Survey 1 Competency Screening

ATTACHMENT A1. SURVEY 1 AND 2 CLASSIFICATION QUESTIONS
Measure

Response Options

SSA-455

Question
What are the names of the conditions you would say are the
main reasons why working is dfficult for you?
Would you say that in general your mental health is
Would you say that in general your health is
Now thinking about your physical health, which includes
physical illness and injury, how many days during the past 30
days was your physical health not good?
Now thinking about your mental health, which includes stress,
depression, and problems with emotions, for how many days
during the past 30 days was your mental health not good?
During the past 30 days, for about how many days did poor
physical or mental health keep your from doing your usual
activities, such as self-care, work, or recreation?
Within the last 2 years have you worked for someone or been
self-employed?
Which best describs your health within the last 2 years:
Within the last 2 years has your doctor told you that you can
return to work?
Within the last 2 years have you attended any school or work
training program(s)?
Would you be interested in receiving rehabilitation or other
services that could help you get back to work?
Within the last 2 years have you been hospitalized or had any
surgery?
Within the last 2 years have you gone to a doctor or clinic for
your condition?

VR-12*
Age

What is your age?

Gender

Are you male or female

text
Male
Female
Other
Refuse

Work-limiting conditions
General Mental Health Question
HRQOL-4

HRQOL-4

HRQOL-4

HRQOL-4
SSA-455
SSA-455
SSA-455
SSA-455
SSA-455
SSA-455

Notes

(Open ended)
Excellent; Very good; Good; Fair; Poor
Excellent; Very good; Good; Fair; Poor

(Number of Days)

(Number of Days)

(Number of Days)
Yes; No
Better; Same; Worse
Yes; No
Yes; No
Yes; No
Yes; No
Yes; No

If response is "yes", collect reason and date (month and year)
for each hospitalization or surgery
If response is "yes", collect reason and date (month and year)
for each visit
*While the VR-12 is in the public domain, permission is
required to use it. SSA and/or Westat will need to contact
Lewis Kazis (details included on page 9 of this document:
http://www.bu.edu/sph/files/2015/01/veterans_rand_12_item_
health_survey_vr-12_2007.pdf)
Taken from BUCAT3

Taken from BUCAT3

Race

What is your race? Please select all that apply:

Ethnicity

Are you of Hispanic or Latino Origin?

American Indian or Alaska Native (RaceAI)
Asian (RaceAS)
Black or African American (RaceBlk)
Native Hawaiian or Pacific Islander
(RaceNH)
White (RaceW)
Don't know (RaceDK)
Refuse (RaceRF)
Other (RaceOther)
Yes
No
Refuse

What is your current relationship status?

Never married
Married
Living with a partner in a committed
relationship
Separated
Divorced
Widowed
Refused

Taken from BUCAT3

What is your highest level of education?
In what zip code do you currently reside?

Less than high school diploma
High school diploma (or a GED)
Associate's degree
Vocational Training
Some college – no degree
College or more
Refused
text

Taken from BUCAT3
Taken from BUCAT3

Marital Status

Education
Zip Code

Taken from BUCAT3

Taken from BUCAT3