# Attachment A-1: Participant Screening Questionnaire

**Potential Focus Group Participant Screening Questionnaire**

OMB Control \# \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***Paperwork Reduction Act Statement***

***A federal 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. Public reporting burden for this
collection of information is estimated to vary from 2 to 15 minutes with
an average of 7 minutes per response, including time for reviewing
instructions and completing and reviewing the collection of
information.***

**PURPOSE:** The purpose of this instrument is to screen callers who
respond by telephone to study recruiting efforts for eligibility to
participate in the study. The screen also collects contact and other
information that will be used to schedule potential study participants
into specific focus group sessions, based on their characteristics.

[It is not necessary to read the response options. Only probe with
options if caller is having difficulty responding to the
question.]{.underline}

##### SECTION A. INTRODUCTORY REMARKS

*Hello, you've reached the HHS Study on Disability and Employment
Supports. My name is \[name\]. Are you calling about participating in
the study?* If no, end or direct call as appropriate. If yes, continue
with the following:

*Thank you for your interest in our study. I am going to ask you some
questions about yourself, including some questions about the nature of
your disability, to determine if you meet the study criteria for
participation. My questions, and your answers to them, will take about
seven minutes.* *All of your comments will be confidential. No names of
individuals will be revealed in the summary of the information collected
during the session or in any reports developed for the study.*

*If you meet the criteria, I will then explain more about the study and
what is involved in participating.* If the caller asks for a brief
description of the study:

*I work for Berkeley Planning Associates, a health policy research firm
located in Berkeley, California. We are working with The Lewin Group, a
health policy research firm located in the Washington, DC area, and we
are under contract to the U.S. Department of Health and Human Services
(HHS) to conduct a study on how people with severe disabilities have
been successful in finding and maintaining employment. Our findings will
be presented to HHS for their consideration in potentially developing
new programs designed to support people with disabilities. As part of
our research, we are interviewing individuals for possible participation
in a focus group to discuss the types of supports that have enabled them
to work.*

If caller probes further, answer questions as appropriate and redirect
to screening questions.

##### Section B. demographic/employment screening characteristics 

1.  **How did you hear about our study?**

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a.  Received white letter

b.  Received SSA (blue) letter

c.  Web site (specify)
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

d.  Email

e.  Advertisement (specify)
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

f.  Personal contact (describe
    relationship)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

g.  Don't know/Refused

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```
2.  **What is the zip code of your home address? \_\_\_\_\_\_\_\_\_\_**

If out of relevant area, terminate with: *I'm sorry, but you live
outside the area of our study and so we won't be able to include you,
but I do want to thank you for calling to help with this important
research.*

3.  **How old are you? \_\_\_\_\_\_\_**

If \< 18, terminate with: *I'm sorry, but we can only include in our
study individuals who are 18 and older, but I do want to thank you for
calling to help with this important research*.

4.  **Are you currently employed?**

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a.  Yes -- Continue with Q5

b.  No -- terminate with: *I'm sorry, but we can only include in our
    study individuals who are currently employed, but I do want to thank
    you for calling to help with this important research.*

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```
5.  **How much did you earn over the last 12 months, before taxes?**

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a.  Less than \$7,500

b.  \$7,501 - \$10,000

c.  \$10,001 - \$15,000

d.  \$15,001 - \$20,000

e.  \$20,001 - \$25,000

f.  \$25,001 - \$35,000

g.  \$35,000 - \$50,000

h.  \$50,001 - \$75,000

i.  More than \$75,000

If Q5 = a, then terminate with *I'm sorry, but your earnings are outside
the range designated for this study, but I do want to thank you for
calling to help with this important research.*

If respondent is unable to recall earnings, probe for time worked
(number of months/weeks/days/hours) and wage during the period. Use the
worksheet below to calculate earnings.

