Appendix 3. The Survey Instruments: The Adult Questionnaire

Irish National Survey of Disability, Pilot 2003 Adult Questionnaire

Area 
Resp. 
Date___ ___ /___ ___/2003
Intno:
Int. name 

Time Interview began (24 hour clock) __ __ : __ __

Introduction

Hello, my name is ______________. I’m from the Economic and Social Research Institute. I am here to ask for your help in completing a survey on disability, as we discussed on the telephone.

You may remember that you recently completed a brief telephone survey on disability with us, and we said that we would be following up with a more detailed interview.

The purpose of the survey is to collect information on the experiences of people with disabilities so that services and facilities can be improved.

The survey is being conducted for the National Disability Authority, and the questionnaire was developed in consultation with organisations that represent the interests of people with disabilities.

I would like to assure you that all the information you give me is completely confidential. We produce statistical reports on social issues that do not identify individual respondents.

At this stage we are testing a questionnaire that is to be used nation-wide after the next census in 2006. We will be very keen to get feedback from you on whether you feel the important issues are adequately covered and on areas where the questions may not be clear enough.

So, are youready to begin?

Respondent Activity Profile Sheet [to be completed by Interviewer based on responses to filter questions in each section]

Does respondent experience any difficulty in …?

 YesNo
A) Seeing12
B) Hearing12
C) Speaking12
D) Mobility / Agility12
E) Pain12
F) Breathing12
G) Learning12
H) Intellectual/Developmental12
J) Memory12
K) Emotional, Psychological, Mental Health12
L) Any other difficulty (specify)12

Note: This profile sheet is not intended to ‘classify’ respondents. It is used solely as a tool in organising the interview using the full questionnaire – to make sure that people are asked the specific questions that apply to their situation.

Section I: Activities and Aids

A. Seeing

I am going to ask you a series of questions about your ability to do certain activities and about aids or forms of assistance that are useful to you. Please tell me only about those difficulties that have lasted, or are expected to last, six months or more.

A1. Do you wear glasses or contact lenses to see up close? [e1251]

Yes1
No2

A2. Do you wear glasses or contact lenses to see at a distance? [e1251]

Yes1
No2

A3.[With glasses or contact lenses], Do you have any difficulty seeing ordinary newspaper print?[b210]

No difficultyJust a little difficultyA moderate level of difficultyA lot of difficultyCannot see
12345

A4. [With glasses or contact lenses], Do you have any difficulty clearly seeing the face of someone across a room (from 4 meters or 12 feet)? [b210]

No difficultyJust a little difficultyA moderate level of difficultyA lot of difficultyCannot see
12345

A5. Interviewer Check: Does person have any seeing difficulty [at A3 or A4]?

Yes1Mark ‘Seeing’ on profile sheet and Go to A6
No2Go to B1

If Seeing Limitation

A6. Have you been diagnosed by an eye specialist as being legally blind?

Yes1
No2

A7. Do you use any other aids (besides glasses or contact lenses) or specialised equipment for persons who are blind or visually impaired (magnifiers, Braille, reading materials)? [e125]

Yes1Go to A8
No2Go to A9

A8. Do you now use any of the following…

 YesNo
a) Magnifiers?[e1251]12
b) Braille reading materials? [e1251]12
c) Large print reading materials? [e1251]12
d) Talking books? [e1251]12
e) Recording equipment or portable note-takers?12
f) Closed circuit devices, e.g. CCTV’s? [e1251]12
g) A computer with Braille, large print or speech access? [e1251]12
h) A white cane?[e1201]12
i) A guide dog?[e350]12
j) Another aid? — specify [e120]12

A9. Are there any aids or specialised equipment for persons who are blind or visually impaired that you think you NEED but do not have?

Yes1Go to A10
No2Go to B1

A10. Which aids are these? [Interviewer: Do not read list. Mark all that apply]

aMagnifiers?[e1251]1
bBraille reading materials? [e1251]2
cLarge print reading materials? [e1251]3
dTalking books? [e1251]4
eRecording equipment or portable note-takers?5
fClosed circuit devices, e.g. CCTV’s? [e1251]6
gA computer with Braille, large print or speech access? [e1251]7
hA white cane?[e1201]8
IA guide dog?[e350]9
jAnother aid? — specify [e120]10

B Hearing

B1. Do you use a hearing aid or hearing aids? [e1251]

Yes1
No2

B2. (WITH your hearing aid(s)), do you have any difficulty hearing what is said in a conversation with ONE other person? [b230]

No difficulty1
Just a little difficulty2
A moderate level of difficulty3
A lot of difficulty4
Cannot hear5

B3. (WITH your hearing aid(s)), do you have any difficulty hearing what is said in a conversation with at least THREE other people? [b230]

No difficulty1
Just a little difficulty2
A moderate level of difficulty3
A lot of difficulty4
Cannot hear5

B4. (WITH your hearing aid(s)), do you have any difficulty hearing what is said in a TELEPHONE conversation? [b230]

No difficulty1
Just a little difficulty2
A moderate level of difficulty3
A lot of difficulty4
Cannot hear5

B5. Interviewer Check: Does person have any hearing difficulty?

Yes1Mark ‘Hearing’ on profile sheet and Go to B6
No2Go to C1

If Hearing Difficulty

B6. Apart from any hearing aids, do you USE any other aids, specialised equipment or services for persons who are deaf or hard of hearing, for example, a volume control telephone or TV decoder?

Yes1Go to B7
No2Go to B8

B7. Do you now USE: [Interviewer: Read list, mark ‘Yes’ or ‘No’ for each]

 YesNo
a) A computer to communicate, e.g. e-mail or chat service? [e1250]12
b) A volume control telephone?[e1251]12
c) A Minicom? [e1251]12
d) A message relay service? [e1250]12
e) Other phone related devices, e.g.flashers? [e1251]12
f) A closed caption TV or decoder? [e1251]12
g) Amplifiers, e.g.FM, acoustic, infrared? [e1251]12
h) Visual or vibrating alarms? [e1251]12
i) A Sign language interpreter? [e398]12
j) A hearing ear dog? [e350]12
k) Another aid? — specify[e1251]12

B8. Are there any aids, specialised equipment or services for persons who are deaf or hard of hearing that you think you NEED but do not have?

Yes1Go to B9
No2Go to B10

B9. Which aids or services do you NEED but do not have?

