Toolbox Vision Survey

Appendix B: Toolbox Vision Survey - Item and Response Option Sources

ITEM ORIGINAL SOURCE RESPONSE ORIGINAL QUESTIONNAIRE OPTIONS RESPONSE OPTIONS A. Color Vision A.1 Because of Because of your NEI-VFQ-25 Not difficult at all; No difficulty at all; your eyesight, eyesight, how A little bit difficult; A little difficulty; how difficult is it much difficulty do Somewhat difficult; moderate for you to match you have picking Very difficult; difficulty; the colors of your out and matching Unable to do Extreme difficulty; clothes? your own because of Stopped doing clothes? eyesight. this because of your eyesight; Stopped doing this for other reasons or not interested in doing this.

A.2 How How much QOLVFQ Not difficult at all; Not at all; difficult is it for problem do you A little bit difficult; Quite a lot; you to recognize have in Somewhat difficult; Very much. colors? Very difficult; recognizing Unable to do. colors?

A.3 How I have difficulty VAQ Not difficult at all; Never; difficult is it for distinguishing A little bit difficult; Rarely; you to distinguish between colors. Somewhat difficult; Sometimes; between colors? Very difficult; Often; Unable to do. Always.

B. Low Lumi- nance Vision B.1 How 1 - Do you have Low Luminance Not difficult at all; No difficulty at all; difficult is it for difficulty seeing in Questionnaire A little bit difficult; A little difficulty; you to see in bright sunlight? (version 1) Somewhat difficult; Some difficulty; bright sunlight? Very difficult; A lot of difficulty; Unable to see in Completely blind bright sunlight. under these conditions; Stopped going out in bright sunlight because of your vision; Stopped for other reasons.

B.2 How Do you have Low Luminance Not difficult at all; No difficulty at all; difficult is it for difficulty seeing in Questionnaire A little bit difficult; A little difficulty; you to see in fluorescent (version 1) Somewhat difficult; Some difficulty; fluorescent Very difficult; A lot of difficulty; lighting, like that lighting such as Unable to see in Completely blind in stores and found in stores fluorescent lighting. under these offices? and offices? conditions;

Revision February 10, 2010 Page 1 Appendix B: Toolbox Vision Survey - Item and Response Option Sources

Stopped going to places with fluorescent lighting because of your vision; Stopped for other reasons.

B.3 How Do you have Low Luminance Not difficult at all; No difficulty at all; difficult is it for difficulty seeing Questionnaire A little bit difficult; A little difficulty; you to see at at night? (version 1) Somewhat difficult; Some difficulty; night? Very difficult; A lot of difficulty; Unable to see in at Completely blind night. under these conditions.

B.4 How During the past 3 ADVS Not difficult at all; Yes; difficult is it for months, have you A little bit difficult; No. you to see street tried to read Somewhat difficult; signs at night Very difficult; street signs at when you are in Unable to see a car? night either when street signs from a driving or when car at night. you are a passenger in a car?

Would you say ADVS No difficulty at all; that you read A little difficulty; Moderate street signs at difficulty; night with Extreme difficulty. (PLEASE CHECK ONLY ONE ANSWER).

B.5 How How much NEI-RQL-42 Not difficult at all; No difficulty at all; difficult is it for difficulty do you A little bit difficult; A little difficulty; you to see when have getting used Somewhat difficult; Moderate you go from a Very difficult; difficulty; to the dark when lighted area into Unable to see A lot of difficulty. a dark place? you move from a when going from a lighted area into lighted area into a dark place, like dark place. walking into a dark movie theatre?

B.6 How Do you have Low Luminance Not difficult at all; No difficulty at all; difficult is it for difficulty reading Questionnaire A little bit difficult; A little difficulty; you to read in menus in dimly lit (version 1) Somewhat difficult; Some difficulty; dim light? Very difficult; A lot of difficulty; Revision February 10, 2010 Page 2 Appendix B: Toolbox Vision Survey - Item and Response Option Sources

restaurants? Unable to read in Completely blind dim light; Unable to under these read in dim light conditions; because of another Stopped doing reason. this because of your vision; Stopped for other reasons; Never reads menus.

C. DISTANCE VISION

C.1 Because of In the PAST IVI Not difficult at all; A Not at all; your eyesight, MONTH, how little bit difficult; Hardly at all; how difficult is it much has YOUR Somewhat difficult; A little; for you to go up EYESIGHT Very difficult; A fair amount; or down steps, INTERFERED Unable to do A lot; stairs, or curbs? with the following because of Can't do because activities: Going eyesight; of eyesight; down steps, Unable to go up or Don't do this for stairs, or curbs? down steps, stairs, other reasons. or curbs because of another reason. C.2 Because of In the PAST IVI Not difficult at all; A Not at all; your eyesight, MONTH, how little bit difficult; Hardly at all; how difficult is it much has YOUR Somewhat difficult; A little; for you to get EYESIGHT Very difficult; A fair amount; around INTERFERED Unable to do A lot; outdoors? with the following because of Can't do because activities: How eyesight; of eyesight; much has your Unable to get Don't do this for eyesight around outdoors other reasons. interfered with because of another getting about reason. outdoors? (on the pavement or crossing the street)

C.3 Because of How much LVQOL Not difficult at all; A Scale: 5-1 your eyesight, problem do you little bit difficult; (5=None; how difficult is it have with seeing Somewhat difficult; 4-2 Moderate; for you to see Very difficult; 1- great). moving objects? moving objects? Unable to do because of eyesight. C.4 Because of How much LVQOL Not difficult at all; A Scale: 5-1 your eyesight, problem do you little bit difficult; (5=None; how difficult is it have with seeing Somewhat difficult; 4-2 Moderate; for you to see Very difficult; 1- great). street signs? street signs? Unable to do because of eyesight.

