**Appendix 3: Cognitive Testing Interview Guide**

**What is cognitive testing? How is it useful?**

The primary purpose of cognitive testing is to investigate how well
questions perform when asked of survey respondents, that is, if
respondents understand the question correctly and if they can provide
accurate answers. Cognitive testing insures that a survey question
successfully captures the scientific intent of the question and, at the
same time, makes sense to respondents. Questions that are misunderstood
by respondents or that are difficult to answer can be improved prior to
fielding the survey, thereby increasing the overall quality of survey
data. Additionally, once survey data has been collected, cognitive
testing results can provide useful information for users by documenting
potential sources of response error as well as providing a richer
understanding of the type of data that has been collected.

In evaluating a question's performance, cognitive testing examines the
question-response process (a process that can be conceptualized by four
stages: comprehension, retrieval, judgment and response) and considers
the degree of difficulty respondents experience as they formulate an
accurate response to the question. In each of the four stages, various
types of response errors can occur. The following chart outlines some of
those problems:

Cognitive Model of Question-Response

  ------- --------------- ---------------------------- -------------------------
          Cognitive Stage Definition                   Response Errors/Question
                                                       Problems

  Stage 1 Comprehension   Respondent interprets the    Unknown terms, Ambiguous
                          question                     concepts, Long and overly
                                                       complex

  Stage 2 Retrieval       Respondent searches memory   Recall difficulty
                          for relevant information     

  Stage 3 Judgment        Respondent evaluates and/or  Biased or sensitive,
                          estimates response           Estimation difficulty

  Stage 4 Response        Respondent provides          Incomplete response
                          information in the format    options
                          requested                    
  ------- --------------- ---------------------------- -------------------------

Typically, cognitive testing is performed by conducting in-depth,
semi-structured interviews with a small number of respondents similar to
those targeted in the survey. The interviews are designed to elicit
respondents' thought processes when answering the tested question,
specifically, how they understood a question and how they arrived at
their answer. Data from cognitive interviews are qualitative, and
analysis of those interviews can indicate the sources of potential
response error as well as various interpretations of the question. By
conducting a comparative analysis of cognitive interviews, it is
possible to identify patterns of error and patterns of interpretation
across groups of people. This type of analysis is especially useful when
examining the comparability of measures, for example, between countries
or between social classes.

The differences between cognitive testing and field testing are
important to understand. Unlike a field test, the primary objective of a
cognitive test is not to produce statistical data that can be
generalized to an entire population. Rather, the objective of cognitive
testing is to provide an in-depth exploration of particular concepts,
processes and patterns of interpretation. As a result, cognitive testing
draws upon a much smaller, purposive sample. Finally, because the
interview involves examining what a respondent is actually thinking or
feeling when answering a question, the cognitive interview can seem
somewhat personal or even strange to respondents, and it is important to
make this clear to respondents when they have volunteered for a
cognitive interview.

**Testing the Washington Group questions: What are the goals? What are
the challenges?**

The primary goal of cognitive testing is to

-   Determine whether questions are being interpreted as intended. That
    is, if they are capturing aspects of the selected functional domains

-   Determine whether questions are interpreted consistently across
    countries and among subpopulations

Challenges for conducting the cognitive test

-   Interviewers may have little or no training

-   Interviewers may have no understanding of cognitive methods

-   Multiple languages

-   Multiple cultures

-   Variety of levels of country resources

Given the challenges, the cognitive testing protocol must:

-   Be a more structured interview guide than traditional cognitive
    interviewing

-   Provide very simple instructions

-   Contain few skip patterns

-   Rely on quantitative data and analysis

The final protocol, though unconventional because it is not qualitative,
is based on the principles of traditional cognitive testing and is
designed to collect information regarding the question response process,
including patterns of interpretation, evaluation and decision-making
patterns, as well as potential response error.

**Instructions for conducting the Washington Group Cognitive Test**

In comparison to the field test, few resources are required to conduct
the cognitive test. The cognitive test can be conducted in the time of
approximately one week and requires only a few interviewers. The
following steps outline the procedures to conduct the cognitive test of
the Washington Group questions:

1.  [Translating the Cognitive Test Questionnaire]{.underline}

> It is important to modify the cognitive test questionnaire
> specifically for your country and the respondents that you will be
> interviewing. The cognitive test questionnaire was initially developed
> in English in the United States. A Spanish version of the
> questionnaire was also produced to test the protocol among
> Spanish-speaking respondents in the United States. It was then pilot
> tested in Mexico City. In the pilot test, however, the translated
> questionnaire did not perform in Mexico as it did in the United
> States. Even though both tests were performed in Spanish, cultural and
> linguistic differences in the two countries generated significant
> differences in the terms and meanings of the questions. Consequently,
> the Spanish questionnaire needed to be modified specifically for the
> country of Mexico.
>
> To produce an appropriate translation of the cognitive test
> questionnaire for your country, have two or three bilingual speakers
> translate and review the questionnaire. In drafting a translation,
> refer to the Question Specifications that describe the purpose of each
> question. Reviewers should work independently, but then meet to
> discuss their impressions and reconcile discrepancies. This small
> group approach produces a more accurate translation than the
> subjective opinion of a single translator or by conducting a
> forward/back translation.
>
> In the end, the translated version of the questionnaire should be
> conceptually identical to the original version. That is, the ideas and
> meanings of the questions must be conveyed in the way that respondents
> will understand them as originally intended. The questionnaire should
> not simply be a word-for-word translation of the original protocol. If
> you have any questions regarding the meaning or intention in the
> original questionnaire, please contact the Washington Group
> secretariat. Additionally, be sure to document and report all changes
> that are made to the protocol in the translation process.

2.  [Selecting and Training Interviewers]{.underline}

> The cognitive test questionnaire was developed to be easily
> administered. However, if it is possible to select interviewers who
> understand the purpose of the test and who have experience conducting
> survey interviews, the data collected will likely be of higher
> quality. The number of interviewers that are required will depend on
> the available resources and the number of interviews that you want to
> conduct. It is possible to conduct all of the interviews yourself. Or,
> you can use as many as 20 interviewers to conduct only four or five
> interviews each.
>
> To train interviewers, read through the questionnaire and refer to the
> interviewer instructions that appear below. Be sure that interviewers
> understand the purpose of the interview as well as the various
> components of the interview guide. [It is critical that interviewers
> understand that they are not to correct or help the respondent to
> answer questions, especially the core questions which are being
> tested]{.underline}. The interviewer must read the question exactly as
> it is written and then record the answer as it is reported by the
> respondent. If the respondent cannot answer the question, the
> interviewer should record "don't know" and then continue on to the
> next question.
>
> Interviewers should conduct a couple of practice interviews so that
> they become familiar with the questionnaire's skip patterns and are
> able to accurately record the interviewer coding questions. It is also
> important to observe practice interviews to be sure that interviewers
> understand the purpose of the cognitive interview and are not
> "helping" or "assisting" respondents.

3.  [Recruiting Respondents]{.underline}

> The sample selection for the cognitive test is "purposive." That is,
> respondents are not selected through a random process, but rather are
> selected for specific characteristics such as their gender, race or
> type of disability. Before recruiting respondents, decide what
> respondent characteristics are necessary to have represented in the
> sample. At a minimum, the sample should be composed of respondents who
> posses limited physical abilities in each of the represented
> dimensions. This will ensure that each question can be tested for
> false negative responses. Additionally, to test for false positive
> responses, it is important to select some respondents who are not
> disabled and a few who have injuries or other types of temporary
> limitations. Depending on the demographic makeup of your country, you
> may also want to select respondents representing various ages,
> ethnicities, incomes and education levels.
>
> Because the cognitive test sample is purposive and not random,
> respondents can be recruited by a variety of informal methods.
> Respondents can be found through personal contacts (e.g. through
> friends or relatives), through a community center or by placing an
> advertisement in a local paper. It will be important to track the
> demographic characteristics of respondents as interviews are collected
> so that, by the time all interviews are collected, the characteristic
> requirements of the completed sample are met.

4.  [Debriefing Interviewers]{.underline}

> If possible, discuss the interviews with the interviewers after they
> are completed. Did some questions in the protocol not work? If so,
> which questions? What seemed to be the problem with the question? Did
> any questions work particularly well? If so, which questions? Be sure
> to document and report interviewer perceptions at the end of the excel
> spread sheet. This information will provide valuable insight when
> performing analysis of the cognitive test data.

