APPENDIX A

National Blind Rehabilitation Outcome Measurement Survey

Revised
2-23-98
    Name:
 
       
      SS#:        
      Telephone #:        
      Referring Center or BROS:
 
       
      Date of Survey:        
      SINCE YOUR DISCHARGE, HAVE YOU HAD ANY CHANGES IN VISION OR HEALTH?        
      (y/n) - if yes then comment        
      SINCE DISCHARGE HAVE YOU: Fre-
quency
Import-
ant?
Indep
Level
Satis
Level
Skill
Area
Resp
Set
    (0-4) (Y/N) (1-3) (1-4)
LS A 1 Measured using common kitchen measuring devices (measuring cups and spoons)?

N=1,370
0=474 (35%)
1=17 (1%)
2=108 (8%)
3=288 (21%)
4=483 (35%)
Yes =967 (71%)
No =400 (29%)
1=90 (7%)
2=174 (13%)
3=1103 (81%)
1=8 (1%)
2=61 (4%)
3=1219 (89%)
4=81 (6%)
LS LV A 2 Told time with a watch or clock?

N=1,369
0=28 (2%)
1=0 (0%)
2=1 (0%)
3=9 (1%)
4=1331 (97%)
Yes =1354 (99%)
No =13 (97%)
1=9 (1%)
2=174 (13%)
3=1103 (81%)
1=1 (0%)
2=31 (2%)
3=1167 (85%)
4=170 (12%)
MS OM A 3 Performed outdoor household chores (such as taking out trash, or raking lawn)?

N=1,368
0=264 (19%)
1=0 (0%)
2=33 (2%)
3=526 (38%)
4=544 (40%)
Yes =1196 (87%)
No =173 (13%)
1=106 (8%)
2=188 (14%)
3=1074 (79%)
1=9 (1%)
2=100 (7%)
3=1213 (89%)
4=47 (3%)
MS A 4 Performed home maintenance (such as changing a light bulb, paint something)?

N=1,365
0=370 (27%)
1=86 (6%)
2=505 (37%)
3=319 (23%)
4=85 (6%)
Yes =1125 (82%)
No =244 (18%)
1=127 (9%)
2=289 (21%)
3=952 (70%)
1=7 (1%)
2=115 (8%)
3=1210 (89%)
4=437(3%)
LS A 5 Made a phone call without operator assistance?

N=1,369
0=97 (7%)
1=6 (0%)
2=45 (3%)
3=245 (18%)
4=976 (71%)
Yes =1290 (94%)
No =80 (6%)
1=61 (4%)
2=242 (18%)
3=1065 (78%)
1=2 (0%)
2=63 (5%)
3=1231 (90%)
4=74 (5%)
LV OM A 6 Spotted signs or house numbers?

N=1,363
0=686 (50%)
1=22 (2%)
2=109 (8%)
3=266 (20%)
4=280 (21%)
Yes =1077 (79%)
No =289 (21%)
1=350 (26%)
2=395 (29%)
3=620 (45%)
1=73 (5%)
2=484 (36%)
3=783 (57%)
4=27 (2%)
LV A 7 Read mail (such as letters or bills)?

N=1369
0=290 (21%)
1=3 (0%)
2=23 (2%)
3=171 (12%)
4=882 (64%)
Yes =1279 (93%)
No =90 (7%)
1=187 (14%)
2=217 (16%)
3=965 (70%)
1=26 (2%)
2=167 (12%)
3=1075 (79%)
4=102 (7%)
LV A 8 Watched television comfortably?

N=1,370
0=265 (19%)
1=2 (0%)
2=8 (1%)
3=108 (8%)
4=987 (72%)
Yes =1212 (88%)
No =157 (9%)
1=70 (5%)
2=143 (10%)
3=1155 (84%)
1=26 (2%)
2=286 (21%)
3=1017 (74%)
4=39 (3%)
LS LV A 9 Maintained your checking account?