C.5 Because of How much LVQOL Not difficult at all; A Scale: 5-1 your eyesight, problem do you little bit difficult; (5=None; how difficult is it have with seeing Somewhat difficult; 4-2 Moderate; for you to see Very difficult; 1- great). the television? television? Unable to do because of eyesight; Unable to see television because of another reason. C.6 Because of Would you say ADVS Not difficult at all; A No difficulty at all; your eyesight, that you drive at little bit difficult; A little difficulty; how difficult is it night with (pick Somewhat difficult; Moderate for you to drive at Very difficult; difficulty; level of difficulty night? Unable to do Extreme difficulty. from none to because of extreme). eyesight; Unable to drive at night because of another reason. C.7 Because of During the last RSVP Not difficult at all; A With glasses, your eyesight, month, how much little bit difficult; With Contact how difficult is it trouble have you Somewhat difficult; Lenses; With No for you to drive Very difficult; Correction: had with driving due to glare from Unable to do 1-No difficulty at oncoming when there is because of all; headlights? glare from eyesight; 2-A little difficulty; oncoming Unable to drive 3-Moderate headlights? because of another difficulty; reason. 4-Severe difficulty; 5-So much difficulty that I did not do the activity with this type of correction; 6-Never did the activity for other reasons (not related to vision).

C.8 Because of Because of your QOLVFQ Not difficult at all; A Not at all; your eyesight, vision do you little bit difficult; Quite a lot; how difficult is it have problems in Somewhat difficult; Very much. for you to Very difficult; recognizing a recognize people Unable to do from across a person in a because of room? crowded room? eyesight.

D. General Vision

Distance Vision D.1 In general, At the present NEI-VFQ-25 Poor; Excellent;

Revision February 10, 2010 Page 4 Appendix B: Toolbox Vision Survey - Item and Response Option Sources how would you time, would you Fair; Good; rate your say your eyesight Good; Fair; eyesight for using both eyes Very Good; Poor; seeing things at (with glasses or Excellent. Very poor; a distance? contact lenses, if Completely blind. you wear them) is excellent, good, fair, poor, or very poor or are you completely blind?

Because of your NEI-VFQ-25 No difficulty at all; eyesight, how A little difficulty; moderate much difficulty difficulty; do you have extreme difficulty; stopped doing this going out to see because of your movies, plays, or eyesight; stopped sports events? doing this for other reasons or not interested in doing this.

No difficulty at all; How much NEI-VFQ-25 A little difficulty; difficulty do you moderate have reading difficulty; street signs or extreme difficulty; the names of stopped doing this because of your stores? eyesight; stopped doing this for other reasons or not interested in doing this.

D.2 How much At the present NEI-VFQ-25 No problem at all; Excellent; of a problem do time, would you A little bit of a Good; you have with say your eyesight problem; Fair; seeing things at using both eyes Somewhat of a Poor; a distance (with glasses or problem; Very poor; during the day? contact lenses, if Very much of a Completely blind. you wear them) is problem; excellent, good, Unable to see. fair, poor, or very poor or are you completely blind?

During the past 3 ADVS Yes; months, have you No. tried to read street signs in daylight?

Would you say ADVS No difficulty at all; that you read A little difficulty; street signs in Moderate daylight with difficulty; (PLEASE Extreme difficulty. CHECK ONLY ONE ANSWER).

Is it because of ADVS Yes; visual problems No. that you do not read street signs in daylight?

D.3 How much At the present NEI-VFQ-25 No problem at all; Excellent; of a problem do time, would you A little bit of a Good; you have with say your eyesight problem; Fair; seeing things at using both eyes Somewhat of a Poor; a distance (with glasses or problem; Very poor; at nighttime? contact lenses, if Very much of a Completely blind. you wear them) is problem; excellent, good, Unable to see. fair, poor, or very poor or are you completely blind?

How much LVQOL Scale: 5-1 problem do you (5=None, 4-2 have with your Moderate, 1- vision at night great) inside the house?

During the past 3 ADVS months, have you Yes; tried to read No. street signs at night either when driving or when you are a passenger in a car?

Would you say ADVS No difficulty at all; that you read A little difficulty; street signs at Moderate night with: difficulty; (PLEASE Extreme difficulty. CHECK ONLY ONE ANSWER)

Is it because of ADVS Yes; your visual No.

problems that you do not read street signs at night?