5.  [Entering Data, Checking Data, and Performing Analysis]{.underline}

> We have included a spreadsheet to facilitate having the data recorded
> in a uniform way. The attached spreadsheet should also be sent to NCHS
> for the cross-country analysis and it can be used as well for your
> analysis of the data. Variables in the spreadsheet correspond to the
> variables that appear on the questionnaire by the question number.
>
> Each line in the spreadsheet will represent one respondent's answers
> to all the questions. I identify the respondent in the first column of
> the spreadsheet. To record a respondent's answer to a specific
> question in the spreadsheet, enter the number in the parenthesis that
> appears next to the respondent's answer on the questionnaire. Open
> ended questions should be recorded verbatim into the spreadsheet in
> the language that was spoken by the respondent. The respondent's
> answer should then be recorded in their native language in one column
> and translated into English and recorded in the next column. A column
> has been provided for answers in both the native language and then the
> English translation. If the respondent responds in English, record the
> response once in the English column.
>
> Once entered, check the data to ensure that there are no obvious
> errors. NCHS will identify patterns in the response process
> (specifically, interpretations and judgment) and response errors
> across countries and demographic variables.

**Cognitive Test Questionnaire**

The evaluation consists of the 6 core questions followed by probe
questions designed to illustrate: 1) whether core questions were
administered with relative ease; 2) how core questions were interpreted
by respondents; 3) the factors considered by respondents when forming
answers to core questions; and 4) the degree of consistency between core
question responses and responses to a set of more detailed questions
addressing respondent functioning in each of the domains covered by the
6 core questions. The questionnaire also contains a proxy-report
component. After each respondent has answered the questions about their
own health and functioning status, they will then be asked to answer the
same questions about another household member's health and functioning
status. This will allow us to investigate whether respondents interpret
and consider the same questions differently when reporting for another
person as opposed to when reporting for themselves. The demographic and
general health sections provide essential background information that
will be used to understand whether the questions work consistently
across all respondents, or if nationality, education, gender or
socio-economic status impact the ways in which respondents interpret the
question or other aspects of the question response process. Questions
can be added to meet individual country needs and circumstances at the
end of the questionnaire. However, the questions we are supplying should
not be changed and all the questions should be asked. The interview will
take approximately one hour, though the exact length will vary depending
on the respondent and their particular disability.

**Outline of the Cognitive Testing Protocol:**

I.  Demographics

II. Self-Report Component: Respondent answers questions regarding their
    own health and abilities

    a.  Vision Question

        i.  Interviewer coding

        ii. Open-ended follow-up probe

        iii. Cognitive follow-up probes

        iv. Functioning follow-up probes

    b.  Hearing Question

        i.  Interviewer coding

        ii. Open-ended follow-up probe

        iii. Cognitive follow-up probes

        iv. Functioning follow-up probes

    c.  Cognitive Functioning Question

        i.  Interviewer coding

        ii. Open-ended follow-up probe

        iii. Cognitive follow-up probes

        iv. Functioning follow-up probes

    d.  Walking Question

        i.  Interviewer coding

        ii. Open-ended follow-up probe

        iii. Cognitive follow-up probes

        iv. Functioning follow-up probes

    e.  Self-Care Question

        i.  Interviewer coding

        ii. Open-ended follow-up probe

        iii. Cognitive follow-up probes

        iv. Functioning follow-up probes

    f.  Communication Question

        i.  Interviewer coding

        ii. Open-ended follow-up probe

        iii. Cognitive follow-up probes

        iv. Functioning follow-up probes

    g.  General Health Question

        i.  Interviewer coding

        ii. Open-ended follow-up probe

        iii. Health Status follow-up probes

III. Proxy-Report Component: The same respondent answers questions
     regarding another household member's health and abilities

     a.  Vision Question

         i.  Interviewer coding

         ii. Open-ended follow-up probe

         iii. Cognitive follow-up probes

         iv. Functioning follow-up probes

     b.  Hearing Question

         i.  Interviewer coding

         ii. Open-ended follow-up probe

         iii. Cognitive follow-up probes

         iv. Functioning follow-up probes

     c.  Cognitive Functioning Question

         i.  Interviewer coding

         ii. Open-ended follow-up probe

         iii. Cognitive follow-up probes

         iv. Functioning follow-up probes

     d.  Walking Question

         i.  Interviewer coding

         ii. Open-ended follow-up probe

         iii. Cognitive follow-up probes

         iv. Functioning follow-up probes

     e.  Self-Care Question

         i.  Interviewer coding

         ii. Open-ended follow-up probe

         iii. Cognitive follow-up probes

         iv. Functioning follow-up probes

     f.  Communication Question

         i.  Interviewer coding

         ii. Open-ended follow-up probe

         iii. Cognitive follow-up probes

         iv. Functioning follow-up probes

     g.  General Health Question

         i.  Interviewer coding

         ii. Open-ended follow-up probe

         iii. Health Status follow-up probes

**Interviewer Instructions**

This protocol should be administered like a traditional questionnaire:
start at the beginning, go through each page to the end, and read each
question along with the response options exactly as they appear. Check
the box next to the response that is given by the respondent. The
numbers appearing after each response are [not]{.underline} meant to be
read out loud to respondents. The numbers will be used after all of the
interviews have been conducted to compile responses. Words appearing in
italics, bold print or in shaded boxes are also [not]{.underline} meant
to be read out loud to the respondent. Instead, these are instructions
to you\-- the interviewer. In a few places, you will be instructed to
skip some questions depending on the respondent's answer to a previous
question. Additionally, in each section there are a few questions that
are asked of you and not the respondent. You should take a few seconds
to answer those questions as they appear in the questionnaire. They
should not be read out loud to the respondent. To ensure a smooth
interview, read through the questionnaire or (even better) conduct a
practice interview with a friend or family member before conducting an
interview with a "real" respondent. The questionnaire was designed to be
easy to administer, so (with only a little preparation) you should find
the interview process itself to be very simple and straight-forward.

The following outlines the various types of questions\-- including
interviewer instructions and tips for administering them\-- that make up
the cognitive testing protocol:

[Core Questions]{.underline}: These are the 6 disability questions to be
tested by this cognitive interview. All of the other questions in this
questionnaire are designed to examine how well these core questions
perform. Therefore, it is imperative that you [ask the core question and
the response categories exactly as they are written]{.underline}. You
may repeat the question and/or the answer categories, but do not try to
help or assist the respondent if they are experiencing difficulty. That
is, **do not attempt to explain the question or help them figure out
what their answer should be**. It is important to learn how respondents
are interpreting the question, regardless of whether or not their
interpretation is correct. Additionally, it is important to discover the
degree of difficulty that they experience without the help of an
interviewer. If the respondent is unable to answer the question, this is
important information to know.

[Interviewer Coding]{.underline}: These 3 questions appear in the shaded
box immediately after the core question. They are to be answered by you,
the interviewer, and are designed to capture basic information about the
ease of administration for the core question, specifically, whether the
question (or any part of the question) needed to be repeated, if the
response categories worked appropriately, and if the respondent needed
clarify their answer. To ensure accuracy, these questions must be
answered immediately, when they appear in the questionnaire. Do not wait
until the end of the interview.

For the first interviewer-coded question (*Did the respondent need you
to repeat any part of the question?*), check the box marked "Yes" if the
respondent asked you to repeat any part of the question---the question
portion, the response options or the entire question. Also, check the
box marked "Yes," if (when administering the question) you saw that the
respondent did not hear or understand the question so repeated it for
their benefit.

For the second interviewer-coded question (*Did the respondent have any
difficulty using the response options?*), check the box marked "Yes" if
the respondent did not answer using one of the provided response
categories (for example, if they made up their own category or used
other words) or if they experienced any other kind of difficulty with
the response options.

For the third interviewer-coded question (*Did the respondent ask for
clarification or qualify their answer?*), check the box marked "Yes" if
the respondent needed to provide additional information along with their
answer or if they asked you to clarify some aspect of the question.