[Interviewer: Do not read list, Mark all that apply]

aHearing aid or new hearing aid[e1251]1
bA computer to communicate, e.g., e-mail or chat service[e1250]2
cA volume control telephone[e1251]3
dA Minicom[e1251]4
eA message relay service[e1250]5
fOther phone related devices, e.g., flashers[e1251]6
gA closed caption TV or decoder[e1251]7
hAmplifiers, e.g. FM, acoustic, infrared[e1251]8
IVisual or vibrating alarms[e1251]9
jA Sign language interpreter[e398]10
kA hearing ear dog[e350]11
lAnother aid or service — specify[e1251]12

B10. Do you consider yourself to be a member of the Deaf Community, that is, a member of a minority community whose language is Irish Sign Language?

Yes1
No2

B11. This question deals with certain communication skills. I will read you a list. Please answer Yes or No to each. Do you

 

Yes

No

aUse Sign language such as ISL? [d340]12
bSpeech read or lip read? [d3602]12

[If Yes at B11a or B11b, Go to B12; otherwise go to C1]

B12. Using these methods, how well are you able to communicate with

 

Completely

Partially

Not at all

aMembers of your own family123
bYour friends123
cProfessionals and service providers such as doctors and home help workers123
dOther people123

C. Speaking and Communication

C1. Do you have any difficulty speaking or making yourself understood when speaking?[d330]

No difficulty1Go to D1
Just a little difficulty2Mark ‘Speaking’ on profile sheet and Go to C2
A moderate level of difficulty3
A lot of difficulty4
Cannot speak5

C2. How well are you able to make yourself understood when speaking with …

 

Completely

Partially

Not at all

aMembers of your own family123
bYour friends123
cProfessionals and service providers such as doctors and home help workers123
dOther people123

C3. Do you use …

 

Yes

No

aSign language such as ISL[d340]12
bSome other form of communication [d349]12

If Yes to C3a or C3b, go to C4 otherwise go to C5

C4. How well are you able to communicate in this manner with …

[Interviewer: Read list.]

 

Completely

Partially

Not at all

aMembers of your own family123
bYour friends123
cProfessionals and service providers such as doctors and home help workers123
dOther people123

C5. Do you USE any aids or specialised equipment for persons who have difficulty speaking or making themselves understood, for example, a keyboard device to communicate? [d360]

Yes1Go to C6
No2Go to C7

C6. Which aids do you use?

[Interviewer: Read list; mark all that apply]

 

Yes

No

aVoice amplifier12
bComputer or keyboard12
cCommunications board12
dOther, specify12

C7. Are there any aids or specialised equipment for people who have difficulty speaking or making themselves understood that you think you NEED but do not have?

Yes1Go to C8
No2Go to D1

C8. Which aids are these?

[Interviewer: Do not read list; mark all that apply]

aVoice amplifier1
bComputer or keyboard2
cCommunications board3
dOther, specify4

D. Mobility

The next few questions are about your ability to move around, even when using an aid or specialised equipment such as a cane or crutches. Remember, I am asking about difficulties that have lasted or are expected to last 6 months or more.

D1. (WITH your aid or specialised equipment), do you have any difficulty walking for short distances, such as walking around rooms or hallways or for short distances outside? [d450]

No difficulty1
Just a little difficulty2
A moderate level of difficulty3
A lot of difficulty4
Cannot do5

D2. (WITH your aid or specialised equipment), do you have any difficulty walking up and down a flight of stairs, about 12 steps, without resting? [d4551]

No difficulty1
Just a little difficulty2
A moderate level of difficulty3
A lot of difficulty4
Cannot do5

D3. (WITH your aid or specialised equipment), do you have any difficulty moving from one room to another?[d4600]

No difficulty1
Just a little difficulty2
A moderate level of difficulty3
A lot of difficulty4
Cannot do5

D4. (WITH your aid or specialised equipment), do you have any difficulty getting into and out of bed?[d4100]

No difficulty1
Just a little difficulty2
A moderate level of difficulty3
A lot of difficulty4
Cannot do5

D5. (WITH your aid or specialised equipment), do you have any difficulty lifting or carrying something like a cup or a bag of groceries? [d430]

No difficulty1
Just a little difficulty2
A moderate level of difficulty3
A lot of difficulty4
Cannot do5

D6. (WITH your aid or specialised equipment), do you have any difficulty bending down and picking up an object from the floor (for example a shoe)?[d4105]

No difficulty1
Just a little difficulty2
A moderate level of difficulty3
A lot of difficulty4
Cannot do5

D7. (WITH your aid or specialised equipment), do you have any difficulty difficulty using your fingers to grasp or to hold an object, such as pliers or scissors? [d4401]

No difficulty1
Just a little difficulty2
A moderate level of difficulty3
A lot of difficulty4
Cannot do5

D8. Interviewer Check: Does respondent have any difficulty in terms of mobility (D1 to D7)?

Yes1Mark ‘Mobility/Agility’ on profile sheet and Go to D9
No2Go to E1

[If any Mobility Difficulty ]

D9. Do you USE any aids or specialised equipment for people who have difficulty in terms of mobility, or any personal support services such as a home help or personal assistant?

Yes1Go to D10
No2Go to D11

D10. Do you now USE ...

Interviewer: read list, mark ‘yes’ or no for each]

 

Yes

No

aOrthopaedic footwear? [e1202]12
bA cane or walking stick? [e1202]12
cCrutches? [e1202]12
dA manual wheelchair? [e1202]12
eAn electric wheelchair? [e1202]12
fA walking frame? [e1202]12
gA scooter? [e1202]12
hBraces or supportive devices? [e1151]12
iLifts or lift type devices? [e1202]12
jGrab bars or bathroom aids? [e1551]12
kHand or arm brace [e1151]12
lGrasping tools or reach extenders [e1151]12
mA home help or personal assistant (not a family member) [e340]12
nAnother aid or type of assistance? — specify12

D11. Are there any aids or specialised equipment for people who have difficulty in terms of mobility, or any or personal support services such as a home help or personal assistant that you NEED but do not have?

Yes1Go to D12
No2Go to E1

D12. Which aids do you NEED but do not have?

[Interviewer: Do not read list; tick all that apply]

aOrthopaedic footwear? [e1202]1
bA cane or walking stick? [e1202]2
cCrutches? [e1202]3
dA manual wheelchair? [e1202]4
eAn electric wheelchair? [e1202]5
fA walking frame? [e1202]6
gA scooter? [e1202]7
hBraces or supportive devices? [e1151]8
iLifts or lift type devices? [e1202]9
jGrab bars or bathroom aids? [e1551]10
kHand or arm brace [e1151]11
lGrasping tools or reach extenders [e1151]12
mA home help or personal assistant (not a family member) [e340]13
nAnother aid or type of assistance? — specify14

E. Pain

The next few questions deal with long-term pain and discomfort.

