GCC Research Questionnaires Step 1 of 6 16% Email Name First Last Client Name File Number ChapterAndhra PradeshGujaratKarnatakaKeralaMaharashtra ThaneMaharashtra RatnagiriTamil Nadu VillupuramTamil Nadu TrichyTamil Nadu ChengalpattuTamil Nadu TirunelveliAssamMadhya PradeshOdishaSri LankaBangladeshPoint of Data CollectionBaselineMidlineEndlineDate of Administering MM slash DD slash YYYY Upload Client Consent FormMax. file size: 2 GB. WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE (WHODAS 2.0)This questionnaire asks about difficulties due to health conditions. Health conditions include diseases or illnesses, other health problems that may be short or long lasting, injuries, mental or emotional problems, and problems with alcohol or drugs.Think back over the past 30 days and answer these questions, thinking about how much difficulty you had doing the following activities. For each question, please mark only one response.In the past 30 days, how much difficulty did you have in:In the past 30 days, how much difficulty did you have in doing the following tasks?NoneMildModerateSevereExtreme or Cannot doNot ApplicableNo Response1. Standing for long periods such as 30 minutes?2. Taking care of your household responsibilities?3. Learning a new task, for example, learning how to get to a new place?4. How much of a problem did you have joining in community activities (for example, festivities, religious or other activities) in the same way as anyone else can?5. How much have you been emotionally affected by your health problems?6. Concentrating on doing something for ten minutes?7. Walking a long distance such as a kilometre [or equivalent]?8. Washing your whole body?9. Getting dressed?10. Dealing with people you do not know?11. Maintaining a friendship?12. Your day-to-day work?Overall, in the past 30 days, how many days were these difficulties present?Please enter a number from 0 to 30.In the past 30 days, for how many days were you totally unable to carry out your usual activities or work because of any health condition?Please enter a number from 0 to 30.In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition?Please enter a number from 0 to 30. Quality of Life InterviewThe questionnaire asks about your quality of life, how you are doing and how you feel about things. Please read each question carefully and mark the appropriate responses.1. How you feel about your life in general? Terrible Unhappy Mostly Dissatisfied Mixed Mostly Satisfied Pleased Delighted 2. Fill in the best describes where you have been living during the past month? In a house or apartment alone or with a spouse, friend, family or children In a house, apartment or boarding home where a mental health professional like a counselor or case manager visits regularly In a treatment program or boarding home where a mental health professional like a counselor or case manager is there all or almost all the time In a hospital or nursing home In a jail or prison On the streets or in an emergency shelter for the homeless 3. How you feel about the privacy you where you live? Terrible Unhappy Mostly Dissatisfied Mixed Mostly Satisfied Pleased Delighted 4. During the past month did you do the following4.a During the past month, did you work at a job for pay? Yes No IF YES, ABOUT HOW MANY DAYS DID YOU SPEND ON THE JOB? 1-5 6-10 11-15 16+ 4.b During the past month, did you go to school? Yes No IF YES, ABOUT HOW MANY DAYS DID YOU SPEND IN SCHOOL? 1-5 6-10 11-15 16+ 4.c During the past month, did you do volunteer work? Yes No IF YES, ABOUT HOW MANY DAYS DID YOU SPEND AS VOLUNTEER? 1-5 6-10 11-15 16+ 4.d During the past month, did you keep house or take care of children? Yes No IF YES, ABOUT HOW MANY DAYS DID YOU SPEND KEEPING HOUSE OR TAKING CARE OF CHILDREN? 1-5 6-10 11-15 16+ 4.e During the past month, did you go to a day program? Yes No IF YES, ABOUT HOW MANY DAYS DID YOU SPEND AT THE PROGRAM? 1-5 6-10 11-15 16+ 5. Which of these activities did you consider your main activity during the past month? Working at a job for pay Going to school Doing volunteer work Keeping house/taking care of children Going to a day program None of these 6. How you feel about the amount of fun you have? Terrible Unhappy Mostly Dissatisfied Mixed Mostly Satisfied Pleased Delighted 7. How you feel about how you spend your time? Terrible Unhappy Mostly Dissatisfied Mixed Mostly Satisfied Pleased Delighted 8. Fill in only one option for each questionDAILYWEEKLYMONTHLYLESS THAN MONTHLYNOT AT ALL8.a How often you talk to a member of your family on the telephone?8.b How often do you get together with a member of your family?9. How you feel about the way things are between you and your family? Terrible Unhappy Mostly Dissatisfied Mixed Mostly Satisfied Pleased Delighted 10. Fill in only one option for each questionDAILYWEEKLYMONTHLYLESS THAN MONTHLYNOT AT ALL10.a How often do you spend time with your friend who does not live with you?10.b How often do you phone a friend who does not live with you?10.c How often do you make plans ahead of time to do something with a friend?10.d How often do you spend time with someone you consider more than a friend, like a boyfriend, girlfriend or your spouse?11. How you feel about the amount of friendship in your life? Terrible Unhappy Mostly Dissatisfied Mixed Mostly Satisfied Pleased Delighted 12. Amount of money you had to spend on yourself during the past month, not counting money for room and board (housing and meals.) Less than Rs.1500 Rs.1500 - Rs.3700 Rs.3701 - Rs.7500 More than Rs.7500 13. Answer Yes or No to each of the following questionsYesNo13.a In the past month did you have enough money for food?13.b In the past month did you have enough money for clothes?13.c In the past month did you have enough money for housing?13.d In the past month did you have enough money for transportation?13.e In the past month did