[Open-ended Follow-up Probes]{.underline}: The open-ended probe question
(*Why did you answer that way?*) appears directly after the
interviewer-coding questions. This is the first question asked of the
respondent after they have answered the core question and is designed to
elicit what the respondent was thinking when answering the question. As
much as possible, record exactly what the respondent states in the
provided space. More than any other probe-question, this qualitative
information will provide detailed insight into how the respondent
interpreted the core question and how their response was formulated.

[Cognitive Follow-up Probes]{.underline}: The cognitive probe-questions
are designed to capture how the respondent came up with their answer,
specifically, what the respondent considered when formulating a
response. These questions are based on analysis of previous open-ended
cognitive interviews and represent all of the various considerations
used by respondents to construct answers to the core questions. The
cognitive probe-questions are subjective; there is no right or wrong
answer. Additionally, because they are subjective and based solely on
the respondents perceptions, these probe-questions should be relatively
easy for respondents to answer. However, if a respondent is unable to
answer (for whatever reason), check box marked "*No Answer/Don't Know*"
which appears below the list of response options. This *No Answer*
option (appearing in italics) is not to be read to the respondent and is
only to be used in rare occasions\-- if the respondent, in all
sincerity, cannot answer the question.

[Functioning Follow-up Probes]{.underline}: These functioning
probe-questions appear at the end of each section. They are designed to
provide an objective assessment of the respondent's physical
abilities---information that will help to assess the validity of the
core question. However, in our testing of this questionnaire, we found
these questions to be the most difficult questions in the
questionnaire---especially for respondents who have little education or
experience taking surveys. In asking these questions, you may find that
these respondents misunderstand the intention of the question or are not
able to apply the question to their personal circumstances. In this
cases, please do your best to get the most accurate answer---by asking
the question in different ways, explaining the purpose, or by
observation.

[Proxy-Report Component]{.underline}: For this second half of the
interivew, the same questions are repeated to the respondent, however,
the questions in this section pertain to another household member's
abilities and health status. The same respondent that answered questions
in the first part of the interview should continue to answer the
questions in the second part of the interview. The purpose of this
section is to determine whether respondents interpret or consider the
same questions differently when reporting for another person as opposed
to when reporting for themselves. You will choose the name of the other
household member in Question 6 of the demographic section. You may
choose any household member from the list provided in Question 6. Once
you have chosen the name of the other household member, write the name
in the blank and refer to that name when asking the questions in the
proxy-report component.

**Instructions to the respondent:**

Thank you for agreeing to participate in this interview. The purpose of
this project is to develop questions about people's health and abilities
to do certain acitivities that will eventually be asked of many people
of all ages around the world. For this project, we need to find out if
the questions make sense to everyone and if everyone understands the
questions in the same way. Your interview will help us find out how the
questions are working.

This interview will last about one hour and will primarily be about your
abilities to do certain activities. Many of these questions will seem
repetitive and even somewhat strange or personal. This is because we are
testing the questions, and we need to understand what people are
considering when they form an answer. Please do you best to answer the
questions as you understand them.

Everything that you tell me is confidential and will be kept private. If
you do not want to answer a question, please tell me and I will move to
the next question. Before we begin, do you have any questions?

+----------------------+------------------------+----------------------+
| ID#                  |                        |                      |
+----------------------+------------------------+----------------------+
| LANGUAGE             |                        |                      |
+----------------------+------------------------+----------------------+
| *COUNTRY*            |                        |                      |
+----------------------+------------------------+----------------------+
| *RECORD SEX AS       |                        | Female 1             |
| OBSERVED*            |                        |                      |
|                      |                        | Male 2               |
+----------------------+------------------------+----------------------+
| 1\. How old are you  |                        | \_\_\_\_\_\_\_ years |
| now?                 |                        |                      |
+----------------------+------------------------+----------------------+
| 2\. How many years   |                        | \_\_\_\_\_\_ years   |
| in all did you spend |                        |                      |
| [studying in         |                        |                      |
| school]{.underline}, |                        |                      |
| college or           |                        |                      |
| university?          |                        |                      |
+----------------------+------------------------+----------------------+
| 3\. Which describes  |                        | Paid work 1          |
| your [main work      |                        |                      |
| status]{.underline}  |                        | Self employed, such  |
| best?                |                        | as own 2             |
|                      |                        |                      |
| ***(select the       |                        | your business or     |
| single best          |                        | farming              |
| option***            |                        |                      |
|                      |                        | Non paid work, such  |
|                      |                        | as 3                 |
|                      |                        |                      |
|                      |                        | volunteer or charity |
|                      |                        |                      |
|                      |                        | Student 4            |
|                      |                        |                      |
|                      |                        | Keeping              |
|                      |                        | house/Homemaker 5    |
|                      |                        |                      |
|                      |                        | Retired 6            |
|                      |                        |                      |
|                      |                        | Unemployed (health   |
|                      |                        | reasons) 7           |
|                      |                        |                      |
|                      |                        | Unemployed (other    |
|                      |                        | reasons) 8           |
|                      |                        |                      |
|                      |                        | Other *(specify)* 9  |
+----------------------+------------------------+----------------------+
| 4\. Are you now      |                        | Married 1            |
| married, widowed,    |                        |                      |
| divorced, separated, |                        | Widowed 2            |
| never married, or    |                        |                      |
| living with a        |                        | Divorced 3           |
| partner?             |                        |                      |
|                      |                        | Separated 4          |
|                      |                        |                      |
|                      |                        | Never Married 5      |
|                      |                        |                      |
|                      |                        | Living with partner  |
|                      |                        | 6                    |
|                      |                        |                      |
|                      |                        | Don\'t know/Refused  |
|                      |                        | 9                    |
+----------------------+------------------------+----------------------+
| 5\. What is your     |                        | J                    |
| household income?    |                        |                      |
| (See card)           |                        | C                    |
|                      |                        |                      |
|                      |                        | M                    |
|                      |                        |                      |
|                      |                        | F                    |
|                      |                        |                      |
|                      |                        | S                    |
|                      |                        |                      |
|                      |                        | K                    |
|                      |                        |                      |
|                      |                        | P                    |
|                      |                        |                      |
|                      |                        | D                    |
|                      |                        |                      |
|                      |                        | H                    |
|                      |                        |                      |
|                      |                        | U                    |
|                      |                        |                      |
|                      |                        | N                    |
+----------------------+------------------------+----------------------+
| 6\. Including        |                        |                      |
| yourself, What are   |                        |                      |
| the names and ages   |                        |                      |
| of all of the people |                        |                      |
| living in your home? |                        |                      |
+----------------------+------------------------+----------------------+
| Name:                | ###                    |                      |
+----------------------+------------------------+----------------------+
| Name:                | ###                    |                      |
+----------------------+------------------------+----------------------+
| Name:                | ###                    |                      |
+----------------------+------------------------+----------------------+
| Name:                | ###                    |                      |
+----------------------+------------------------+----------------------+
| Name:                | ###                    |                      |
+----------------------+------------------------+----------------------+
| Name:                | ###                    |                      |
+----------------------+------------------------+----------------------+
| Name:                | ###                    |                      |
+----------------------+------------------------+----------------------+
| Name:                | ###                    |                      |
+----------------------+------------------------+----------------------+
| Name:                | ###                    |                      |
+----------------------+------------------------+----------------------+

**Interviewer: Select one of the household members (other than the
respondent) to use for the proxy-reporting portions of the
questionnaire. Name of Proxy Respondent:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**VISION---SELF-REPORT**

**The next questions ask about difficulties you may have doing certain
activities because of a HEALTH PROBLEM.**

**1.** (VSVISION) **Do you have difficulty seeing, even if wearing
glasses?**

> ⁯ **No,** **No difficulty** (0)
>
> ⁯ **Yes,** **Some difficulty** (1)
>
> ⁯ **Yes,** **A lot of difficulty** (2)
>
> ⁯ **Can not do at all** (3)
>
> ⁯ *No Answer/Don't Know* (9)

1\. (VSWHY) Can you tell me what you were thinking? Why did you answer
\[*fill with respondent's answer to the core question*\]?

2\. (VSGLASS) Do you wear glasses all of the time, only for certain
activities, or none of the time?