N=1,369
0=729 (53%)
1=8 (1%)
2=279 (20%)
3=274 (20%)
4=79 (6%)
Yes =986 (72%)
No =384 (28%)
1=326 (24%)
2=308 (22%)
3=735 (54%)
1=13 (1%)
2=125 (9%)
3=1200 (88%)
4=31 (2%)
OM A 10 Walked in your house without difficulty?

N=1,369
0=33 (2%)
1=1 (0%)
2=0 (0%)
3=32 (2%)
4=1302 (95%)
Yes =1361 (99%)
No =9 (1%)1=17 (1%)
2=58 (4%)
3=1293 (95%)
1=5 (0%)
2=46 (3%)
3=1187 (87%)
4=129 (9%)
MS A 11 Assembled something (such as a toy or furniture)?

N=1,369
0=843 (62%)
1=127 (9%)
2=239 (17%)
3=82 (6%)
4=78 (6%)
Yes =709 (52%)
No =660 (48%)
1=200 (15%)
2=505 (37%)
3=660 (48%)
1=28 (2%)
2=248 (18%)
3=1067 (78%)
4=26 (2%)
OM A 12 Used escalators, elevators, or revolving doors?

N=1,368
0=201 (15%)
1=125 (9%)
2=604 (44%)
3=319 (23%)
4=119 (9%)
Yes =1093 (80%)
No =275 (20%)
1=45 (3%)
2=420 (31%)
3=902 (66%)
1=3 (0%)
2=99 (7%)
3=1229 (90%)
4=37 (3%)
LS A 13 Cut food using a knife and fork?

N=1,368
0=114 (8%)
1=4 (0%)
2=26 (2%)
3=161 (12%)
4=1063 (78%)
Yes =1287 (94%)
No =82 (6%)
1=59 (4%)
2=182 (13%)
3=1127 (82%)
1=3 (0%)
2=89 (7%)
3=1212 (89%)
4=365 (5%)
OM A 14 Familiarized yourself to a new area.

N=1,367
0=520 (38%)
1=220 (16%)
2=421 (31%)
3=156 (9%)
4=50 (4%)
Yes =775 (57%)
No =591 (43%)
1=114 (8%)
2=662 (48%)
3=589 (43%)
1=22 (2%)
2=208 (15%)
3=1110 (81%)
4=29 (2%)
LS OM A 15 Shopped (such as clothes or food)?

N=1,369
0=211 (15%)
1=19 (1%)
2=252 (18%)
3=782 (57%)
4=105 (8%)
Yes =1215 (89%)
No =154 (11%)
1=151 (9%)
2=709 (52%)
3=507 (37%)
1=9 (1%)
2=142 (10%)
3=1191 (87%)
4=26 (2%)
LS CATS A 16 Communicated in writing (such as hand writing, type writing, or word processing)?

N=1,365
0=666 (49%)
1=74 (5%)
2=201 (15%)
3=243 (18%)
4=181 (13%)
Yes =901 (66%)
No =467 (34%)
1=158 (12%)
2=300 (22%)
3=908 (67%)
1=15 (1%)
2=223 (16%)
3=1096 (80%)
4=33 (2%)
LV LS A 17 Read a magazine or newspaper article or a book?

N=1,363
0=274 (20%)
1=10 (1%)
2=81 (6%)
3=268 (20%)
4=735 (54%)
Yes =1256 (92%)
No =110 (8%)
1=104 (8%)
2=152 (9%)
3=1110 (81%)
1=41 (3%)
2=171 (12%)
3=1064 (78%)
4=90 (7%)
OM LV A 18 Crossed a street with a traffic light?

N=1,368
0=469 (34%)
1=72 (5%)
2=253 (19%)
3=322 (24%)
4=251 (18%)
Yes =929 (6%)
No =439 (32%)
1=80 (8%)
2=285 (21%)
3=1000 (73%)
1=20 (1%)
2=113 (8%)
3=1172 (86%)
4=61 (4%)
OM A 19 Generally avoided obstacles while walking?

