No Some A lot of Cannot Questions difficulty difficulty difficulty do at all 3.1. Do you have difficulty seeing, even if □ □ □ □ wearing glasses? 3.2 Do you have difficulty hearing, even if using a hearing aid? □ □ □ □ 3.3 Do you have difficulty walking or □ □ □ □ climbing steps? 3.4 Do you have difficulty remembering or □ □ □ □ concentrating? 3.5 Do you have difficulty with self-care, such as washing all over or dressing □ □ □ □ yourself? 3.6 Using your usual (customary) language, do you have difficulty communicating? (for □ □ □ □ example, understanding or being understood by others)? 3.7 Do you have an assistive device to help you with your disability? Check each one that applies ☐ Yes, for seeing ☐ Yes, for hearing ☐ Yes, for walking ☐ Yes, for communicating ☐ No assistive device 4. Participation in community** THIS SECTION IS ABOUT YOUR PARTICIPATION IN THE COMMUNITY. YOU WILL BE ASKED TO COMPARE YOURSELF TO OTHER PEOPLE IN THE COMMUNITY. EACH QUESTION HAS FIVE OPTIONS. YOU CAN ONLY CHOOSE ONE OF THESE OPTIONS. Check one box per row you must check one box only in each row – Irrelevant, Participation Scale or I don’t No Small Medium Large Compare yourself to the other want to, or problem problem problem problem people in the community I don’t have to
Questions No difficulty Some difficulty A lot of difficulty Cannot do at all 3.1. Do you have difficulty seeing, even if wearing glasses? □ □ □ □ 3.2 Do you have difficulty hearing, even if using a hearing aid? □ □ □ □ 3.3 Do you have difficulty walking or climbing steps? □ □ □ □ 3.4 Do you have difficulty remembering or concentrating? □ □ □ □ 3.5 Do you have difficulty with self-care, such as washing all over or dressing yourself? □ □ □ □ 3.6 Using your usual (customary) language, do you have difficulty communicating? (for example, understanding or being understood by others)? □ □ □ □ 3.7 Do you have an assistive device to help you with your disability? Check each one that applies ☐ Yes, for seeing ☐ Yes, for hearing ☐ Yes, for walking ☐ Yes, for communicating ☐ No assistive device 4. Participation in community** THIS SECTION IS ABOUT YOUR PARTICIPATION IN THE COMMUNITY. YOU WILL BE ASKED TO COMPARE YOURSELF TO OTHER PEOPLE IN THE COMMUNITY. EACH QUESTION HAS FIVE OPTIONS. YOU CAN ONLY CHOOSE ONE OF THESE OPTIONS. Check one box per row – you must check one box only in each row Participation Scale Compare yourself to the other people in the community No problem Small problem Medium problem Large problem Irrelevant, or I don’t want to, or I don’t have to
Field%20Test%20-ISAT-Final.docx