> ⁯All of the time (2) ⁯Certain activities (1) ⁯None of the time (0)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIEWER: ASK QUESTIONS 3 AND 4 ONLY TO RESPONDENTS WHO REPORTED
ANY DIFFICULTY SEEING]{.underline}**

3\. (VSDIFF) \[Without your glasses\], how often do you have difficulty
seeing well?

> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Glasses wearers only:**
>
> 3a. (VSDIFFG) With your glasses, how often do you have difficulty
> seeing well?
>
> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)

4\. (VSEFF) \[Without your glasses\], when you are having difficulty,
how much effort do you have to put into seeing?

> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Glasses wearers only:**
>
> 4a. (VSEFFG) With your glasses, how much effort do you have to put
> into seeing?
>
> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIWER: ASK NEXT QUESTIONS TO ALL RESPONDENTS REGARDLESS OF
PREVIOUS ANSWERS]{.underline}**

5\. (VSACT) Are there any activities that you cannot do because of a
problem with your vision?

> ⁯ No (1)
>
> ⁯ Yes (2) (If yes, go to Question 5a)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 5a. (VSACTOPEN) What activity are you thinking about that you cannot
> do?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6\. (VSWORR) How concerned or worried are you about your vision?

> ⁯Not at all (0)
>
> ⁯Somewhat concerned (1)
>
> ⁯Very concerned (2)
>
> ⁯ *No Answer/Don't Know* (9)

7\. (VSCOND) Have you ever been told by a health professional that you
have an injury, disease or condition (such as cataracts or glaucoma)
affecting your sight?

> ⁯Yes (1) ⁯No (0)
>
> ⁯ *No Answer/Don't Know* (9)

8\. (VSTEST) In the past 2 years, have you had your vision tested?

> ⁯Yes (1) ⁯No (0)
>
> ⁯ *No Answer/Don't Know* (9)

9\. \[Without your glasses\], Do you have difficulty...

> a\. (VSNEAR) Seeing the print in a map, newspaper or book?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> b\. (VSFAR) [Seeing and recognizing a person]{.underline} you know
> from 7 meters (20 feet) away?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Glasses wearers only:**
>
> 9a. \[With your glasses\], Do you have difficulty...
>
> a\. (VSNEARG) Seeing the print in a map, newspaper or book?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> b\. (VSFARG) [Seeing and recognizing a person]{.underline} you know
> from 7 meters (20 feet) away?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

**HEARING---SELF-REPORT**

**2.** (HSHEAR) **Do you have difficulty hearing, even if using a
hearing aid?**

> ⁯ **No,** **No difficulty** (0)
>
> ⁯ **Yes,** **Some difficulty** (1)
>
> ⁯ **Yes,** **A lot of difficulty** (2)
>
> ⁯ **Can not do at all** (3)
>
> ⁯ *No Answer/Don't Know* (9)

1\. (HSWHY) Can you tell me what you were thinking? Why did you answer
\[*fill with respondent's answer to the core question*\]?

2\. (HSAID) Do you wear a hearing aid all of the time, only for certain
activities, or none of the time?

> ⁯All of the time (2) ⁯Certain activities (1) ⁯None of the time (0)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIEWER: ASK QUESTIONS 3 AND 4 ONLY TO RESPONDENTS WHO REPORTED
ANY DIFFICULTY HEARING]{.underline}**

3\. (HSDIFF) \[Without your hearing aid\], how often do you have
difficulty hearing well?

> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Hearing aid users only:**
>
> 3a. (HSDIFFA) With your hearing aid, how often do you have difficulty
> hearing well?
>
> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)

4\. (HSEFF) \[Without your hearing aid\], when you are having
difficulty, how much effort do you have to put into hearing?

> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Hearing aid users only:**
>
> 4a. (HSEFFA) With your hearing aid, how much effort do you have to put
> into hearing?
>
> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIWER: ASK NEXT QUESTIONS TO ALL RESPONDENTS REGARDLESS OF
PREVIOUS ANSWERS]{.underline}**

5\. (HSACT) Are there any activities that you cannot do because of a
problem with your hearing?

> ⁯ No (1)
>
> ⁯ Yes (2) (If yes, go to Question 5a)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 5a. (HSACTOPEN) What activity are you thinking about that you cannot
> do?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6\. (HSWORR) How concerned or worried are you about your hearing?

> ⁯Not at all (0)
>
> ⁯Somewhat concerned (1)
>
> ⁯Very concerned (2)
>
> ⁯ *No Answer/Don't Know* (9)

7\. (HSLOSS) Have you ever been told by a health professional that you
have any hearing loss?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

8\. (HSTEST) In the past 2 years, have you had a test to see if you can
hear well?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

9\. \[Without your hearing aid,\] Do you have difficulty hearing what is
said in a conversation with one other person...

a.  (HSCROWD) In a crowded room?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

b.  (HSQUIET) In a quiet room?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Hearing aid users only:**
>
> 9a. When wearing your hearing aid, Do you have difficulty hearing what
> is said in a conversation with one other person...
>
> a\. (HSCROWDA) In a crowded room?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> b\. (HSQUIETA) In a quiet room?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

10\. (HSMISS) How often do you miss words in conversation or on the
radio or television because you have difficulty hearing?

> ⁯Everyday (2) ⁯About once a week (1) ⁯Never (0)
>
> ⁯ *No Answer/Don't Know* (9)

11\. (HSPROB) Do household or family members often tell you that you
have a hearing problem?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

**COGNITIVE---SELF-REPORT**

**3.** (CSCOG) **Do you have difficulty remembering or concentrating?**

> ⁯ **No,** **No difficulty** (0)
>
> ⁯ **Yes,** **Some difficulty** (1)
>
> ⁯ **Yes,** **A lot of difficulty** (2)
>
> ⁯ **Can not do at all** (3)
>
> ⁯ *No Answer/Don't Know* (9)

1\. (CSWHY) Can you tell me what you were thinking? Why did you answer
\[*fill with respondent's answer to the core question*\]?

**[INTERVIEWER: ASK QUESTIONS 2, 3, 4 AND 5 ONLY TO RESPONDENTS WHO
REPORTED ANY DIFFICULTY CONCENTRATING]{.underline}**

2\. (CSREMCON) Do you have difficulty remembering, concentrating or
both?

> ⁯Remembering (1) ⁯Concentrating (2) ⁯Both (3)
>
> ⁯ *No Answer/Don't Know* (9)

3\. (CSDIFF) How often do you have difficulty remembering or
concentrating well?

> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)

4\. (CSEFF) When you are having difficulty, how much effort do you have
to put into remembering or concentrating?

> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)

5\. (CSCAUSE) Do you believe that your memory or concentration
difficulties are...

> \[MARK ALL THAT APPLY\]
>
> ⁯ because you have too many things to do? (1)
>
> ⁯ because you getting older? (2)
>
> ⁯ Or, because of something else? (3)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIWER: ASK NEXT QUESTIONS TO ALL RESPONDENTS REGARDLESS OF
PREVIOUS ANSWERS]{.underline}**

6\. (CSACT) Are there any activities that you cannot do because of a
problem with your memory or concentration?

> ⁯ No (1)
>
> ⁯ Yes (2) (If yes, go to Question 6a)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 6a. (CSACTOPEN) What activity are you thinking about that you cannot
> do?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7\. (CSWORR) How concerned or worried are you about your ability to
remember or concentrate?

> ⁯Not at all (0)
>
> ⁯Somewhat concerned (1)
>
> ⁯Very concerned (2)
>
> ⁯ *No Answer/Don't Know* (9)

8\. Do you have difficulty...

a\. (CSNAMES) Remembering the names of people or places?

> ⁯Yes (1) ⁯No (2) ⁯ *No Answer/Don't Know* (9)

b\. (CSAPPT) Remembering appointments?

> ⁯Yes (1) ⁯No (2) ⁯ *No Answer/Don't Know* (9)

c\. (CSPLACES) Remembering how to get to familiar places?

> ⁯Yes (1) ⁯No (2) ⁯ *No Answer/Don't Know* (9)

d\. (CSTASKS) Remembering important tasks, like taking medications or
paying bills?