+---------------+---+--------------------+---+--------------------------+
| **Time        |   | **Wage (Choose     |   | **Total Earnings**       |
| Worked**      |   | One)**             |   |                          |
|               |   |                    |   |                          |
| **(Last 12    |   |                    |   |                          |
| months)**     |   |                    |   |                          |
+---------------+---+--------------------+---+--------------------------+
| Months        | $ | \                  | = | \_\_\_\_\_\_\_\_\_\_\_\_ |
| worked:       | $ | $\_\_\_\_\_\_\_per |   |                          |
| \_\_\_\_      | $ | month              |   | If \> \$7,500, continue  |
|               | $ |                    |   | with Q6                  |
+---------------+---+--------------------+---+--------------------------+
|               | $ | 4 $$\$\_\_\_\_\_\_ | = |                          |
|               | $ | per week           |   |                          |
|               | $ |                    |   |                          |
|               | $ |                    |   |                          |
+---------------+---+--------------------+---+--------------------------+
|               | $ | 30                 | = |                          |
|               | $ | $$\$\_\_\_\_\_\_   |   |                          |
|               | $ | per day            |   |                          |
|               | $ |                    |   |                          |
+---------------+---+--------------------+---+--------------------------+
|               | $ | 173                | = |                          |
|               | $ | $$\$\_\_\_\_\_\_   |   |                          |
|               | $ | per hour           |   |                          |
|               | $ |                    |   |                          |
+---------------+---+--------------------+---+--------------------------+
| Weeks worked: | $ | \                  | = | \_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_      | $ | $\_\_\_\_\_\_\_per |   |                          |
|               | $ | week               |   | If \> \$7,500 continue   |
|               | $ |                    |   | with Q6                  |
+---------------+---+--------------------+---+--------------------------+
|               | $ | .25                | = |                          |
|               | $ | $$\$\_\_\_\_\_\_\_ |   |                          |
|               | $ | per month          |   |                          |
|               | $ |                    |   |                          |
+---------------+---+--------------------+---+--------------------------+
|               | $ | 5                  | = |                          |
|               | $ | $$\$\_\_\_\_\_\_\_ |   |                          |
|               | $ | per day            |   |                          |
|               | $ |                    |   |                          |
+---------------+---+--------------------+---+--------------------------+
|               | $ | 40                 | = |                          |
|               | $ | $$\$\_\_\_\_\_\_\_ |   |                          |
|               | $ | per hour           |   |                          |
|               | $ |                    |   |                          |
+---------------+---+--------------------+---+--------------------------+
| Days worked:  | $ | \$\_\_\_\_\_\_\_   | = | \_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_      | $ | per day            |   |                          |
|               | $ |                    |   | If \> \$7,500, continue  |
|               | $ |                    |   | with Q6                  |
+---------------+---+--------------------+---+--------------------------+
|               | $ | .033               | = |                          |
|               | $ | $$\                |   |                          |
|               | $ | $\_\_\_\_\_\_\_per |   |                          |
|               | $ | month              |   |                          |
+---------------+---+--------------------+---+--------------------------+
|               | $ | .2                 | = |                          |
|               | $ | $$\                |   |                          |
|               | $ | $\_\_\_\_\_\_\_per |   |                          |
|               | $ | week               |   |                          |
+---------------+---+--------------------+---+--------------------------+
|               | $ | 8                  | = |                          |
|               | $ | $$\                |   |                          |
|               | $ | $\_\_\_\_\_\_\_per |   |                          |
|               | $ | hour               |   |                          |
+---------------+---+--------------------+---+--------------------------+
| Hours worked: | $ | \$\_\_\_\_\_\_ per | = | \_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_      | $ | hour               |   |                          |
|               | $ |                    |   | If \> \$7,500, continue  |
|               | $ |                    |   | with Q6                  |
+---------------+---+--------------------+---+--------------------------+
|               | $ | 0.006              | = |                          |
|               | $ | $$\                |   |                          |
|               | $ | $\_\_\_\_\_\_\_per |   |                          |
|               | $ | month              |   |                          |
+---------------+---+--------------------+---+--------------------------+
|               | $ | .025               | = |                          |
|               | $ | $$\                |   |                          |
|               | $ | $\_\_\_\_\_\_\_per |   |                          |
|               | $ | week               |   |                          |
+---------------+---+--------------------+---+--------------------------+
|               | $ | .125               | = |                          |
|               | $ | $$\                |   |                          |
|               | $ | $\_\_\_\_\_\_\_per |   |                          |
|               | $ | day                |   |                          |
+---------------+---+--------------------+---+--------------------------+

6.  **How old were you when you first started working, earning at least
    minimum wage?**

