Innovation Panel Questionnaire Module
scasf12_ip17
Self-Completion SF12 Module
Questions 12
scasf12_ip17.scsf2a
Health limits moderate activities
Type: choice
Source: Quality Metric Inc., 2007
Text: The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf
| Option | Label |
|---|---|
| 1 | Yes, limited a lot |
| 2 | Yes, limited a little |
| 3 | No, not limited at all |
Universe:
if [(GRIDVARIABLES.ModeType = 1 & CASISTART.scac = 1 thru 4) | (GRIDVARIABLES.ModeType = 2 | 3)] // Mode is face-to-face and translator not needed OR Mode is telephone or web
scasf12_ip17.scsf2b
Health limits several flights of stairs
Type: choice
Source: Quality Metric Inc., 2007
Text: Climbing several flights of stairs
| Option | Label |
|---|---|
| 1 | Yes, limited a lot |
| 2 | Yes, limited a little |
| 3 | No, not limited at all |
Universe:
if [(GRIDVARIABLES.ModeType = 1 & CASISTART.scac = 1 thru 4) | (GRIDVARIABLES.ModeType = 2 | 3)] // Mode is face-to-face and translator not needed OR Mode is telephone or web
scasf12_ip17.scsf3a
Last 4 weeks: Physical health limits amount of work
Type: choice
Source: Quality Metric Inc., 2007
Text: During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
Accomplished less than you would like
| Option | Label |
|---|---|
| 1 | All of the time |
| 2 | Most of the time |
| 3 | Some of the time |
| 4 | A little of the time |
| 5 | None of the time |
Universe:
if [(GRIDVARIABLES.ModeType = 1 & CASISTART.scac = 1 thru 4) | (GRIDVARIABLES.ModeType = 2 | 3)] // Mode is face-to-face and translator not needed OR Mode is telephone or web
scasf12_ip17.scsf3b
Last 4 weeks: Physical health limits kind of work
Type: choice
Source: Quality Metric Inc., 2007
Text: Were limited in the kind of work or other activities
| Option | Label |
|---|---|
| 1 | All of the time |
| 2 | Most of the time |
| 3 | Some of the time |
| 4 | A little of the time |
| 5 | None of the time |
Universe:
if [(GRIDVARIABLES.ModeType = 1 & CASISTART.scac = 1 thru 4) | (GRIDVARIABLES.ModeType = 2 | 3)] // Mode is face-to-face and translator not needed OR Mode is telephone or web
scasf12_ip17.scsf1
General health
Type: choice
Source: Quality Metric Inc., 2007
Text: In general, would you say your health is...
| Option | Label |
|---|---|
| 1 | Excellent |
| 2 | Very good |
| 3 | Good |
| 4 | Fair |
| 5 | Poor |
Universe:
if [(GRIDVARIABLES.ModeType = 1 & CASISTART.scac = 1 thru 4) | (GRIDVARIABLES.ModeType = 2 | 3)] // Mode is face-to-face and translator not needed OR Mode is telephone or web
scasf12_ip17.scsf4b
Last 4 weeks: Mental health meant worked less carefully
Type: choice
Source: Quality Metric Inc., 2007
Text: Did work or other activities less carefully than usual
| Option | Label |
|---|---|
| 1 | All of the time |
| 2 | Most of the time |
| 3 | Some of the time |
| 4 | A little of the time |
| 5 | None of the time |
Universe:
if [(GRIDVARIABLES.ModeType = 1 & CASISTART.scac = 1 thru 4) | (GRIDVARIABLES.ModeType = 2 | 3)] // Mode is face-to-face and translator not needed OR Mode is telephone or web
scasf12_ip17.scsf4a
Last 4 weeks: Mental health meant accomplished less
Type: choice
Source: Quality Metric Inc., 2007
Text: During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
Accomplished less than you would like
| Option | Label |
|---|---|
| 1 | All of the time |
| 2 | Most of the time |
| 3 | Some of the time |
| 4 | A little of the time |
| 5 | None of the time |
Universe:
if [(GRIDVARIABLES.ModeType = 1 & CASISTART.scac = 1 thru 4) | (GRIDVARIABLES.ModeType = 2 | 3)] // Mode is face-to-face and translator not needed OR Mode is telephone or web
scasf12_ip17.scsf5
Last 4 weeks: Pain interfered with work
Type: choice
Source: Quality Metric Inc., 2007
Text: During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
| Option | Label |
|---|---|
| 1 | Not at all |
| 2 | A little bit |
| 3 | Moderately |
| 4 | Quite a bit |
| 5 | Extremely |
Universe:
if [(GRIDVARIABLES.ModeType = 1 & CASISTART.scac = 1 thru 4) | (GRIDVARIABLES.ModeType = 2 | 3)] // Mode is face-to-face and translator not needed OR Mode is telephone or web
scasf12_ip17.scsf6a
Last 4 weeks: Felt calm and peaceful
Type: choice
Source: Quality Metric Inc., 2007
Text: These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks...
Have you felt calm and peaceful?
| Option | Label |
|---|---|
| 1 | All of the time |
| 2 | Most of the time |
| 3 | Some of the time |
| 4 | A little of the time |
| 5 | None of the time |
Universe:
if [(GRIDVARIABLES.ModeType = 1 & CASISTART.scac = 1 thru 4) | (GRIDVARIABLES.ModeType = 2 | 3)] // Mode is face-to-face and translator not needed OR Mode is telephone or web
scasf12_ip17.scsf6b
Last 4 weeks: Had a lot of energy
Type: choice
Source: Quality Metric Inc., 2007
Text: Did you have a lot of energy?
| Option | Label |
|---|---|
| 1 | All of the time |
| 2 | Most of the time |
| 3 | Some of the time |
| 4 | A little of the time |
| 5 | None of the time |
Universe:
if [(GRIDVARIABLES.ModeType = 1 & CASISTART.scac = 1 thru 4) | (GRIDVARIABLES.ModeType = 2 | 3)] // Mode is face-to-face and translator not needed OR Mode is telephone or web
scasf12_ip17.scsf6c
Last 4 weeks: Felt downhearted and depressed
Type: choice
Source: Quality Metric Inc., 2007
Text: Have you felt downhearted and depressed?
| Option | Label |
|---|---|
| 1 | All of the time |
| 2 | Most of the time |
| 3 | Some of the time |
| 4 | A little of the time |
| 5 | None of the time |
Universe:
if [(GRIDVARIABLES.ModeType = 1 & CASISTART.scac = 1 thru 4) | (GRIDVARIABLES.ModeType = 2 | 3)] // Mode is face-to-face and translator not needed OR Mode is telephone or web
scasf12_ip17.scsf7
Last 4 weeks: Physical or mental health interfered with social
Type: choice
Source: Quality Metric Inc., 2007
Text: During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives)?
| Option | Label |
|---|---|
| 1 | All of the time |
| 2 | Most of the time |
| 3 | Some of the time |
| 4 | A little of the time |
| 5 | None of the time |
Universe:
if [(GRIDVARIABLES.ModeType = 1 & CASISTART.scac = 1 thru 4) | (GRIDVARIABLES.ModeType = 2 | 3)] // Mode is face-to-face and translator not needed OR Mode is telephone or web