> ⁯Yes (1) ⁯No (2) ⁯ *No Answer/Don't Know* (9)

9\. (CSTEN) Do you have difficulty [concentrating]{.underline} on doing
something for [ten minutes]{.underline}?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

10\. (CSNEW) Do you have difficulty learning a [new task]{.underline},
for example, [learning]{.underline} how to get to a new place?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

11\. (CSSOLUT) Do you have difficulty finding solutions to problems in
day to day life?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

**LOWER MOBILITY---SELF-REPORT**

**4.** (MSWALK) **Do you have difficulty walking or climbing steps?**

> ⁯ **No,** **No difficulty** (0)
>
> ⁯ **Yes,** **Some difficulty** (1)
>
> ⁯ **Yes,** **A lot of difficulty** (2)
>
> ⁯ **Can not do at all** (3)
>
> ⁯ *No Answer/Don't Know* (9)

1\. (MSWHY) Can you tell me what you were thinking? Why did you answer
\[*fill with respondent's answer to the core question*\]?

2\. (MSAID) Do you use any kind of equipment, such as a wheelchair,
walker or cane, to help you get around?

> ⁯No (0)
>
> ⁯Yes (1) (If yes, go to Question 2a)

⁯*No Answer/Don't Know* (9)

> 2a. (MSAIDTYPE) What type of equipment do you use?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[INTERVIEWER: ASK QUESTIONS 3, 4 AND 5 ONLY TO RESPONDENTS WHO
REPORTED ANY DIFFICULTY WALKING OR CLIMBING STAIRS]{.underline}**

> 3\. (MSWALKSTEP) Do you have difficulty walking, climbing steps or
> both?
>
> ⁯Walking (1) ⁯Climbing (2) ⁯Both (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 4\. (MSDIFF) Without your equipment, \...\] How often do you have
> difficulty walking or climbing steps?
>
> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Equipment users only:**
>
> 4a. (MSDIFFA) When using your equipment, how often do you have
> difficulty walking or climbing steps?
>
> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 5\. (MSEFF) When you are having difficulty \[without using your
> equipment\], how much effort do you have to put into walking or
> climbing steps?
>
> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Equipment users only:**
>
> 5a.(MSEFFA) When you are using your equipment, how much effort do you
> have to put into walking or climbing steps?
>
> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIWER: ASK NEXT QUESTIONS TO ALL RESPONDENTS REGARDLESS OF
PREVIOUS ANSWERS]{.underline}**

6\. (MSACT) Are there any activities that you cannot do because of a
problem with your legs?

> ⁯ No (1)
>
> ⁯ Yes (2) (If yes, go to Question 6a)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 6a. (MSACTOPEN) What activity are you thinking about that you cannot
> do?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7\. (MSWORR) How concerned or worried are you about your ability to walk
or climb steps?

> ⁯Not at all (0)
>
> ⁯Somewhat concerned (1)
>
> ⁯Very concerned (2)
>
> ⁯ *No Answer/Don't Know* (9)

8\. (MSINSIDE) Do you have difficulty moving around inside your home?

> ⁯Can't do at all (3)
>
> ⁯A lot of difficulty (2)
>
> ⁯Some difficulty (1)
>
> ⁯No difficulty (0)
>
> ⁯ *No Answer/Don't Know* (9)

9\. (MSOUTSIDE) Do you have difficulty going outside of your home?

> ⁯Can't do at all (3)
>
> ⁯A lot of difficulty (2)
>
> ⁯Some difficulty (1)
>
> ⁯No difficulty (0)
>
> ⁯ *No Answer/Don't Know* (9)

10\. (MSLONG) Do you have difficulty walking a long distance such as a
kilometer (or a mile)?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

11\. By yourself and not using aids, do you have any difficulty...

> a\. (MSQUARTER) Walking for a quarter of a mile (about 2 or 3 blocks)?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> b\. (MSSTEPS) Walking up ten steps without resting?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> c\. (MSSTAND) Standing or being on your feet for about 2 hours?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> d\. (MSSIT) Sitting for about 2 hours?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> e\. (MSSTOOP) Stooping, crouching or kneeling?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

**SELFCARE---SELF-REPORT**

**5.** (SSSCARE) **Do you have difficulty with self-care, such as
washing all over or dressing?**

⁯**No,** **No difficulty** (0)

⁯**Yes,** **Some difficulty** (1)

⁯**Yes,** **A lot of difficulty** (2)

⁯**Can not do at all** (3)

⁯*No Answer/Don't Know* (9)

1\. (SSWHY) Can you tell me what you were thinking? Why did you answer
\[*fill with respondent's answer to the core question*\]?

**[INTERVIEWER: ASK QUESTIONS 2 AND 3 ONLY TO RESPONDENTS WHO REPORTED
ANY DIFFICULTY WITH SELF-CARE]{.underline}**

> 2\. (SSDIFF) How often do you have difficulty with self-care?
>
> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 3\. (SSEFF) When you are having difficulty, how much effort do you
> have to put into self-care?
>
> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIWER: ASK NEXT QUESTIONS TO ALL RESPONDENTS REGARDLESS OF
PREVIOUS ANSWERS]{.underline}**

4\. (SSWORR) How concerned or worried are you about your ability to do
self-care?

> ⁯Not at all (0)
>
> ⁯Somewhat concerned (1)
>
> ⁯Very concerned (2)
>
> ⁯ *No Answer/Don't Know* (9)

5\. By yourself and not using aids, do you have any difficulty...

> a\. (SSHEAD) Reaching up over your head?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> b\. (SSHAND) Reaching out as if to shake someone's hand?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> c\. (SSFINGER) Using your fingers to button a shirt or dress?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> d\. (SSSOCK) Putting on socks or stockings?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> e\. (SSSHOE) Tying your shoelaces?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> f\. (SSHAIR) Combing your hair?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

g\. (SSFEED) Feeding yourself?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

6\. (SSDAILY) Do you ever need someone to help you with everyday
activities such as eating, showering, dressing or toileting?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

7\. (SSOBJECTS) Do you have difficulty [using your hands and
fingers]{.underline}, such as picking up small objects or opening or
closing containers?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

8\. (SSTIRED) Do you ever feel too tired or sad to dress or bathe?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

**COMMUNICATION---SELF-REPORT**

**6.** (TSCOMM) **Because of a physical, mental or emotional health
condition, do you have difficulty communicating, for example
understanding or being understood by others?**

> ⁯ **No,** **No difficulty** (0)
>
> ⁯ **Yes,** **Some difficulty** (1)
>
> ⁯ **Yes,** **A lot of difficulty** (2)
>
> ⁯ **Can not do at all** (3)
>
> ⁯ *No Answer/Don't Know* (9)

1\. (TSWHY) Can you tell me what you were thinking? Why did you answer
\[*fill with respondent's answer to the core question*\]?

**[INTERVIEWER: ASK QUESTIONS 2 AND 3 ONLY TO RESPONDENTS WHO REPORTED
ANY DIFFICULTY COMMUNICATING]{.underline}**

> 2\. (TSDIFF) How often do you have difficulty understanding or being
> understood?
>
> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 3\. (TSEFF) When you are having difficulty, how much effort do you
> have to put into understanding or being understood?
>
> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIWER: ASK NEXT QUESTIONS TO ALL RESPONDENTS REGARDLESS OF
PREVIOUS ANSWERS]{.underline}**

4\. (TSWORR) How concerned or worried are you about your ability to
understand or be understood?

> ⁯Not at all (0)
>
> ⁯Somewhat concerned (1)
>
> ⁯Very concerned (2)
>
> ⁯ *No Answer/Don't Know* (9)

5\. (TSSAY) Do you have difficulty in [generally
understanding]{.underline} what people say?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

6\. (TSCONVO) Do you have difficulty in [starting and maintaining a
conversation]{.underline}?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

7\. (TSFRIEND) Do you have difficulty in [making new
friends]{.underline}?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

8\. (TSSHY) Do you feel shy in group or social situations?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

**GENERAL HEALTH---SELF-REPORT**

7\. (GSHEALTH) **Would you say your health in general is excellent, very
good, good, fair, or poor?**

> **⁯Excellent** (4) **⁯Very Good** (3) **⁯Good** (2) **⁯Fair** (1) **⁯Poor**
> (0)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 1\. (GSWHY) Can you tell me what you were thinking? Why did you answer
> \[*fill with respondent's answer to the core question*\]?
>
> *2.* (GSWHYCODE) *Was the respondent thinking about: (Mark all that
> apply)*
>
> *Physical \_\_\_\_\_\_* (1)
>
> *Mental \_\_\_\_\_\_\_\_* (2)
>
> *Spiritual \_\_\_\_\_\_\_* (3)

1.  (GSCOND) Do you have any of the following conditions?

