SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 22: QUALITY OF LIFE FORM INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 22: Quality of Life Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Source Citations: Endicott, J., Nee, J., Harrison, W., and Blumenthal, R. (1993). Quality of life enjoyment and satisfaction questionnaire: A new measure. Psychopharmacology Bulletin, 9, 321-326; Padilla, G. V., Ferrell, B., Grant, M. M., and Rhiner, M. (1990). Defining the content domain of quality of life for cancer patients with pain. Cancer Nursing, 13, 108-115.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Specific Parts of Module 22: Quality of Life Form

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. Site codes are 3 letters.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Date. Enter the numbers representing today's date in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "96" for 1996). Make sure that, if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure than each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Client Gender. Darken the circle next to the response that indicates the person's gender.

Instructions: Module 22 lists six items related to quality of life. For each item, ask the client to rate how he or she felt during the past week. Note that the rating scale is represented by the rungs of a ladder. Negative responses form the lower rungs of the ladder, while more positive responses are located on the top rungs of the ladder. For each of the six items, the client will darken the circle that represents how he or she felt about the item during the past week. For example, in item 1 (My Health), if the client felt healthy a moderate amount of time during the past week, he or she would darken the circle next to "7."