Age: \_\_\_\_\_

##### Section C. Nature of Impairment 

*As I mentioned earlier, the purpose of this study is to find out more
about how people with significant disabilities have been successful in
finding and keeping jobs.*

1.  **Do you have a physical, sensory or mental disability or health
    condition that has posed any challenges for you in choosing, finding
    or keeping a job?**

a\. Yes -- Continue with Q2

b\. No --terminate with, *I'm sorry we can only include in the study
people who have a disability, but I do want to thank you for calling to
help with this important research.*

2.  **How old were you when this disability or health condition began?**

Age \_\_\_\_\_\_

If Section C, Q2 \> Section B, Q6, terminate with***:*** *I'm sorry, but
in this study we are focusing on individuals whose disability occurred
before they first began working, but I do want to thank you for calling
to help with this important research.*

3.  **Are you *currently* receiving any Social Security disability
    benefits because of your disability?**

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```
a.  Yes -- Skip to Q7

b.  No -- Continue with Q4

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```
4.  **Have you *ever* received any Social Security disability benefits
    because of your disability?**

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```
a.  Yes -- Continue with Q5

b.  No -- Skip to Q7

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```
5.  Is the reason you are not receiving benefits now that your
    disability is no longer considered sufficiently severe to qualify?

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```
a.  Yes -- Screen in and continue with Q6

b.  No

[(continued on next page)]{.smallcaps}

**6. What condition is the primary cause of your disability?**

+-----------------------------------+----------------------------------+
| ###                               |                                  |
| ## Question 6: List of Conditions |                                  |
+-----------------------------------+----------------------------------+
| ##### Cognitive                   | ##### Other Chronic Illnesses    |
|                                   |                                  |
| a.  \*Mental retardation          | a.  Blood Disease/Disorders      |
|                                   |                                  |
| b.  \*Autism                      | ```{=html}                       |
|                                   | <!-- -->                         |
| c.  Other                         | ```                              |
|     \_\_                          | 1.  \*Acute leukemia             |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                                  |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | 2.  \*Coagulation defects        |
|                                   |     (requiring 3 transfusions in |
| ***Probe for functional           |     past 5 months)               |
| limitation in Section IV of Q7    |                                  |
| Table, and continue as            | 3.  Other                        |
| necessary**.*                     |                                  |
|                                   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| ##### Communication               | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                  |
| a.  \*Deaf -- Unable to hear      | ```{=html}                       |
|     normal conversation, even     | <!-- -->                         |
|     with the use of a hearing aid | ```                              |
|                                   | b.  Cancer                       |
| b.  \*Legally blind               |                                  |
|                                   | ```{=html}                       |
| c.  \*Unable to have speech       | <!-- -->                         |
|     understood without the use of | ```                              |
|     an assistive device           | 1.  \*Cancer (not controlled by  |
|                                   |     prescribed therapy)          |
| d.  Other:                        |                                  |
|     \_\_\_\_                      | 2.  \*Brain tumor (inoperable)   |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                                  |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | 3.  Other                        |
|                                   |     \_                           |
| ***Probe for functional           | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| limitation in Section IV of Q7    | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Table, and continue as            |                                  |
| necessary.***                     | ```{=html}                       |
|                                   | <!-- -->                         |
| ##### Mobility/Musculoskeletal    | ```                              |
|                                   | c.  Digestive disorders          |
| a.  Missing limbs, specifically:  |                                  |
|                                   | Condition                        |
| ```{=html}                        | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| <!-- -->                          | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| ```                               |                                  |
| 1.  \*Both feet                   | d.  Endocrine System             |
|                                   |                                  |
| 2.  \*Both hands                  | Condition                        |
|                                   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   |
| 3.  \*Leg and half of pelvis      | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|     (hemipelvectomy)              |                                  |
|                                   | e.  Genito-Urinary               |
| 4.  \*Leg, at hip (hip            |     Disease/Disorders            |