E1. Do you have any pain or discomfort that is ALWAYS present? [b280]

Yes1Go to E3
No2Go to E2

E2. Do you have SPELLS of pain or discomfort that REOCCUR from time to time? [b280]

Yes1Go to E3
No2Go to E3

E3. Interviewer Check: Does person have any difficulty in terms of pain [Yes at E1 or E2]?

Yes1Mark ‘Pain’ on profile sheet and Go to E4
No2Go to F1

E4. Does this pain or discomfort reduce the amount or the kind of activities you can do?

Yes, sometimes1
Yes, often or always2
No3

E5. When this pain is present, how much of a problem is it for you?

Just a slight problem1
A moderate problem2
A severe problem3
Completely incapacitates me4

F. Breathing

F1. Do you have shortness of breath or difficulty breathing? [b440]

No difficulty1Go to G1
Just a little difficulty2Interviewer: Mark ‘Breathing’ on profile sheet and Go to F2
A moderate level of difficulty3
A lot of difficulty4

F2. Does this shortness of breath or breathing difficulty reduce the amount or the kind of activities you can do? [b440]

Yes, sometimes1
Yes, often or always2
No3

F3. Do you USE any aids or specialised equipment designed to assist breathing? [Note: an asthma inhaler is counted as medication rather than ‘aids or specialised equipment’]

Yes1Go to F4
No2Go to F5

F4. Do you now USE: ? [Interviewer: Read list. Mark ‘Yes’ or ‘No’ for each

 

Yes

No

aNebulisers12
bOxygen concentrator or cylinder12
cVentilator12

F5. Are their any aids or specialised equipment designed to assist breathing that you think you NEED but do not have?

Yes1Go to F6
No2Go to G1

F6. Which aidsdo you NEED but do not have? [Interviewer: Do not read list. Mark all that apply]

aNebulisers1
bOxygen concentrator or cylinder2
cVentilator3

G. Learning

G1. Do you have a condition that makes it difficult in general for you to learn? Such conditions include attention problems, hyperactivity, dyslexia and others. [d100]

Yes1
No2

G2. Has a teacher, doctor, psychologist or other health professional ever said that you had a learning disability or learning difficulty?

Yes1
No2

G3. Interviewer Check: Is ‘Yes’ marked at either G1 or G2 above?

Yes1Mark ‘Learning’ on Profile sheet and Go to G4
No2Go to H1

G4. Does this condition reduce the amount or kind of activities that you can do?

Yes, sometimes1Go to G5
Yes, often or always2Go to G5
No3Go to G6

G5. How much difficulty do you have in learning as a result of this condition?[d100]

No difficulty1
Just a little difficulty2
A moderate level of difficulty3
A lot of difficulty4
Completely unable5

G6. Do you use any aids or specialised equipment or personal support to help you with your learning disability? [e1301]..

Yes1Go to G7
No2Go to G8

G7. Do you now use …[Interviewer: Read list. Mark ‘yes’ or ‘no’ for each]

 

Yes

No

aPortable spell checkers? [e1300]12
bRecording equipment? [e1300]12
cTalking books? [e1300]12
dPocket organisers? [e1300]12
eA home computer? [e1300]12
 Interviewer: If e is Yes (has computer), ask f to i, otherwise skip to j.
fA scanner or printer? [e1300]12
gSpell /grammar checking software? [e1300]12
hVoice recognition software? [e1300]12
iSoftware organisational tools? [e1300]12
jClass Room Assistant, [e360]12
kSpecial Needs Assistant[e360]12
lRemedial or other Resource Teaching Support [e360]12
mAnother aid or support? — specify [e1301]12

G8. Are there any learning aids or specialised equipment or supports that you think you need but do not have? ..

Yes1Go to G9
No2Go to H1

G9. Which aids are these? [Interviewer: Do not read list. Mark all that apply]..

aPortable spell checkers? [e1300]1
bRecording equipment? [e1300]2
cTalking books? [e1300]3
dPocket organisers? [e1300]4
eA home computer? [e1300]5
fA scanner or printer? [e1300]6
gSpell /grammar checking software? [e1300]7
hVoice recognition software? [e1300]8
iSoftware organisational tools? [e1300]9
jClass Room Assistant, [e360]10
kSpecial Needs Assistant[e360]11
lRemedial or other Resource Teaching Support [e360]12
mAnother aid or support? — specify [e1301]13

H. Intellectual/Developmental Difficulties

H1. Has a doctor, psychologist, or other health professional ever said that you had an intellectual or developmental disability? This includes Down’s syndrome, autism, mental impairment due to lack of oxygen at birth etc.? [b117]

Yes1Mark Intellectual/Developmental on Profile Sheet and Go to H2
No2Go to J1

H2. Does this condition reduce the amount or kind of activities that you can do?..

Yes, sometimes1Go to H3
Yes, often or always2Go to H3
No3Go to J1

H3. To what extent has this reduced the amount or kind of activities you can do?..

Just a little1
To a moderate degree2
A great deal3
Completely4

J. Memory

J1. Do you FREQUENTLY have periods of confusion or difficulty remembering things? These difficulties are often associated with diseases such as Alzheimer’s or may be the result of a brain injury. [b144]

Yes1Mark ‘Memory’ on Profile sheet and Go to J2
No2Go to K1

J2. Does this condition reduce the amount or kind of activities that you can do?..

Yes, sometimes1 
Yes, often or always2 
No3Go to K1

J3. To what extent has this reduced the amount or kind of activities you can do?..

Just a little1
To a moderate degree2
A great deal3
Completely4

K. Emotional, Psychological or Mental Health Difficulties

K1. Do you have any emotional, psychological or mental health conditions that have lasted, or are expected to last, 6 months or more? These include phobias, depression, schizophrenia, drinking or drug problems, and others. [b150,b160,B1303]

Yes1Mark Emotional/Psychological/Mental Health on Profile sheet and Go to K2
No2Go to L1

K2. Does this condition reduce the amount or kind of activities that you can do?..

Yes, sometimes1 
Yes, often or always2 
No3Go to L1

K3. To what extent has this reduced the amount or kind of activities you can do?..

Just a little1
To a moderate degree2
A great deal3
Completely4

L. Any Other Difficulty

L1. Do you have any other difficulties or limitations because of a physical condition, mental health condition or health problem that we have not already covered? Please think of difficulties or limitations that have lasted or are expected to last for 6 months or more..