N=1,367
0=33 (2%)
1=0 (0%)
2=6 (0%)
3=75 (5%)
4=1255 (92%)
Yes =1356 (99%)
No =12 (1%)
1=16 (1%)
2=163 (12%)
3=1188 (87%)
1=7 (1%)
2=59 (4%)
3=1236 (90%)
4=64 (5%)
MS LS A 20 Organize your supplies, tools, or kitchen utensils?

N=1,369
0=219 (16%)
1=8 (1%)
2=45 (3%)
3=219 (16%)
4=876 (64%)
Yes =1215 (89%)
No =153 (11%)
1=61 (4%)
2=211 (15%)
3=1094 (80%)
1=5 (0%)
2=50 (4%)
3=1259 (92%)
4=53 (4%)
LS LV A 21 Paid your own bills?

N=1,366
0=585 (43%)
1=7 (1%)
2=438 (32%)
3=265 (19%)
4=71 (5%)
Yes =1099 (80%)
No =267 (20%)
1=290 (21%)
2=332 (24%)
3=745 (55%)
1=11 (1%)
2=89 (7%)
3=1234 (90%)
4=31 (2%)
LS A 22 Performed household chores (such as sweep, dust, scrub, dishes, clothes)?

N=1,367
0=216 (16%)
1=3 (0%)
2=58 (4%)
3=293 (21%)
4=797 (58%)
Yes =1191 (87%)
No =176 (13%)
1=85 (6%)
2=164 (12%)
3=1117 (82%)
1=5 (0%)
2=54 (4%)
3=1248 (91%)
4=59 (4%)
MS A 23 Measured the size of something?

N=1,367
0=542 (40%)
1=116 (8%)
2=389 (28%)
3=205 (15%)
4=115 (8%)
Yes =900 (66%)
No =468 (34%)
1=131 (10%)
2=297 (22%)
3=937 (69%)
1=15 (1%)
2=141 (10%)
3=1163 (85%)
4=48 (4%)
OM A 24 Crossed any street?

N=1,367
0=279 (20%)
1=19 (1%)
2=129 (9%)
3=387 (28%)
4=553 (40%)
Yes =1117 (82%)
No =249 (18%)
1=58 (4%)
2=221 (16%)
3=1086 (79%)
1=15 (1%)
2=100 (7%)
3=1205 (88%)
4=46 (3%)
MS A 25 Made small repairs (such as hang picture or tighten loose screw)?

N=1,367
0=457 (33%)
1=85 (6%)
2=420 (31%)
3=314 (23%)
4=91 (7%)
Yes =1021 (75%)
No =346 (25%)
1=150 (9%)
2=360 (26%)
3=856 (63%)
1=16 (1%)
2=169 (12%)
3=1153 (84%)
4=28 (2%)
OM A 26 Used public transportation?

N=1,367
0=728 (53%)
1=77 (6%)
2=198 (14%)
3=246 (18%)
4=118 (9%)
Yes =779 (57%)
No =588 (43%)
1=70 (5%)
2=296 (22%)
3=994 (73%)
1=5 (0%)
2=95 (7%)
3=1227 (90%)
4=36 (3%)
OM LV LS A 27 Gone to a movie, play, concert, fair, restaurant, or sports event?

N=1,367
0=163 (12%)
1=57 (4%)
2=361 (26%)
3=634 (46%)
4=152 (11%)
Yes =1228 (90%)
No =139 (10%)
1=58 (4%)
2=735 (54%)
3=574 (42%)
1=7 (1%)
2=101 (7%)
3=1219 (89%)
4=39 (3%)
LV Other B 28 Felt comfortable describing your vision loss?

N=1,175
Yes =1228 (90%)
No =139 (10%)
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1=7 (1%)
2=101 (7%)
3=1219 (89%)
4=39 (3%)


 

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Last revised Fri 07/16/1999