|     disarticulation)              |                                  |
|                                   | ```{=html}                       |
| 5.  \*One hand and one foot       | <!-- -->                         |
|                                   | ```                              |
| 6.  Other                         | 1.  \*Chronic hemodialysis due   |
|                                   |     to renal failure             |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |                                  |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | 2.  \*Chronic peritoneal         |
|                                   |     dialysis due to renal        |
| ```{=html}                        |     failure                      |
| <!-- -->                          |                                  |
| ```                               | 3.  \*Renal osteodystrophy       |
| b.  \*Osteomylitis/Septic         |                                  |
|     arthritis (inflammation of    | 4.  Other                        |
|     the bone) of the pelvis,      |                                  |
|     vertebra, femur (thigh bone), | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|     tibia (shin) or any major     | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|     joint                         |                                  |
|                                   | ```{=html}                       |
| c\. Other                         | <!-- -->                         |
| \_\_\_\_                          | ```                              |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ | f.  Heart/Cardiovascular         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |     disease/disorders            |
|                                   |                                  |
| ***Probe for functional           | Condition                        |
| limitation in Section I of Q7     | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   |
| Table, and continue as            | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| necessary**.*                     |                                  |
|                                   | g.  Immune System                |
| ##### Psychiatric                 |                                  |
|                                   | ```{=html}                       |
| a.  \*Major depression            | <!-- -->                         |
|                                   | ```                              |
| b.  \*Manic-episodes or manic     | 1.  \*HIV with presence of two   |
|     depression, also called       |     or more opportunistic        |
|     bipolar disorder              |     infections                   |
|                                   |                                  |
| c.  \*Psychosis or psychotic      | 2.  Other                        |
|     disorder                      |                                  |
|                                   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| d.  \*Schizophrenia               | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                  |
| Other                             | ```{=html}                       |
| \_\_\_\_\_                        | <!-- -->                         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ | ```                              |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | h.  Neurological disease and     |
|                                   |     disorders                    |
| ***Probe for functional           |                                  |
| limitation in Section IV of Q7    | ```{=html}                       |
| Table, and continue as            | <!-- -->                         |
| necessary.***                     | ```                              |
|                                   | 1.  \*Convulsive disorders       |
|                                   |     (which persist despite       |
|                                   |     treatment)                   |
|                                   |                                  |
|                                   | 2.  Other                        |
|                                   |     \_\_                         |
|                                   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                  |
|                                   | ```{=html}                       |
|                                   | <!-- -->                         |
|                                   | ```                              |
|                                   | i.  Respiratory disease and      |
|                                   |     disorders                    |
|                                   |                                  |
|                                   | Condition                        |
|                                   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                  |
|                                   | j.  Skin Disease/Disorders       |
|                                   |                                  |
|                                   | Condition                        |
|                                   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_   |
|                                   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                  |
|                                   | k\. Other                        |
|                                   | \_\_\_\_                         |
|                                   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                   |                                  |
|                                   | ***Probe for functional          |
|                                   | limitation in Section I of Q7    |
|                                   | Table, and continue as           |
|                                   | necessary.***                    |
+-----------------------------------+----------------------------------+

