?
UEFM	Are you able to turn a key in a door lock?
UEFM	Are you able to remove a gas cap from a car?
UEFM	Are you able to change the bulb in a table lamp?
UEFM	Are you able to reach behind you to get your seatbelt? Hint: A shoulder harness seatbelt.
UEFM	Are you able to remove something from your back pocket?
UEFM	Are you able to hold a book while reading?
UEFM	Are you able to pick up coins from a table top?
UEFM	Are you able to turn a door knob?
UEFM	Are you able to tighten screws by hand with a screwdriver?
UEFM	Are you able to write for 20 minutes?
UEFM	Are you able to put batteries in a flashlight, or remote control for your television?
UEFM	Are you able to staple 2 sheets of paper together?
UEFM	Are you able to pull a pillow case off a pillow?
UEFM	Are you able to tie a knot?
WBM	Are you able to stand on your feet for one hour?
WBM	Are you able to stand on your feet for one hour using your walking aid?
WBM	Are you able to walk a mile without resting?
WBM	Are you able to walk a mile without resting using your walking aid?
WBM	Are you able to walk up a steep slope (e.g. on a hill)?
WBM	Are you able to walk on uneven surfaces (e.g. grass, dirt road or sidewalk)?
WBM	Are you able to walk quickly indoors (e.g. to answer the telephone or the front door)?
WBM	Are you able to run a short distance, such as to catch a bus? A short distance is roughly half a block or about 15-20 yards.
WBM	Are you able to walk for at least 15 minutes?
WBM	Are you able to remain on your feet for at least 20 minutes?
WBM	Are you able to remain on your feet for 2 hours with short breaks?
WBM	How long are you able to walk without stopping? If you cannot walk without stopping for 15 minutes please select unable.
WBM	How long are you able to walk without stopping using your walking aid?
WBM	How fast are you able to walk?
WBM	Are you able to walk for at least 30 minutes?
WBM	Are you able to cross the road at a 4-lane traffic light with curbs using your walking aid?
WBM	Are you able to walk around one floor of your home without tripping or losing your balance?
WBM	Are you able to walk in a busy place (e.g., crowded store) without losing your balance using your walking aid?
WBM	Are you able to run fast for 2 minutes?
WBM	Are you able to remain on your feet for 6 hours with short breaks?
WBM	Are you able to walk 150 feet (45 meters) on flat ground?
WBM	Are you able to walk up a steep slope (e.g. on a hill) using your walking aid?
WBM	Are you able to walk on uneven surfaces (e.g. grass, dirt road or sidewalk) using your walking aid?
WBM	Are you able to walk for at least 15 minutes using your walking aid?
WBM	Are you able to remain on your feet for at least 20 minutes using your walking aid?
WBM	Are you able to remain on your feet for 2 hours with short breaks using your walking aid?
WBM	Are you able to walk for at least 30 minutes using your walking aid?
WBM	Are you able to remain on your feet for 6 hours with short breaks using your walking aid?
WC	Are you able to move your wheelchair for at least 15 minutes?
WC	Are you able to get in and out of a car from your wheelchair? Please consider a sedan sized car when considering your answer.
WC	Are you able to get into and out of a truck, bus, shuttle van, or sport utility vehicle from your wheelchair?
WC	Are you able to move around in the bathroom, including getting on and off the toilet from your wheelchair?
WC	Are you able to move around one floor of your home in your wheelchair without bumping into things?
WC	Are you able to cross the street at a traffic light in your wheelchair?
WC	Are you able to move your wheelchair up and down curbs? Please base your response on the most difficult part of this activity.
WC	Are you able to get in and out of your wheelchair? Please base your response on the most difficult part of this activity.

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