> **⁯**Asthma/breathing problem (1)
>
> **⁯**Arthritis/rheumatism (2)
>
> **⁯**Back or neck problem (3)
>
> **⁯**Fracture, bone/joint injury (4)
>
> **⁯**Heart problem (5)
>
> **⁯**Stroke problem (6)
>
> **⁯**Hypertension/high blood pressure (7)
>
> **⁯**Diabetes (8)
>
> **⁯**Cancer (9)
>
> **⁯**Mental retardation (10)
>
> **⁯**Developmental problem (11)
>
> **⁯**Depression/anxiety/emotional problem (12)
>
> **⁯**Missing limbs, amputee (13)
>
> **⁯**Kidney, bladder or renal problem (14)
>
> **⁯**Neurological disorder, such as Multiple Sclerosis (MS) and
> Muscular Dystrophy (MD) (15)
>
> ⁯ *No Answer/Don't Know* (90)

**VISION---PROXY REPORT**

**1A.** (VPVISION) **Does \[Name\] have difficulty seeing even if
wearing glasses?**

> ⁯ **No,** **No difficulty** (0)
>
> ⁯ **Yes,** **Some difficulty** (1)
>
> ⁯ **Yes,** **A lot of difficulty** (2)
>
> ⁯ **Can not do at all** (3)
>
> ⁯ *No Answer/Don't Know* (9)

1\. (VPWHY) Can you tell me what you were thinking? Why did you answer
\[*fill with respondent's answer to the core question*\]?

2\. (VPGLASS) Does \[Name\] wear glasses all of the time, only for
certain activities, or none of the time?

> ⁯All of the time (2) ⁯Certain activities (1) ⁯None of the time (0)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIEWER: ASK QUESTIONS 3 AND 4 ONLY TO RESPONDENTS WHO REPORTED
ANY DIFFICULTY SEEING]{.underline}**

3\. (VPDIFF) \[Without his/her glasses\], how often does \[Name\] have
difficulty seeing well?

> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Glasses wearers only:**
>
> 3a. (VPDIFFG) With his/her glasses, how often does \[Name} have
> difficulty seeing well?
>
> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)

4\. (VPEFF) \[Without his/her glasses\], when \[Name\] is having
difficulty, how much effort does he/she have to put into seeing?

> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Glasses wearers only:**
>
> 4a. (VPEFFG) With his/her glasses, how much effort does \[Name\] have
> to put into seeing?
>
> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIWER: ASK NEXT QUESTIONS TO ALL RESPONDENTS REGARDLESS OF
PREVIOUS ANSWERS]{.underline}**

5\. (VPACT) Are there any activities that \[Name\] cannot do because of
a problem with his/her vision?

> ⁯ No (1)
>
> ⁯ Yes (2) (If yes, go to Question 5a)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 5a. (VPACTOPEN) What activity are you thinking about that \[Name\]
> cannot do?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6\. (VPWORR) How concerned or worried are you about \[Name's\] vision?

> ⁯Not at all (0)
>
> ⁯Somewhat concerned (1)
>
> ⁯Very concerned (2)
>
> ⁯ *No Answer/Don't Know* (9)

7\. (VPCOND) Has \[Name\] ever been told by a health professional that
he/she has an injury, disease or condition (such as cataracts or
glaucoma) affecting his/her sight?

> ⁯Yes (1) ⁯No (0)

⁯*No Answer/Don't Know* (9)

8\. (VPTEST) In the past 2 years, has \[Name\] had his/her vision
tested?

> ⁯Yes (1) ⁯No (0)
>
> ⁯ *No Answer/Don't Know* (9)

9\. \[Without his/her glasses\], Does \[Name\] have difficulty...

> a\. (VPNEAR) Seeing the print in a map, newspaper or book?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> b\. (VPFAR) [Seeing and recognizing a person]{.underline} you know
> from 7 meters (20 feet) away?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Glasses wearers only:**
>
> 9a. With his/her glasses, does \[Name\] have difficulty...
>
> a\. (VPNEARG) Seeing the print in a map, newspaper or book?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> b\. (VPFARG) [Seeing and recognizing a person]{.underline} he/she
> knows from 7 meters (20 feet) away?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

**\
**

**HEARING---PROXY-REPORT**

**2a.** (HPHEAR) **Does \[Name\] have difficulty hearing, even if using
a hearing aid?**

> ⁯ **No,** **No difficulty** (0)
>
> ⁯ **Yes,** **Some difficulty** (1)
>
> ⁯ **Yes,** **A lot of difficulty** (2)
>
> ⁯ **Can not do at all** (3)
>
> ⁯ *No Answer/Don't Know* (9)

1\. (HPWHY) Can you tell me what you were thinking? Why did you answer
\[*fill with respondent's answer to the core question*\]?

2\. (HPAID) Does \[Name\] wear a hearing aid all of the time, only for
certain activities, or none of the time?

> ⁯All of the time (2) ⁯Certain activities (1) ⁯None of the time (0)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIEWER: ASK QUESTIONS 3 AND 4 ONLY TO RESPONDENTS WHO REPORTED
ANY DIFFICULTY HEARING]{.underline}**

3\. (HPDIFF) \[Without his/her hearing aid\], how often does \[Name\]
have difficulty hearing well?

> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Hearing aid users only:**
>
> 3a. (HPDIFFA) With his/her hearing aid, how often does \[Name\] have
> difficulty hearing well?
>
> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)

4\. (HPEFF) \[Without his/her hearing aid\], when \[Name\] is having
difficulty, how much effort does \[Name\] have to put into hearing?

> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Hearing aid users only:**
>
> 4a. (HPEFFA) With his/her hearing aid, how much effort does \[Name\]
> have to put into hearing?
>
> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIWER: ASK NEXT QUESTIONS TO ALL RESPONDENTS REGARDLESS OF
PREVIOUS ANSWERS]{.underline}**

5\. (HPACT) Are there any activities that \[Name\] cannot do because of
a problem with his/her hearing?

> ⁯ No (1)
>
> ⁯ Yes (2) (If yes, go to Question 5a)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 5a. (HPACTOPEN) What activity are you thinking about that \[Name\]
> cannot do?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6\. (HPWORR) How concerned or worried are you about \[Name's\] hearing?

> ⁯Not at all (0)
>
> ⁯Somewhat concerned (1)
>
> ⁯Very concerned (2)
>
> ⁯ *No Answer/Don't Know* (9)

7\. (HPLOSS) Has \[Name\] ever been told by a health professional that
he/she has any hearing loss?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

8\. (HPTEST) In the past 2 years, has \[Name\] had a test to see if
he/she can hear well?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

9\. \[Without his/her hearing aid,... \] Does \[Name\] have difficulty
hearing what is said in a conversation with another person...

> a\. (HPCROWD) In a crowded room?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> b\. (HPQUIET) In a quiet room?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Hearing aid users only:**
>
> 9a. When wearing his/her hearing aid, Does \[Name\] have difficulty
> hearing what is said in a conversation with another person...
>
> a\. (HPCROWDA) In a crowded room?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> b\. (HPQUIETA) In a quiet room?
>
> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

10\. (HPMISS) How often does \[Name\] miss words in conversation or on
the radio or television because he/she has difficulty hearing?

> ⁯Everyday (2) ⁯About once a week (1) ⁯Never (0)
>
> ⁯ *No Answer/Don't Know* (9)

11\. (HPPROB) Do household or family members often tell \[Name\] that
he/she has a hearing problem?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

**COGNITIVE---PROXY-REPORT**

**3a.** (CPCOG) **Does \[Name\] have difficulty remembering or
concentrating?**

> ⁯ **No,** **No difficulty** (0)
>
> ⁯ **Yes,** **Some difficulty** (1)
>
> ⁯ **Yes,** **A lot of difficulty** (2)
>
> ⁯ **Can not do at all** (3)
>
> ⁯ *No Answer/Don't Know* (9)

1\. (CPWHY) Can you tell me what you were thinking? Why did you answer
\[*fill with respondent's answer to the core question*\]?

