Community Participation Indicators
CaseId #
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Not like this:
In a typical week, how many days
do you:
Spend time with family
Keep in touch with family by phone or
Internet
Spend time with friends
Keep in touch with friends by phone or
Internet
Go to parties, out to dinner, or other
social activities
Get out and about
Is this activity
important to you?
No Yes Enough
Not
Enough
Too
Much
1. How often? --> 2. Important? --> 3. Doing enough?
Community Participation Indicators
CaseId #
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This survey is voluntary. If you choose to participate, your information will be kept
private. Your name will never be linked to any of the information you share.
The statements below describe many of the ways that people participate in society. For
each item, tell us:
1) How often you do the activity,
2) If the activity is important to you, and
3) If you feel you are doing the activity enough, too much, or not enough.
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Are you doing this activity:
1-2Days
3-4Days
5-6Days
7Days
None
Spend time with a significant other or
intimate partner
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In a typical week, how many
hours do you:
Cook, clean, and look after your
home
Manage household bills and
expenses
Look after children or provide
care for a loved one
Go to classes or participate in
learning activities
Volunteer
Work for money
Is this activity
important to you?
No Yes Enough
Not
Enough
Too
Much
1. How often? --> 2. Important? --> 3. Doing enough?
For each item, tell us:
1) How often you do the activity,
2) If the activity is important to you, and
3) If you feel you are doing the activity enough, too much, or not enough.
Are you doing this activity:
2
10-19Hours
20-34Hours
Hours
35ormore
5-9Hours
1-4Hours
None
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CaseId #
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In a typical month, how many
times do you:
Go to support groups or self-help
meetings
Engage in hobbies or leisure
activities
Go to movies, sporting events or
entertainment events
Exercise, participate in sports or
active recreation
Participate in community clubs or
organizations
Participate in civic or political
activities
Participate in religious or spiritual
activities
Is this activity
important to you?
No Yes Enough
Not
Enough
Too
Much
1. How often? --> 2. Important? --> 3. Doing enough?
For each item, tell us:
1) How often you do the activity,
2) If the activity is important to you, and
3) If you feel you are you are doing the activity enough, too much, or not enough.
Are you doing this activity:
3
Once
None
2Times
3Times
4Times
5orMore
Times
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1. I live my life the way that I want...........................................
23. I take responsibility for my own life......................................
3. I participate in a variety of activities......................................
4. I am uncomfortable participating in community activities....
5. I spend time doing things that improve my community........
6. I participate in activities that I choose....................................
7. I spend time helping others....................................................
8. I count as a person in society..................................................
9. I have the freedom to make my own decisions......................
10. I live my life fully...................................................................
12. I have reliable access to a telephone.......................................
13. I have a say on decisions in my community...........................
14. I have choices about the activities I do...................................
15. I actively pursue my dreams and desires................................
16. I do things that are important to me........................................
17. People have high expectations of me.....................................
19. I contribute to society.............................................................
21. I speak up for myself..............................................................
22. People speak to me disrespectfully.........................................
24. I have good job opportunities.................................................
2. People try to put limits on me................................................
Community Participation Indicators
CaseId #
25. People underestimate me........................................................
20. I have opportunities to make new friends..............................
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18. I am able to go out and have fun............................................
11. I regularly seek out new challenges.......................................
Please mark the choice that most closely reflects
your opinion:
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33. I am in control of my own life................................................
34. I am ignored............................................................................
35. I feel safe participating in community activities....................
36. I am treated as a valued member of society............................
37. People see my potential..........................................................
38. I have access to reliable transportation...................................
39. I have reliable access to the Internet.......................................
40. I have control over how I spend my time...............................
41. People listen to what I say......................................................
42. I participate in activities when I want.....................................
44. I am treated like a human being.............................................
45. People count on me................................................................
46. I contribute to the well-being of my community....................
47. I am actively involved in my community...............................
30. I do important things with my life..........................................
32. I have influence in my community.........................................
31. My community respects me the way that I am.......................
48. It is hard for me to get information about community
services..................................................................................
27. I am welcome in my community............................................
28. I am treated equally................................................................
29. I have reliable access to community services.........................
43. I am uncomfortable participating in public meetings.............
5
Please mark the choice that most closely reflects
your opinion:
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26. I assume leadership roles in organizations.............................
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5. Did you vote in the last major election?
Yes No
Demographics
2. What is your age?
4. Which of the following best describes your race?
White
Asian
Black or African American
Native Hawaiian or Pacific Islander
American Indian or Alaskan Native
Other:
3. Are you of Spanish or Hispanic origin?
Male Female
1. Respondent's GENDER:
Yes No
Years
7. Are you limited in any way in any
activities because of physical, mental, or
emotional problems?
Yes No
If YES, please describe:
10. Do you now have any health problem
that requires the assistance of equipment
such as a cane, a wheelchair, a special bed,
or a modified telephone? Include
occassional use or use in certain
circumstances.
Yes No
8. Would you describe your handicap,
disability, or health problem as:
Slight
Moderate
Somewhat severe, or
Very severe
[Skip to #9]
9. How old were you when your handicap,
disability or health problem began? Or were
you born with your disability?
Years
Enter "00" if born
with a disability
Married
A member of an unmarried couple
Single and never been married
Widowed
Divorced
Separated
6. Are you currently:
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12. What is your household's largest source
of income? (Mark only one)
That was the last question. Thank you for your help. If you would like more
information about this study, please call (866) 577-7430. Again, thank you!
My employment
Other household members' employment
Social Security Disability Insurance
Long term disability insurance
Retirement income
Investments and savings
Lawsuit settlement
Inheritance
Public sources (Social Security Supplement, etc.)
11. Do you have:
(Please mark all that apply)
A learning disability of any kind
Any emotional or mental disability
Any disability that limits the ability to speak or communicate
Any disability that limits hearing
Any vision or sight-related disability, except for ordinary eyeglasses
Any physical disability that limits the use of the legs, arms, or hands
7
Copyright © 2007
Rehabilitation Research and Training Center (RRTC) on Measuring Rehabilitation Outcomes and Effectiveness
A project funded by the National Institute of Disability and Rehabilitation Research
Allen W. Heinemann, PhD
345 East Superior Street
Chicago, IL 60611-2654 USA
+1.312.238.2802 (v) +1.312.238.2383 (f)
a-heinemann@northwestern.edu
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