NOTE: Items marked with an asterisk (\*) qualify as a presumptive severe
disability. If such a condition is selected, screen in and continue with
Section D.

7\. Please describe how this condition affects your daily activities.

Probe as necessary, inquiring about level of difficulty:

-   If criteria are met (two or more [Column 3]{.underline} responses,
    or one or more [Column 4]{.underline}) skip to Section D.

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-   If criteria are not met, return to listing of functional limitations
    and probe further. Skip to Section D if criteria are met, otherwise
    terminate with: I'm sorry, but your condition does not meet the
    requirements for participating in this study, but I do want to thank
    you for calling to help with this important research.

+-----------------------------------+--------+---+-----+----+---+-----------+
| **Question 7: Functional          |        |   |     |    |   |           |
| Limitations**                     |        |   |     |    |   |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
|                                   | ***Col | * |     | ** |   | ***Col    |
|                                   | 1***   | * |     | *C |   | 4***      |
|                                   |        | * |     | ol |   |           |
|                                   |        | C |     | 3* |   |           |
|                                   |        | o |     | ** |   |           |
|                                   |        | l |     |    |   |           |
|                                   |        | 2 |     |    |   |           |
|                                   |        | * |     |    |   |           |
|                                   |        | * |     |    |   |           |
|                                   |        | * |     |    |   |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| **Section I. Mobility -- Lower    |        |   |     |    |   |           |
| Body**                            |        |   |     |    |   |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| a\. Do you use a wheelchair to    | No     |   |     | Mo |   |           |
| get around?                       |        |   |     | st |   |           |
|                                   |        |   |     | or |   |           |
|                                   |        |   |     | a  |   |           |
|                                   |        |   |     | ll |   |           |
|                                   |        |   |     | of |   |           |
|                                   |        |   |     | t  |   |           |
|                                   |        |   |     | he |   |           |
|                                   |        |   |     | ti |   |           |
|                                   |        |   |     | me |   |           |
|                                   |        |   |     |    |   |           |
|                                   |        |   |     | *  |   |           |
|                                   |        |   |     | ** |   |           |
|                                   |        |   |     | Sk |   |           |
|                                   |        |   |     | ip |   |           |
|                                   |        |   |     | to |   |           |
|                                   |        |   |     | S  |   |           |
|                                   |        |   |     | ec |   |           |
|                                   |        |   |     | ti |   |           |
|                                   |        |   |     | on |   |           |
|                                   |        |   |     | D* |   |           |
|                                   |        |   |     | ** |   |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| b\. Walk up a flight of stairs,   | No     |   | S   | A  | U |           |
| without resting and without       | diff   |   | ome | l  | n |           |
| assistance (person or device)     | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| c\. Walk ¼ mile (about three city | No     |   | S   | A  | U |           |
| blocks)                           | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| d\. Stand in line for 20 minutes, | No     |   | S   | A  | U |           |
| without support                   | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| e\. Sit in a chair for long       | No     |   | S   | A  | U |           |
| periods, such as for two hours to | diff   |   | ome | l  | n |           |
| watch a movie                     | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| f\. Bending down, as if to pick   | No     |   | S   | A  | U |           |
| something up from the floor       | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| **Section II. Mobility -- Upper   |        |   |     |    |   |           |
| Body**                            |        |   |     |    |   |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| g\. Lift or carry a 10-pound bag  | No     | S |     | A  |   | Unable to |
| of groceries                      | diff   | o |     | l  |   | Do        |
|                                   | iculty | m |     | ot |   |           |
|                                   |        | e |     |    |   |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| h\. Reaching out, as if to shake  | No     | S |     | A  |   | Unable to |
| someone's hand                    | diff   | o |     | l  |   | Do        |
|                                   | iculty | m |     | ot |   |           |
|                                   |        | e |     |    |   |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| i\. Using both hands to do things | No     | S |     | A  |   | Unable to |
| like shuffle cards, cut food and  | diff   | o |     | l  |   | Do        |
| tie shoelaces                     | iculty | m |     | ot |   |           |
|                                   |        | e |     |    |   |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| j\. Grasp objects, such as pencil | No     | S |     | A  |   | Unable to |
| or scissors                       | diff   | o |     | l  |   | Do        |
|                                   | iculty | m |     | ot |   |           |
|                                   |        | e |     |    |   |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| k\. Reach overhead                | No     | S |     | A  |   | Unable to |
|                                   | diff   | o |     | l  |   | Do        |
|                                   | iculty | m |     | ot |   |           |
|                                   |        | e |     |    |   |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| **Section III. Ability to Care    |        |   |     |    |   |           |
| for Self**                        |        |   |     |    |   |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| l\. Bathing or showering          | No     |   | S   | A  | U |           |
|                                   | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| m\. Dressing                      | No     |   | S   | A  | U |           |
|                                   | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| n\. Eating                        | No     |   | S   | A  | U |           |
|                                   | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| o\. Getting in and out of bed or  | No     |   | S   | A  | U |           |
| chairs                            | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| p\. Using the toilet, including   | No     |   | S   | A  | U |           |
| getting to the toilet             | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| q\. Getting around inside the     | No     |   | S   | A  | U |           |
| home                              | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| r\. Preparing your own meals      | No     |   | S   | A  | U |           |
|                                   | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| s\. Shopping for personal items   | No     |   | S   | A  | U |           |
|                                   | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| t\. Using the telephone           | No     |   | S   | A  | U |           |
|                                   | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| u\. Doing light work around the   | No     |   | S   | A  | U |           |
| house, such as doing dishes,      | diff   |   | ome | l  | n |           |
| straightening up, light cleaning  | iculty |   |     | ot | a |           |
| or taking out the trash           |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| **Section IV. Social              |        |   |     |    |   |           |
| Functioning/Concentration**       |        |   |     |    |   |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| v\. Get along with others         | No     |   | S   | A  | U |           |
|                                   | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| w\. Communicate clearly with      | No     |   | S   | A  | U |           |
| others                            | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| x\. Interact and actively         | No     |   | S   | A  | U |           |
| participate in group activities   | diff   |   | ome | l  | n |           |
|                                   | iculty |   |     | ot | a |           |
|                                   |        |   |     |    | b |           |
|                                   |        |   |     |    | l |           |
|                                   |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+
| y\. Ability to concentrate or     | No     |   | S   | A  | U |           |
| stay focused on individual tasks, | diff   |   | ome | l  | n |           |
| such as following a recipe,       | iculty |   |     | ot | a |           |
| balancing a checkbook, or looking |        |   |     |    | b |           |
| up telephone numbers and          |        |   |     |    | l |           |
| addresses                         |        |   |     |    | e |           |
|                                   |        |   |     |    | t |           |
|                                   |        |   |     |    | o |           |
|                                   |        |   |     |    | D |           |
|                                   |        |   |     |    | o |           |
+-----------------------------------+--------+---+-----+----+---+-----------+