**[INTERVIEWER: ASK QUESTIONS 2, 3, 4 AND 5 ONLY TO RESPONDENTS WHO
REPORTED ANY DIFFICULTY CONCENTRATING]{.underline}**

2\. (CPREMCON) Does \[Name\] have difficulty remembering, concentrating
or both?

> ⁯Remembering (1) ⁯Concentrating (2) ⁯Both (3)
>
> ⁯ *No Answer/Don't Know* (9)

3\. (CPDIFF) How often does \[Name\] have difficulty remembering or
concentrating well?

> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)

4\. (CPEFF) When \[Name\] is having difficulty, how much effort does
\[Name\] have to put into remembering or concentrating?

> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)

5\. (CPCAUSE) Do you believe that \[Name's\] memory or concentration
difficulties are...

> \[MARK ALL THAT APPLY\]
>
> ⁯ because \[Name\] has too many things to do? (1)
>
> ⁯ because \[Name\] is getting older? (2)
>
> ⁯ Or, because of something else? (3)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIWER: ASK NEXT QUESTIONS TO ALL RESPONDENTS REGARDLESS OF
PREVIOUS ANSWERS]{.underline}**

6\. (CPACT) Are there any activities that \[Name\] cannot do because of
a problem with his/her memory or concentration?

> ⁯ No (1)
>
> ⁯ Yes (2) (If yes, go to Question 6a)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 6a. (CPACTOPEN) What activity are you thinking about that \[Name\]
> cannot do?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7\. (CPWORR) How concerned or worried are you about \[Name's\] ability
to remember or concentrate?

> ⁯Not at all (0)
>
> ⁯Somewhat concerned (1)
>
> ⁯Very concerned (2)
>
> ⁯ *No Answer/Don't Know* (9)

8\. Does \[Name\] have difficulty...

a\. (CPNAMES) Remembering the names of people or places?

> ⁯Yes (1) ⁯No (2) ⁯ *No Answer/Don't Know* (9)

b\. (CPAPPT) Remembering appointments?

> ⁯Yes (1) ⁯No (2) ⁯ *No Answer/Don't Know* (9)

c\. (CPPLACES) Remembering how to get to familiar places?

> ⁯Yes (1) ⁯No (2) ⁯ *No Answer/Don't Know* (9)

d\. (CPTASKS) Remembering important tasks, like taking medications or
paying bills?

> ⁯Yes (1) ⁯No (2) ⁯ *No Answer/Don't Know* (9)

9\. (CPTEN) Does \[Name\] have difficulty [concentrating]{.underline} on
doing something for [ten minutes]{.underline}?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

10\. (CPNEW) Does \[Name\] have difficulty learning a [new
task]{.underline}, for example, [learning]{.underline} how to get to a
new place?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

11\. (CPSOLUT) Does \[Name\] have difficulty finding solutions to
problems in day to day life?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

**LOWER MOBILITY---PROXY-REPORT**

**4a.** (MPWALK) **Does \[Name\] have difficulty walking or climbing
steps?**

> ⁯ **No,** **No difficulty** (0)
>
> ⁯ **Yes,** **Some difficulty** (1)
>
> ⁯ **Yes,** **A lot of difficulty** (2)
>
> ⁯ **Can not do at all** (3)
>
> ⁯ *No Answer/Don't Know* (9)

1\. (MPWHY) Can you tell me what you were thinking? Why did you answer
\[*fill with respondent's answer to the core question*\]?

2\. (MPAID) Does \[Name\] use any kind of equipment, such as a
wheelchair, walker or cane, to help him/her get around?

> ⁯No (0)
>
> ⁯Yes (1) (If yes, go to Question 2a)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 2a (MPAIDTYPE) What type of equipment do he/she use?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[INTERVIEWER: ASK QUESTIONS 3, 4 AND 5 ONLY TO RESPONDENTS WHO
REPORTED ANY DIFFICULTY WALKING OR CLIMBING STEPS]{.underline}**

> 3\. (MPWALKSTEP) Does \[Name\] have difficulty walking, climbing steps
> or both?
>
> ⁯Walking (1) ⁯Climbing (2) ⁯Both (3)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 4\. (MPDIFF) \[Without his/her equipment,\] How often does \[Name\]
> have difficulty walking or climbing steps?
>
> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Equipment users only:**
>
> 4a. (MPDIFFA) When using his/her equipment, how often does \[Name\]
> have difficulty walking or climbing steps?
>
> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 5\. (MPEFF) When \[Name\] is having difficulty \[without using his/her
> equipment\], how much effort does \[Name\] have to put into walking or
> climbing steps?
>
> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> **Equipment users only:**
>
> 5a. (MPEFFA) When \[Name\] is using his/her equipment, how much effort
> does \[Name\] have to put into walking or climbing steps?
>
> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIWER: ASK NEXT QUESTIONS TO ALL RESPONDENTS REGARDLESS OF
PREVIOUS ANSWERS]{.underline}**

6\. (MPACT) Are there any activities that \[Name\] cannot do because of
a problem with his/her legs?

> ⁯ No (1)
>
> ⁯ Yes (2) (If yes, go to Question 6a)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 6a. (MPACTOPEN) What activity are you thinking about that \[Name\]
> cannot do?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

7\. (MPWORR) How concerned or worried are you about \[Name's\] ability
to walk or climb steps?

> ⁯Not at all (0)
>
> ⁯Somewhat concerned (1)
>
> ⁯Very concerned (2)
>
> ⁯ *No Answer/Don't Know* (9)

8\. (MPINSIDE) Does \[Name\] have difficulty moving around inside
his/her home?

> ⁯Can't do at all (3)
>
> ⁯A lot of difficulty (2)
>
> ⁯Some difficulty (1)
>
> ⁯No difficulty (0)
>
> ⁯ *No Answer/Don't Know* (9)

9\. (MPOUTSIDE) Does \[Name\] have difficulty going outside of his/her
home?

> ⁯Can't do at all (3)
>
> ⁯A lot of difficulty (2)
>
> ⁯Some difficulty (1)
>
> ⁯No difficulty (0)
>
> ⁯ *No Answer/Don't Know* (9)

10\. (MPLONG) Does \[NAME\] have difficulty walking a long distance such
as a kilometer (or a mile)?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

11\. By his/her self and not using aids, does \[Name\] have any
difficulty...

> a\. (MPQUARTER) Walking for a quarter of a mile (about 2 or 3 blocks)?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> b\. (MPSTEPS) Walking up ten steps without resting?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> c\. (MPSTAND) Standing or being on your feet for about 2 hours?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> d\. (MPSIT) Sitting for about 2 hours?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> e\. (MPSTOOP) Stooping, crouching or kneeling?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

**SELFCARE---PROXY-REPORT**

**5a.** (SPSCARE) **Does \[Name\] have difficulty with self-care, such
as washing all over or dressing?**

> ⁯ **No,** **No difficulty** (0)
>
> ⁯ **Yes,** **Some difficulty** (1)
>
> ⁯ **Yes,** **A lot of difficulty** (2)
>
> ⁯ **Can not do at all** (3)
>
> ⁯ *No Answer/Don't Know* (9)

1\. (SPWHY) Can you tell me what you were thinking? Why did you answer
\[*fill with respondent's answer to the core question*\]?

**[INTERVIEWER: ASK QUESTIONS 2 AND 3 ONLY TO RESPONDENTS WHO REPORTED
ANY DIFFICULTY WITH SELF-CARE]{.underline}**

> 2\. (SPDIFF) How often does \[Name\] have difficulty with self-care?
>
> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 3\. (SPEFF) When \[Name\] is having difficulty, how much effort does
> \[Name\] have to put into self-care?
>
> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIWER: ASK NEXT QUESTIONS TO ALL RESPONDENTS REGARDLESS OF
PREVIOUS ANSWERS]{.underline}**

4\. (SPWORR) How concerned or worried are you about \[Name's\] ability
to do self-care?

> ⁯Not at all (0)
>
> ⁯Somewhat concerned (1)
>
> ⁯Very concerned (2)
>
> ⁯ *No Answer/Don't Know* (9)

5\. By himself/herself and not using aids, does \[Name\] have any
difficulty...