Yes1Mark ‘Other’ on Profile Sheet and Go to L2
No2Go to M1

L2. Could you tell me in what areas this condition limits your activities? For example, your energy levels, eating, socialising and so on....

_______________________________________________

_______________________________________________

L3. Does this condition reduce the amount or kind of activities that you can do?..

Yes, sometimes1 
Yes, often or always2 
No3Go to M1

L4. To what extent has this reduced the amount or kind of activities you can do?..

Just a little1
To a moderate degree2
A great deal3
Completely4

Section 2: Help from Other People and Attitudes of Other People

Now I’d like to ask if you have difficulty with any of the following because of your condition or health problem.

Do you have difficulty because of your condition?

M1. With preparing your meals [d630]

How much difficulty …

None

Slight

Fair amount

Great Deal

Cannot do

12345

M2. With shopping for groceries and other things you need [d6200].

How much difficulty …

None

Slight

Fair amount

Great Deal

Cannot do

12345

M3. With normal everyday housework, for example, tidying up, cleaning and laundry [d640]

How much difficulty …

None

Slight

Fair amount

Great Deal

Cannot do

12345

M4. With heavy household work such as spring cleaning, gardening or mowing lawns [d650]

How much difficulty …

None

Slight

Fair amount

Great Deal

Cannot do

12345

M5. Looking after your personal finances, such as banking or paying bills [d860]

How much difficulty …

None

Slight

Fair amount

Great Deal

Cannot do

12345

M6. With your personal care, such as bathing and dressing and taking medication [d520]

How much difficulty …

None

Slight

Fair amount

Great Deal

Cannot do

12345

M7. In communicating with other people, such as when you see a doctor or at a job interview? [d310/d330]

How much difficulty …

None

Slight

Fair amount

Great Deal

Cannot do

12345

M8. Interviewer Check: Does respondent have any level of difficulty with the above activities?

Yes1Go to M9
No2Go to M15

M9. Do you get help with any of the above activities? [e300].....

Yes1Go to M10
No2Go to M13

M10. Who helps with these activities? For each person who helps, perhaps you could also tell me (A) how often they help and (B) whether they get paid for the help they provide.

 

(A) How often person helps …

(B) Is this person paid?

 Note: If more than one person in each category helps, mark the code for the one who helps most.

No

Less than once a week

Once a week

At least twice a week

Daily

Yes No

aHusband or male partner [e310]123451 2
bWife or female partner[e310]123451 2
cDaughter[e310]123451 2
dSon[e310]123451 2
eMother[e310]123451 2
fFather[e310]123451 2
gSister[e310]123451 2
hBrother[e310]123451 2
IOther relative [e315]123451 2
jHousemate or friend [e320]123451 2
kNeighbour [e325]123451 2
lLocal Health Board [e340]123451 2
mOther voluntary organisation [e340]123451 2
nAn organisation, type unknown123451 2
oOther person (specify)123451 2

M11. Interviewer Check: Are any of the people who help paid?..

Yes, at least one is paid1Go to M12
No, none are paid2Go to M13

M12. Who pays them? [Interviewer: Mark all that apply]..

aYou or your family1
bGovernment agency (Health Board, etc.)2
cOther3
dDon’t know9

M13. In the last 12 months, have you, because of your condition, needed help with any of these everyday activities, which you were unable to get? I’m talking about help from providers other than family or friends.

Yes1Go to M14
No2Go to N1

M14. Why couldn’t you get that help? [Interviewer: Mark all that apply]..

aIt is too costly or you can’t afford it1
bYou applied for help but were not eligible2
cThat service is not available in your area3
dYou don’t like the service that is available4
eYou were on a waiting list5
fOther reason (specify)6

M15. Interviewer Check: Does respondent have any disability or impairment?

Yes1Go to M16
No2Go to N1

Now I would like to ask some questions about how you feel other people view you because of your condition.

M16. Is the fact that you have a condition that reduces your activities evident to people you meet in person for the first time?

Always1
Sometimes2
Not usually3
Never4

M17. Are there things you are able to do and would like to do that you avoid doing because of how other people react to your condition? [[e460].

Not at all1
Occasionally2
Fairly often3
Very Often4
All the time5

M18. Now I would like to ask about the attitudes of specific groups of people. I’d like you to tell me whether their attitudes towards your condition support you in achieving your potential or hinder you from doing things you might otherwise be able to do.

 

These people’s attitudes …

Strongly support

Support

Neither support nor hinder

Hinder

Strong-ly hinder

aYour immediate family [e410]12345
bYour extended family (such as aunts, uncles etc.) who do not live with you [e415]     
cYour friends [e420]12345
dYour acquaintances, work colleagues, classmates, neighbours or people in the community [e425]12345
ePeople in positions of authority such as employers or teachers [e430]12345
fDoctors, nurses and other health professionals [e450]12345
gOther professionals, such as social workers, psychologists [e455]12345
hStrangers [e445]12345

Section 3: Background to Reduction in Activities

N. Background to Reduction in Activities

N1Interviewer Check: Does Respondent experience difficulty in any of the areas A to L?

Yes1Go to N2
No2Go to P1

You reported that because of a physical condition, mental condition or health problem you have difficulties or limitations in doing certain activities.

N2. Do you think that these difficulties or activity limitations create a certain disadvantage for you in terms of being able to relate to other people? [d710]

Not at all

Just a little

A fair amount

A great deal

Complete

12345

N3. Do you think that these difficulties or activity limitations create a certain disadvantage for you at work or in terms of finding work? [d840-d859]

Not at all

Just a little

A fair amount

A great deal

Complete

12345

N4. Do you think that these difficulties or activity limitations create a certain disadvantage for you at school or college? [d810-d839]

Not at all

Just a little

A fair amount

A great deal

Complete

12345

N5. Do you think that these difficulties or activity limitations create a certain disadvantage for you in other areas, such as recreation or leisure? [d920]

Not at all

Just a little

A fair amount

A great deal

Complete

12345

N6. At what age did you first start having any difficulty or activity limitation?

Age ____ _____

[If less than 1 year, enter 0]

N7. What is the MAIN condition that causes you difficulty or limits your activities, e.g., cataracts, arthritis, multiple sclerosis, etc.?

 

N8. Did this condition exist from birth?

Yes1Go to N11
No2Go to N9

N9. Which one of the following best describes the CAUSE of this condition?

[Interviewer: Read list. Mark one only.]

A disease or illness1Go to N11
Ageing2Go to N11
Work conditions3Go to N11
Stress4Go to N11
An accident5Go to N10
Another cause, specify6Go to N11

N10. What type of accident? [Interviewer: Read list. Mark one only.]..