##### 

##### Section D. Additional Demographic characteristics

**1. Gender of caller** (interviewer determination or query)

> a\. Male
>
> b\. Female

**2. What is the highest grade or year in school that you have
completed?**

a\. Less than high school (K - 8)

b\. Some high school ( any of 9 - 12, but no diploma)

b\. High school graduate or equivalent

c\. Some college or vocational education

d\. Completed four-year college degree

e\. Postgraduate degree

f\. Refused/don't know

**3. Which of the following groups best describes you?**

a\. American Indian or Alaska Native

b\. Asian

c\. Black or African American

d\. Native Hawaiian or Other Pacific Islander

e\. White

**4. Do you consider yourself to be of Hispanic, Latino, or Spanish
origin?**

a\. Yes

b\. No

##### Section E. contact and scheduling information

*Thank you for answering my questions. You meet all of the criteria for
participation in the study. Now I'd like to tell you a little about the
study. The study is being conducted for the US Department of Health and
Human Services. The Department of Health and Human Services is
interested in learning more about the kinds of supports that people with
disabilities use and need in order to work. We will be conducting focus
groups with working people with disabilities in the (Seattle/Newark/Los
Angeles) area to discuss employment-related supports and their
employment experiences. Focus groups are meetings where a small number
of people get together and discuss their views on issues raised by a
moderator who leads the discussion.*

*The focus group sessions will be held at a location in the
(Seattle/Newark/Los Angeles) area during the weeks of (dates). Each
session will last about 2 hours and you will be paid for your
participation. Each focus group participant will receive \$25. We will
also provide special transportation, child care and communication
assistance if necessary.*

*Would you be willing to be contacted in the future regarding your
potential participation in one of these focus groups?*

If yes:

**1. Name**

**2. Mailing Address**

**3. Phone Number**

**4. Email Address**

**5. We will be conducting the focus groups in (Seattle/Newark/Los
Angeles) during the weeks of xxxxx and xxxx. What are the best days and
times for you to participate in a 2-hour focus group?**

List of expected session dates and times. Not necessary to read list
unless asked specifically. Give general days and times, probe based on
response, and check those indicated as most convenient by caller.

**Date/time Session 1 \_\_\_\_\_\_**

**Date/time Session 2 \_\_\_\_\_\_**

**Data/time Session 3 \_\_\_\_\_\_**

**.**

**.**

**Date/time Session N \_\_\_\_**

**6. Do you have transportation or personal assistance needs of which we
should be aware?**

a.  Requires transportation (regular)

b.  Requires transportation (wheelchair)

c.  Requires sign language interpreter

d.  Requires letters/study materials in Braille

e.  Requires large-print materials

f.  Requires letter/study materials in electronic format

g.  Requires assistance with completing forms/all activities

h.  Requires own personal assistant to attend session

i.  Other (specify) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**7. Any other assistance needed for you to participate?**

Specify\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Thank you for your willingness to help us with our study. If you are
selected for a focus group session, we will be contacting you to
determine your availability for the session and provide you with more
information.*

#