> a\. (SPHEAD) Reaching up over his/her head?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> b\. (SPHAND) Reaching out as if to shake someone's hand?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> c\. (SPFINGER) Using his/her fingers to button a shirt or dress?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> d\. (SPSOCK) Putting on socks or stockings?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> e\. (SPSHOE) Tying his/her shoelaces?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> f\. (SPHAIR) Combing his/her hair?
>
> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

g\. (SPFEED) Feeding himself/herself?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

6\. (SPDAILY) Does \[Name\] ever need someone to help him/her with
everyday activities such as eating, showering, dressing or toileting?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

7\. (SPOBJECTS) Does \[Name\] have difficulty [using your hands and
fingers]{.underline}, such as picking up small objects or opening or
closing containers?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

8\. (SPTIRED) Does \[Name\] ever feel too tired or sad to dress or
bathe?

> ⁯Yes (1) ⁯No (2)
>
> ⁯ *No Answer/Don't Know* (9)

**COMMUNICATION---PROXY-REPORT**

6a**.** (TPCOMM) **Because of a physical, mental or emotional health
condition, does \[Name\] have difficulty communicating, for example
understanding or being understood by others?**

> ⁯ **No,** **No difficulty** (0)
>
> ⁯ **Yes,** **Some difficulty** (1)
>
> ⁯ **Yes,** **A lot of difficulty** (2)
>
> ⁯ **Can not do at all** (3)
>
> ⁯ *No Answer/Don't Know* (9)

1\. (TPWHY) Can you tell me what you were thinking? Why did you answer
\[*fill with respondent's answer to the core question*\]?

**[INTERVIEWER: ASK QUESTIONS 2 AND 3 ONLY TO RESPONDENTS WHO REPORTED
ANY DIFFICULTY WITH COMMUNICATION]{.underline}**

> 2\. (TPDIFF) How often does \[Name\] have difficulty understanding or
> being understood?
>
> ⁯Never (0)
>
> ⁯Somewhat often (1)
>
> ⁯Very often (2)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 3\. (TPEFF) When \[Name\] is having difficulty, how much effort does
> \[Name\] have to put into understanding or being understood?
>
> ⁯ No effort (0)
>
> ⁯Some effort (1)
>
> ⁯A lot of effort (2)
>
> ⁯ *No Answer/Don't Know* (9)

**[INTERVIWER: ASK NEXT QUESTIONS TO ALL RESPONDENTS REGARDLESS OF
PREVIOUS ANSWERS]{.underline}**

4\. (TPWORR) How concerned or worried are you about \[Name's\] ability
to understand or be understood?

> ⁯Not at all (0)
>
> ⁯Somewhat concerned (1)
>
> ⁯Very concerned (2)
>
> ⁯ *No Answer/Don't Know* (9)

5\. (TPSAY) Does \[Name\] have difficulty in [generally
understanding]{.underline} what people say?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

6\. (TPCONVO) Does \[Name\] have difficulty in [starting and maintaining
a conversation]{.underline}?

> ⁯No difficulty (0)
>
> ⁯Some difficulty (1)
>
> ⁯A lot of difficulty (2)
>
> ⁯Can't do at all (3)
>
> ⁯ *No Answer/Don't Know* (9)

7\. (TPFRIEND) Does \[Name\] have difficulty in [making new
friends]{.underline}?

⁯Yes (1) ⁯No (2)

> ⁯ *No Answer/Don't Know* (9)

8\. (TPSHY) Does \[Name\] feel shy in group or social situations?

⁯Yes (1) ⁯No (2)

⁯*No Answer/Don't Know* (9)

> **GENERAL HEALTH---PROXY-REPORT**

7a. (GPHEALTH) **Would you say \[Name's\] health in general is
excellent, very good, good, fair, or poor?**

> **⁯Excellent** (4) **⁯Very Good** (3) **⁯Good** (2) **⁯Fair** (1) **⁯Poor**
> (0)
>
> ⁯ *No Answer/Don't Know* (9)
>
> 1\. (GPWHY) Can you tell me what you were thinking? Why did you answer
> \[*fill with respondent's answer to the core question*\]?
>
> *2. (GPWHYCODE) Was the respondent thinking about: (Mark all that
> apply)*
>
> *Physical \_\_\_\_\_\_*
>
> *Mental \_\_\_\_\_\_\_*
>
> *Spiritual \_\_\_\_\_*

3.  (GPCOND) Does \[Name\] have any of the following conditions?

> **⁯**Asthma/breathing problem
>
> **⁯**Arthritis/rheumatism
>
> **⁯**Back or neck problem
>
> **⁯**Fracture, bone/joint injury
>
> **⁯**Heart problem
>
> **⁯**Stroke problem
>
> **⁯**Hypertension/high blood pressure
>
> **⁯**Diabetes
>
> **⁯**Cancer
>
> **⁯**Mental retardation
>
> **⁯**Developmental problem
>
> **⁯**Depression/anxiety/emotional problem
>
> **⁯**Missing limbs, amputee
>
> **⁯**Kidney, bladder or renal problem
>
> **⁯**Neurological disorder, such as Multiple Sclerosis (MS) and
> Muscular Dystrophy (MD)
>
> ⁯ *No Answer/Don't Know* (9)

**INTERVIEWER DEBRIEFING**

+---+-----------------------+-------------------+---------------------+
| # | ###                   |                   |                     |
| # |                       |                   |                     |
| # | #                     |                   |                     |
|   | ## YOUR [HOUSEHOLD]{. |                   |                     |
|   | underline} INCOME[^1] |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | ### Approximate       | ### Approximate   | ### Approximate     |
| # |                       |                   |                     |
| # | ### WEEKLY            | ### MONTHLY       | ### ANNUAL          |
|   |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | ### Less than €40     | #                 | ### Less than €1800 |
| # |                       | ## Less than €150 |                     |
| # |                       |                   |                     |
|   |                       |                   |                     |
| J |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | ### €40 to under €70  | ### €             | ### €               |
| # |                       | 150 to under €300 | 1800 to under €3600 |
| # |                       |                   |                     |
|   |                       |                   |                     |
| R |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | ### €70 to under €120 | ### €             | ### €               |
| # |                       | 300 to under €500 | 3600 to under €6000 |
| # |                       |                   |                     |
|   |                       |                   |                     |
| C |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | #                     | ### €5            | ### €6              |
| # | ## €120 to under €230 | 00 to under €1000 | 000 to under €12000 |
| # |                       |                   |                     |
|   |                       |                   |                     |
| M |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | #                     | ### €10           | ### €12             |
| # | ## €230 to under €350 | 00 to under €1500 | 000 to under €18000 |
| # |                       |                   |                     |
|   |                       |                   |                     |
| F |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | #                     | ### €15           | ### €18             |
| # | ## €350 to under €460 | 00 to under €2000 | 000 to under €24000 |
| # |                       |                   |                     |
|   |                       |                   |                     |
| S |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | #                     | ### €20           | ### €24             |
| # | ## €460 to under €580 | 00 to under €2500 | 000 to under €30000 |
| # |                       |                   |                     |
|   |                       |                   |                     |
| K |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | #                     | ### €25           | ### €30             |
| # | ## €580 to under €690 | 00 to under €3000 | 000 to under €36000 |
| # |                       |                   |                     |
|   |                       |                   |                     |
| P |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | ##                    | ### €30           | ### €36             |
| # | # €690 to under €1150 | 00 to under €5000 | 000 to under €60000 |
| # |                       |                   |                     |
|   |                       |                   |                     |
| D |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | ###                   | ### €50           | ### €60             |
| # |  €1150 to under €1730 | 00 to under €7500 | 000 to under €90000 |
| # |                       |                   |                     |
|   |                       |                   |                     |
| H |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | ###                   | ### €750          | ### €900            |
| # |  €1730 to under €2310 | 0 to under €10000 | 00 to under €120000 |
| # |                       |                   |                     |
|   |                       |                   |                     |
| U |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+
| # | ### €2310 or more     | #                 | ### €120000 or more |
| # |                       | ## €10000 or more |                     |
| # |                       |                   |                     |
|   |                       |                   |                     |
| N |                       |                   |                     |
+---+-----------------------+-------------------+---------------------+

### 

[^1]: Where necessary, insert corresponding amounts in national
    currency, rounding up or down as appropriate. In Euro, weekly
    figures were rounded to the nearest ten.