An accident at home1
A motor vehicle accident2
An accident at work3
A sports related accident4
Another type of accident5

N 11.Is there a SECOND condition that causes you difficulty or limits your activities?..

Yes1Go to N12
No2Go to P1

N12. What is the SECOND condition that causes you difficulty or limits your activities, e.g., cataracts, arthritis, multiple sclerosis, etc.?

_______________________________________________

N13. Did this condition exist from birth?...

Yes1Go to P1
No2Go to N14

N14. Which one of the following best describes the CAUSE of this condition?..

[Interviewer: Read list. Mark one only.]

A disease or illness1Go to P1
Ageing2Go to P1
Work conditions3Go to P1
Stress4Go to P1
An accident5Go to N15
Another cause, specify6Go to P1

N15. What type of accident?...

[Interviewer: Read list. Mark one only.]

An accident at home1
A motor vehicle accident2
An accident at work3
A sports related accident4
Another type of accident5

Section 4: Major Life Areas

P. Education

The next few questions are on education....

P1. In May 2003, were you enrolled in a school, college or university? (Include private schools, colleges or universities.) [d815-d839]

Yes1Go to P3
No2Go to P2

P2. Did you attend school or college after May 1998?

Yes1Go to P3
No2Go to P6

P3. Were you studying …

Full-time1
Part-time2
By correspondence course3

P4. What type of school or college were you enrolled in?...

Mainstream/Regular Primary [d820]1
Special class in a Mainstream/Regular Primary School [d820]2
Mainstream/Regular Secondary (incl. Vocational and Community Schools) [d820]3
Special class in a mainstream/regular secondary school [d820]4
Special primary or secondary school d820]5
Private school, such as business or commercial college [d825]6
Institute of Technology [d830]7
University [d830]8
Other (specify)9

P5. What type of qualification were you studying for?

No qualification1
Junior Cert.2
Leaving Cert.3
Diploma4
Trades certificate5
Bachelor's Degree6
Master's or PhD7

P6. Interviewer Check: Does respondent have difficulty or limitations …...

Yes1Go to P7
No2Go to P14

[If person has difficulties or limitation …]

P7. Did you have your condition before completing all your formal education or training?.

Yes1Go to P8
No2Go to P14

P8. Did you require modified building features or services to attend school or college?.

Yes1Go to P9
No2Go to P10

P9. Did you require … [Interviewer: Read List. For each 'Yes' Item ask .. Was this available to you?]

 

No, did not need

Yes, needed…

and was available

but was not available

aAccessible classrooms? [e1501]123
bAccessible washrooms? [e1501]123
cAccessible residences? [e1550]123
dAccessible buildings, excluding residences? [e1500123
eAccessible transport? [e1201]123
fOther feature or service? (specify)123

P10. Did you need any assistive devices or services to follow your courses or take your exams? [e1301]..

Yes1Go to P11
No2Go to P12

P11. Did you need … [Interviewer: Read List. For each 'Yes' Item ask .. Was this available to you?]...

 

No, did not need

Yes, needed…

and was available

but was not available

aNote takers or readers? [e340]123
bA tutor or teacher’s aide? [e360]123
cA computer with Braille, large print or speech access? [e1301]123
dTalking books? [e1300]123
eMagnifiers or CCTV’s (Closed circuit television readers)? [e1301]123
fBraille or large print reading materials? [e1301]123
gA Sign language interpreter? [e360]123
hRecording equipment or portable note-takers? [E1301]123
IAttendant care services? [e340]123
jExtra time for exams123
kOther aid or service?123

P12. Did you discontinue your formal education or training because of your condition?[d820].

Yes1
No2

P13. Because of your condition … [d820]

[Interviewer: Read list. Mark ‘Yes’ or ‘No’ for each.]

 

Yes

No

aDid you begin school later than most other people your age?12
bWas your education interrupted for long periods of time?12
cDid you ever attend special education school or special education classes in a mainstream/regular school?

1

2

dDid you take fewer courses or subjects than you otherwise would have?12
eDid you take any courses by correspondence or home study?12
fDid you have to leave your community to attend school?12
gDid it take you longer to achieve your present level of education?12

All Respondents...

P14. What is the highest level of schooling you have completed?...

No formal education1
Some primary2
Completed Primary3
Some secondary, no exams4
Junior Cert. or Inter Cert. or Group Cert.5
Trades qualification before Leaving Cert.6
O Levels7
Leaving Cert.8
A Levels9
Trades qualification after Leaving Cert.10
University certificate or Diploma below Bachelor Level11
Bachelor's Degree12
University certificate or Diploma above Bachelor Level13
Higher University Degree14

Q. Employment

Q1. I would like to ask now about your current work and daily activities. Could you tell me which of the following categories best describes your main activity status at present?

Working full-time or part-time (including supported employment or sheltered employment workshop) [d8502]1Go to Q8
Unemployed and seeking work2Go to Q2
Pupil, student, in further training or unpaid work experience3Go to Q2
In retirement or early retirement or has given up business4Go to Q2
Unable to work due to permanent illness or disability5Go to Q2
Fulfilling domestic tasks or care responsibilities6Go to Q2
Other inactive person, specify _________________________7Go to Q2

Q2. Have you taken steps to find work during the past four weeks? [d8450]..

Yes1 
No2Go to Q4

Q3. Are you available to start work within the next two weeks?...

Yes1Go to Q6
No2Go to Q5

Q4. Have you looked for work in the past two years?...

Yes1Go to Q6
No2Go to Q5

Q5. Some people have encountered barriers that have discouraged them from looking for work. Could you think about your own situation and indicate which of the following situations might apply to you? Please answer yes or no to each of the statements. [Interviewer: Read list.] [d8450]

 YesNo
You would lose some or all of your current income if you went to work12
You would lose some or all of your current additional supports such as your Medical Card if you went to work12
Your family or friends have discouraged your going to work12
Family responsibilities prevent you12
Information about jobs is not accessible to you12
You worry about being isolated by other workers on the job12
You have been a victim of discrimination12
You feel your training is not adequate12
Lack of accessible transport12
No jobs available12
Other reason, specify12

Q6. Do you believe that any potential employer would be likely to consider you disadvantaged in employment because of your condition?

Yes1
No2

Q7. Does your condition affect your ability to look for work?...

Yes1Go to Q12
No2Go to Q12

Presently at work...

Q8. Is your present job in a sheltered workshop or supported work environment?..