you have enough money for fun?14. How you feel about how well off you are financially? Terrible Unhappy Mostly Dissatisfied Mixed Mostly Satisfied Pleased Delighted 15. Answer Yes or No to each of the following questionsYesNo15.a In the past month were you the victim of any violent crime like assault, rape, mugging or robbery?15.b In the past month were you the victim of any non-violent crime like a theft, burglary or being cheated?15.c In the past month have you been arrested or picked up for any crime?16. How you feel about protection you have against being robbed or attacked? Terrible Unhappy Mostly Dissatisfied Mixed Mostly Satisfied Pleased Delighted 17. Overall, how would you rate your health? Excellent Very Good Good Fair Poor 18. How you feel about your health in general? Terrible Unhappy Mostly Dissatisfied Mixed Mostly Satisfied Pleased Delighted 19. How you feel about your life in general? Terrible Unhappy Mostly Dissatisfied Mixed Mostly Satisfied Pleased Delighted 20. What do you think of DELIGHTED-TERRIBLE Scale? I liked it. It should be used. I have mixed feelings. It doesn't matter if you use it or not. I did not like it. It should not be used. Community Integration QuestionnaireHome Integration1. Who usually does shopping for groceries or other necessities in your household? Yourself alone Yourself and someone else Someone else 2. Who usually prepares meals in your household? Yourself alone Yourself and someone else Someone else 3. In your home who usually does normal everyday housework? Yourself alone Yourself and someone else Someone else 4. Who usually cares for the children in your home? Yourself alone Yourself and someone else Someone else Not Applicable 5. Who usually plans social arrangements such as get-togethers with family and friends? Yourself alone Yourself and someone else Someone else Social Integration6. Who usually looks after your personal finances such as banking or paying bills? Yourself alone Yourself and someone else Someone else Can you tell me approximately how many times a month you now usually participate in the following activities outside your home?5 or more1 – 4 timesNever7. Shopping8. Leisure activities such as movies, sports, restaurants9. Visiting friends or relatives10. When you participate in leisure activities do you usually do this alone or with other? Mostly alone Mostly with friends who have head injuries Mostly with family members Mostly with friends who do not have head injuries With a combination of family and friends 11. Do you have a best friend with whom you confide? Yes No Integration into Productive Activities12. How often do you travel outside the home? Almost every day Almost every week Seldom/never (less than once per week) 13. Please choose the answer below that best corresponds to your current (during the past month) work situation: Full-time employment (>20 hours/week) Part-time Employment (< 20 hours/week) Not working, but actively looking for work Not working, not looking for work Not applicable, retired due to age Volunteer job in the community 14. Please choose the answer below that best corresponds to your current (during the past month) school or training program situation Full-time Part-time Not attending school or training program 15. In the past month, how often did you engage in volunteer activities? 5 or more 1 - 4 times Never References: Willer, B., Rosenthal, M., et al. (1993). "Assessment of community integration following rehabilitation for traumatic brain injury." The Journal of head trauma rehabilitation 8(2): 75. Modified Colorado Symptom IndexBelow is a list of problems that people sometimes have. Please think about how often you experienced certain problems and how much they bothered or distressed you during the past month.For each problem, please pick one answer choice that best describes how often you have had the problem in the past month (30 days).Not at allOnce during the monthSeveral times during the monthSeveral times a weekAt least every dayNo ResponseDon't Know1. How often have you felt nervous, tense, worried, frustrated, or afraid?2. How often have you felt depressed?3. How often have you felt lonely?4. How often have others told you that you acted “paranoid” or “suspicious”?5. How often did you hear voices, or heard and see things that other people didn’t think were there?6. How often did you have trouble making up your mind about something, like deciding where you wanted to go or what you were going to do, or how to solve a problem?7. How often did you have trouble thinking straight or concentrating on something you needed to do (like worrying so much or thinking about problems so much that you can't remember or focus on other things)?8. How often did you feel that your behavior or actions were strange or different from that of other people?9. How often did you feel out of place or like you did not fit in?10. How often did you forget important things?11. How often did you have problems with thinking too fast (thoughts racing)?12. How often did you feel suspicious or paranoid?13. How often did you feel like hurting yourself or killing yourself?14. How often have you felt like seriously hurting someone else? Herth Hope IndexListed below are a number of statements. Read each statement and mark the appropriate choice that describes how much you agree with that statement right now.Strongly DisagreeDisagreeAgreeStrongly AgreeNo ResponseDon't Know1. I have a positive outlook toward life.2. I have short and/or long range goals.3. I feel all alone.4. I can see possibilities in the midst of difficulties.5. I have a faith that gives me comfort.6. I feel scared about my future.7. I can recall happy/joyful times.8. I have deep inner strength.9. I am able to give and receive caring/love.10. I have a sense of direction.11. I believe that each day has potential.12. I feel my life has value and worth. Δ