Yes1
No2

Q9. How many hours do you usually work each week, including any paid and unpaid overtime? [If you have more than one job at present, please count the hours worked in ALL jobs]..

Hours per week 

Q10. When did you begin work in your present main job or business?..

 Year 
[If 2000 or later]Month 

Q11. Did you work before, or is this your first job?...

Worked before1Go to Q13
First Job2Go to Q15

Q12. Have you ever worked in a job or business?...

Yes1Go to Q13
No2Go to Q26

Q13. When did you leave your previous job?...

 Year 
[If 2000 or later]Month 

Q14. What was the MAIN reason you left your previous job?..

To take up or seek better job1
End of temporary contract2
Obliged to stop by employer (business closure, redundancy, early retirement, dismissal etc.)3
Sale or closure of own/family business4
Child care and care for other dependant5
Marriage or partner’s job required us to move to another area6
Own illness or disability7
Other reasons8

Presently at work for pay or worked in past [Interviewer: if presently at work questions refer to present main job; if previously worked, questions refer to previous job. If person has multiple jobs at the same time and is in doubt as to which was the ‘main’ job: ‘main’ job is the job in which he/she worked the most hours.

I’d like to ask some questions now about your [last] main job...

Q15. What kind of work do [did] you do in your [last] main job? Please describe as fully as possible the nature of the work done.

 
[coded according to 4-digit ISCO-88 (Com)]

Q16. What is [was] the main activity of the business or organisation where you work [worked]? If the business or organisation has [had] more than one branch or outlet, please describe the activity of the branch or outlet where you work[ed].

 
[coded according to 2-digit NACE]

Q17. Please tell me which of the following best describes your employment situation in your [last] main job …

Self-employed with employee(s)1Go to Q19
Self-employed without employee(s)2Go to Q19
Employee3Go to Q18
Unpaid family worker4Go to Q19

Q18. What type of work contract do [did] you have in your job? (Type of contract)..

Permanent job/contract of unlimited duration1
Temporary job/work contract of limited duration2
Casual work, no contract3

Q19. How many people work at the place where you work[ed]? [If self-employed, include ‘self’]

Exact number if between 1 and 10 
11 to 19 persons11
20 to 49 persons12
50 persons or more13
Don’t know but less than 11 persons14
Don’t know but more than 10 persons15

Q20. How may hours a week do [did] you normally work in your [last] MAIN job..

Please include any usual paid and unpaid overtime

Usual hours per week 

Q21. What are [were] your usual gross earnings in this job, including usual paid overtime

Amount 
Per (week, month, etc.) 

Q22. Do [Did] you supervise or manage any personnel in your job?..

Yes1
No2

Q23. Interviewer Check: Does this person have an impairment or disability?

Yes1Go to Q24
No2Go to Q28

Q24. Because of your condition have you ever … [Interviewer Read list]

 

Yes

No

achanged the amount of work you do12
bchanged the kind of work you do12
cchanged your job12
dgiven up your job12

Q25. Do you believe that your condition makes [made] it difficult for you to change jobs or to advance at your job? [Interviewer Read list Mark one only]

Yes, very difficult1
Yes, Difficult2
No, not difficult3

Q26. Because of your condition do [would] you require any of the following to be able to work? [Interviewer Read list. Mark one response on each line]

If yes: Has this been made available to you in your present [last] job?

 

No, do not [would not] require

Yes, do [would] require, and IS available

Yes, do [would] require, but NOT available

Yes, do [would] require, but NEVER Worked

Job redesign, modified or different duties1234
Modified hours or days or reduced work days1234
Human support such as a reader, Sign language interpreter, job coach or personal assistant1234
Technical aids such as a voice synthesiser, a Minicom, an infrared system or portable note-taker1234
A computer with Braille, large print or speech access or a scanner1234
Communication aids such as Braille or large print reading material or recording equipment1234
Handrails or ramps1234
Appropriate parking1234
Accessible lift1234
Modified workstation1234
Accessible toilets1234
Accessible transport1234
Other (Specify)1234

All Respondents - Unemployment...

Q28. Have you had any period or periods of unemployment in the last 12 months? By unemployment, I mean that you were not at work but available for and seeking work.

Yes1Go to Q29
No2Go to Q31

Q29. How many different periods of unemployment did you have? [Interviewer Do not read list Mark one only ]

One1
Two2
Three or more3

Q30. What was the length of the longest period of unemployment? [Interviewer Do not read list Mark one only]

Under one month1
One to three months2
Three to five months3
Six months or more4

All Respondents - Work-related Training

Q31. In the past five years have you taken any work related training courses to either improve your skills or to learn new skills? [d825]

Yes1Go to Q32
No2Go to Q34

Q32. What was the main reason you took this course? Was it ... [Interviewer Read list Mark one only] .

for your current or a future job1
because of your condition2
for personal interest3
for another reason4

Q33. At work, to what extent are you using the skills or knowledge acquired in this course? [Interviewer Read list Mark one only ]

To a great extent1Go to R1
Somewhat2Go to R1
Very little3Go to R1
Not at all4Go to R1
Not at work since5Go to R1

Q34. Did you want to take some work related training courses?...

Yes1Go to Q35
No2Go to R1

Q35. Did any of the following prevent you from taking work related training courses? I will read you a list. Please answer yes or no to each.

 

Yes

No

Location was not physically accessible to you12
Courses were not adapted to your needs12
You requested courses but were denied them by employer12
Your condition12
Inadequate transport12
Too costly12
Other reason (specify)12

R. Leisure and Social Participation

This section will collect information on your day to day activities such as leisure and recreation and voluntary activities.

I will begin with some questions about activities you do in your spare time...

R1. In the past 3 months did you do any of the following activities?

[Interviewer: Read categories. Mark ‘Yes’ or ‘No’ for each.]

 

Yes

No

aexercise or take part in sports [d9201]12
bstay in touch by email, telephone or letter with family or friends [d9205]12
cparticipate in electronic news groups or chat groups [d9205]12
dsurf the internet for information or e-commerce12

R2. Interviewer Check: Does this person have an impairment or disability?

Yes1Go to R3
No2Go to R4

R3. I’d like to ask now how difficult it would be for you to participate in the following kinds of activities, if you wanted to.

  

No difficulty

A little difficulty

A fair amount of difficulty

A great deal of difficulty

Cannot do

aPlaying games for fun such as chess, card games, bingo etc. [d9200]12345
bTaking part in sports or exercise [d9201]12345
cGoing to the cinema, theatre or art gallery or reading for pleasure [d9202]12345
dHandicrafts such as knitting, pottery or other crafts [d9203]12345
eHobbies such as stamp collecting, gardening etc. [d9204]12345
fSocialising such as visiting friends or relatives or meeting informally in pubs, clubs etc. [d9205]12345
gParticipate in religious ceremonies, such as Mass, service, worship meeting etc. [d9300]12345
hVote in a national or local election [d950]12345
iTake part in community life, such as volunteering in charitable organisations, service clubs or professional social organisations [d910]12345

R4. Would you like to do more activities during your spare time?...

Yes1Go to R5
No2Go to R6

R5. What PREVENTS you from doing more leisure activities?...

[Interviewer: Read list and mark ‘Yes’ or ‘No’ for each item].

 

Yes

No

aYour condition prevents you from doing more12
bYou need specialised aid(s) or equipment that you don’t have12
cYou need someone’s assistance12
dYour transport services are inadequate or not accessible12
eYour community has no facilities or programs available12
fThe facilities, equipment or programs are not accessible12
gIt is too expensive12
hOther (specify)12

R6. Does the design and layout of buildings and places in your community make it DIFFICULT for you to participate in leisure activities?

Yes1Go to R7
No2Go to S1

R7. How often in the last 12 months have you found it difficult to participate in leisure activities because of the design and layout of buildings or places in your community?

[Interviewer: Mark one only]

Daily1
Weekly2
Monthly3
Less often than once a month4

S. Transport

I am now going to ask you some questions about local travel for personal or business reasons, by which I mean trips of about 30 miles or less.

S1. In the past 12 months, did you travel locally by CAR for personal or business reasons?

Yes1Go to S5
No2Go to S2

S2. Interviewer Check: Does this person have an impairment or disability?

Yes1Go to S3
No2Go to S12

S3. Were you PREVENTED from travelling locally by car?

Yes1Go to S4
No2Go to S5

S4. What PREVENTED you from travelling locally by car?..

[Interviewer: Read list Mark all that apply]

aThe lack of proper equipment on your car (for example, hand or brake controls, power steering, etc)1
bYou need an attendant to help you2
cThe lack of space for wheelchairs or other specialised equipment3
dOther reason, specify4

S5. In the past 12 months, did you have DIFFICULTY travelling locally by car due to your condition?..

Yes1Go to S6
No2Go to S12

S6. Does this DIFFICULTY occur when you are the driver?

Yes1Go to S7
No2Go to S9

S7. Is this DIFFICULTY ...

Interviewer: Read list. Mark all that apply.

abecause you lack the proper equipment on your car? (e.g. hand or brake controls, power steering)1
bbecause you need an attendant to help you?2
cdue to the lack of space for wheelchairs or other specialised equipment?3
ddue to another reason? (specify)4

S8. How often was this a problem for you?

Daily1
Weekly2
Monthly3
Less often than once a month4

S9. Does this DIFFICULTY occur when you are a passenger?

Yes1Go to S10
No2Go to S12

S10. Is this DIFFICULTY...

Interviewer: Read list. Mark all that apply.

abecause you need an attendant to help you?1
bdue to the lack of space for wheelchairs or other specialised equipment?2
cdue to another reason? (specify)3

S11. How often was this a problem for you?

Daily1
Weekly2
Monthly3
Less often than once a month4

S12. In the past 12 months, did you travel locally by specialised bus services, or local public transport, including buses, DART and taxis? [e540]

Yes1Go to S15
No2Go to S13

S13. Were you PREVENTED from travelling locally by specialised bus service or public transport? ..

Yes1Go to S14
No2Go to S15

S14. What PREVENTED you from travelling locally by specialised bus service or by local public transport? [e5401]

[Interviewer: Read list, mark all that apply].

aservice not available on a 24 hour, 7 day a week basis1
bbooking rules don’t allow for last minute arrangements2
cgetting to or locating bus stops, train or DART stations3
dgetting on or off vehicles4
eseeing signs or notices5
fother (specify)6

S15. Interviewer Check: Does this person have an impairment or disability?

Yes1Go to S16
No2Go to T1

S16. In the past 12 months, did you have any DIFFICULTY travelling locally by specialised bus or van services, or local public transport, because of your condition?

Yes1Go to S17
No2Go to T1

S17. What kind of difficulty did you have? ...

[Interviewer: Read list, Mark all that apply]

aservice not available on a 24 hour, 7 day a week basis1
bbooking rules don’t allow for last minute arrangements2
cgetting to or locating bus stops3
dgetting on or off vehicles4
eseeing signs or notices5
fother, specify6

T. Housing

I am now going to ask you some questions about your residence and any specialised features you may have.

T1. Does your household own this accommodation or are you a tenant or sub-tenant?.

Owner or purchasing1Go to T2
Renter2Go to T3
Accommodation provided rent-free3Go to T4

T2. Do you still have any outstanding loans or mortgages on the accommodation?..

Yes1Go to T4
No2Go to T4

T3. From whom is the accommodation rented?...

Local authority1
Voluntary body (e.g. Respond)2
Private Landlord3

T3a. Interviewer Check: Does respondent have difficulty in any area A to L?

Yes1Go to T4
No2Go to U1

T4. Because of your condition, do you use any specialised features to enter or leave your home, or inside your home? [e155]

Yes1Go to T5
No2Go to T6

T5. Do you now use ...

[Interviewer: Read list and mark Yes or No for each]

 

Yes

No

aRamps on street level entrances? [e1550]12
bAutomatic or easy to open doors (includes lever handles)? [e1550]12
cWidened doorways or hallways? [e1550]12
dLift device? [e155]12
eVisual alarms or audio warning devices? [e155]12
fGrab bars or a bath lift (in the bathroom)? [e1551]12
gLowered counters in the kitchen? [e1551]12
hOther, specify12

T6. Are there any specialised features that you NEED but do not have?

Yes1Go to T7
No2Go to T9

T7. Which specialised features do you NEED but do not have? [Interviewer: Do not read list, mark all that apply]

aRamps on street level entrances?1
bAutomatic or easy to open doors (includes lever handles)?2
cWidened doorways or hallways?3
dLift device?4
eVisual alarms or audio warning devices?5
fGrab bars or a bath lift (in the bathroom)?6
gLowered counters in the kitchen?7
hOther, specify8

T8. Why don’t you have this (these) feature(s)? [Interviewer: Read list, mark all that apply]

aNot covered by Medical Card/Local Authority1
bToo expensive2
cSpecialised features not approved or recommended by health professional/ Local Authority or Health Board

3

dCurrently on a waiting list for aids /features4
eOther reason, specify5

T9. Has the design and layout of your home, including entrance and exits, made it difficult to participate in the activities you want or need to do? (INCLUDE ALL activities of daily living, not just leisure or recreational activities.)

Not at all1
A little difficult2
Fairly difficult3
Very difficult4
Impossible5

Section 5: Demographic Information

U. Demographic Information

Now I would like to ask some general questions about you. Again, please remember that all the information you give me is completely confidential.

U1. [Interviewer: Respondent is …]

Male1
Female2

U2. Could I check how old you were on your last birthday?

 (years)

U3. What is your present legal marital status?...

Married1Go to U4
Separated2Go to U5
Divorced3Go to U5
Widowed4Go to U5
Never married5Go to U5

U4. Are you presently living with your husband/wife?...

Yes1Go to U6
No2Go to U5

U5. Are you presently living with a partner?...

Yes1
No2

U6. I would like you to think now of all the members of your household, could you please tell their (a) gender; (b) age last birthday; (c) their present economic status and finally, their relationship to you. Could I begin with the person responsible for the accommodation … [Int: Householder (person responsible for accommodation) should be on line 1]

No.

First name/Initial

(A) 
Sex

(B) 
Age last birthday

(C) 
Principal Economic Status

(D)

Interviewer Use only:

Per-son No.

INT: Put person responsible for accom. on line 1

M

F

 

At Work

Un-employed

Student

Other

Relationship to Respondent

 

Relationship codes

1 12 1234  0 = Self
2 12 1234  1=Spouse/partner
3 12 1234  2=Child/stepchild
4 12 1234  3=Parent/stepparent
5 12 1234  4=Brother/sister
6 12 1234  5=Other relative
7 12 1234  6=Non-relative
8 12 1234   

U7. Interviewer: Record Person number of respondent

 

U8. Could you tell me the occupation of the Householder (person listed on line 1 above) in his/her most recent job or business?

Please describe as fully as possible the type of work done. [Int. If farmer, record the acreage. If manager or supervisor record the numbers supervised and if relevant, record the rank or grade – e.g. rank in army or Gardaí, grade in Civil Service..

 

U9. Do you live in …...

A city such as Dublin, Cork, Galway, Limerick or Waterford?1Go to U11
Another large town (population over 10,000)2Go to U11
A smaller town (population 1,500 to under 10,000)3Go to U10
A village (population under 1,500)4Go to U10
Open countryside5Go to U10

U10. How far is it to the nearest large town or city?

 miles

U11. Finally, a few questions about how you are able to manage financially. Which of the following sources of income does your household receive? Please think of the income of all household members, not just your own. [Interviewer: Please circle Yes or No for each source of income.]

U12. And which is the largest source? [Circle one number in Column B]...

 

A. Receive?

B. Largest

Yes

No

 
Wages or Salaries121
Income from Self-employment122
Income from Farming123
Occupational or Personal Pensions124
Social Welfare payments125
Income from Investments, Savings or Property126
Children's Allowance (Child Benefit)127
Other Sources (specify)128

U13. Could I ask about the approximate level of net household income? This means the total income, after tax and PRSI, of ALL MEMBERS of the household. It includes ALL TYPES of income: income from employment, social welfare payments, child benefit, rents, interest, pensions etc. We would just like to know into which broad group the total income of your household falls. I'd like to assure you once again that all information you give me is entirely confidential. I can read you the categories as either an amount per week, per month or per year. Which would you prefer?

[Interviewer: read categories from table from ONE of the columns, depending on respondent’s preference and circle one number]

Amount per year

Amount per month

Amount per week

 
under €16,000under €1,300under €3001
€16,001 - €22,500€1,301 - €1,850€301 - €4252
€22,501 - €31,000€1,851 - €2,600€426 - €6003
€31,001 - €47,000€2,601 - €3,900€601 - €9004
€47,001 - €68,000€3,901 - €5,650€901 - €1,3005
over €68,000over €5,650over €1,3006

U14. Time Interview ended (24 hour clock) __ __ : __ __

U15. How was the questionnaire completed?..

Directly by respondent, in person1Go to V1
Interpreted interview (answers given to interpreter by respondent)2Go to U16
Facilitated interview (facilitator helped respondent and/ answered for him/her)3Go to U16
By proxy (facilitator etc. answered all or almost all questions for respondent)4Go to U16

U16. How is the facilitator person providing proxy information related to the Respondent?

Mother1
Father2
Brother or Sister3
Adult child4
Other relative5
Non-relative, carer6
Non-relative, not carer7

Section 6. Feedback From Respondent

At this point I would like to give you an opportunity to provide some feedback on the interview. I can ask the questions now, or I can leave the form for you to complete and return to the ESRI in complete confidence. Which would you prefer?

V1. How satisfied were you with the following aspects of the interviewer’s approach

 

Very satisfied

Satisfied

Neither satisfied nor dis-satisfied

Dis-satisfied

Very Dis-satisfied

aCourtesy12345
bClarity12345
cThe pace of the interview12345
dThe relevance of the topics covered to your situation12345

V2 Were there any questions that were not clear?

(If yes, please specify)

 

V3 Did you feel that the interview was too long, too short or about right?

 

V4 Were there issues that are important to you that were not properly covered?

(If yes, please specify)

 

V5 Do you have any other comments on how the interview was conducted?

 

V6 Were there any questions that you were particularly uncomfortable with?

If yes, which were these?

 

Why were you uncomfortable?

 

Thank you very much for taking the additional time to provide us with this important feedback. Your comments will be carefully considered in developing the final version of the questionnaire.

Section 7: Feedback From INTERVIEWER

Interviewer: Please complete this form as soon as possible after the interview.

W1. How satisfied were you with the following aspects of the questionnaire …

 

Very satisfied

Satisfied

Neither satisfied nor dis-satisfied

Dis-satisfied

Very Dis-satisfied

aLayout12345
bClarity of the questions12345
cThe amount of detail overall12345
dThe balance between different sections12345

W2 Were there any questions that were not clear?

(If yes, please specify)

 

W3 Did you feel that the interview was too long, too short or about right?

 

W4 Were there points at which the respondent seemed to lose interest?

 

W5 Do you have any other comments on the questionnaire?

 

W6. Overall, how would you rate the …

 

Very satisfied

Satisfied

Neither satisfied nor dis-satisfied

Dis-satisfied

Very Dis-satisfied

aLevel of interest of the questions to the respondent12345
bClarity of the questions to the respondent12345

Page last updated: 08/12/2010