Near Vision D.4 In general, At the present NEI-VFQ-25 Poor; Excellent; how would you time, would you Fair; Good; rate your say your eyesight Good; Fair; eyesight for using both eyes Very Good; Poor; seeing things (with glasses or Excellent. Very poor; close up? contact lenses, if Completely blind. you wear them) is excellent, good, fair, poor, or very poor or are you completely blind?

How much NEI-RQL-42 No difficulty at all; difficulty do you A little difficulty; have doing work Moderate or hobbies that difficulty; require you to A lot of difficulty; see up close, Never try to do such as cooking, these activities fixing things because of vision; around the Never do these house, sewing, activities for other using hand tools, reasons. or working with a computer?

How much NEI-VFQ-25 No difficulty at all; difficulty do you A little difficulty; have doing work moderate difficulty; extreme or hobbies that difficulty; stopped require you to doing this see well up close, because of your such as cooking, eyesight; stopped sewing, fixing doing this for other reasons or things around not interested in the house, or doing this. using hand tools?

Do you have any difficulty, even VF14 Yes; No; NA. with glasses, If yes, how much difficulty do you recognizing currently have: A people wihen little ; A moderate they are close to amount; A great you? deal; Are you unable to do the

activity. I have difficulty doing any type of VAQ Never; work which Rarely; requires me to Sometimes; see well up close. Often; Always.

D.5 How much At the present NEI-VFQ-25 No problem at all; Excellent; of a problem do time, would you A little bit of a Good; you have with say your eyesight problem; Fair; seeing things using both eyes Somewhat of a Poor; close up (with glasses or problem; Very poor; during the day? contact lenses, if Very much of a Completely blind. you wear them) is problem; excellent, good, Unable to see. fair, poor, or very poor or are you completely blind?

D.6 How much At the present NEI-VFQ-25 No problem at all; Excellent; of a problem do time, would you A little bit of a Good; you have with say your eyesight problem; Fair; seeing things using both eyes Somewhat of a Poor; close up (with glasses or problem; Very poor; at nighttime? contact lenses, if Very much of a Completely blind. you wear them) is problem; excellent, good, Unable to see. fair, poor, or very poor or are you completely blind?

E. Near Vision

E.1 Because of Do you have any VF14 Not difficult at all; A Yes; your eyesight, difficulty, even little bit difficult; No; how difficult is it with glasses, Somewhat difficult; NA. for you to read a Very difficult; If yes, how much reading a newspaper or Unable to do difficulty do you book? newspaper or a because of currently have: book? eyesight; A little ; Unable to read a A moderate newspaper or book amount; because of another A great deal; reason. Are you unable to do the activity.

E.2 Because of Because of your NEI-VFQ-25 Not difficult at all; No difficulty at all; your eyesight, eyesight, how A little bit difficult; A little difficulty; how difficult is it Somewhat difficult; Moderate for you to find an much difficulty Very difficult; difficulty; item on a do you have Unable to do Extreme difficulty; crowded shelf? because of Stopped doing

finding eyesight; this because of something on a Unable to find an your eyesight; item on a crowded Stopped doing crowded shelf? shelf because of this for other another reason. reasons or not interested in doing this.

E.3 How I have trouble VAQ Not difficult at all; A Never; difficult is it for locating a sign little bit difficult; Rarely; you to see a sign when it is Somewhat difficult; Sometimes; when there are surrounded by a Very difficult; Often; other signs lot of other signs. Unable to do Always. around it? because of eyesight;

E.4 How In the PAST IVI Not difficult at all; A Not at all; difficult is it for MONTH, how little bit difficult; Hardly at all; you to read much has YOUR Somewhat difficult; A little; labels or EYESIGHT Very difficult; A fair amount; instructions? INTERFERED Unable to do A lot; with the following because of Can't do because activities: eyesight; of eyesight; Reading labels or Unable to read Don't do this for instructions on labels or other reasons. medicines? instructions because of another reason. E.5 Because of Over the last 2 IDEEL Not difficult at all; A I did not do this your eyesight, weeks, how little bit difficult; activity for how difficult is it limited were you Somewhat difficult; reasons other for you to use a in doing the Very difficult; than my dry eyes; computer? following Unable to do NA; activities because because of None of the time; of you dry eyes? eyesight; A little of the time; Working on a Unable to use a Some of the time; computer. computer because Most of the time; of another reason. All of the time; I can no longer do this activity due to my dry eyes.

E.6 Because of In the PAST IVI Not difficult at all; A Not at all; your eyesight, MONTH, how little bit difficult; Hardly at all; how difficult is it much has YOUR Somewhat difficult; A little; for you to EYESIGHT Very difficult; A fair amount; operate a INTERFERED Unable to do A lot; household with the following because of Can't do because appliance like a activities: eyesight; of eyesight; microwave, a Operating Unable to operate Don't do this for washing machine household a household other reasons. or a toaster appliances and appliance because oven? the telephone? of another reason.

E.7 Because of Would you say ADVS Not difficult at all; A No visual difficulty

Revision February 10, 2010 Page 9 Appendix B: Toolbox Vision Survey - Item and Response Option Sources your eyesight, that you write little bit difficult; at all; how difficult is it checks with (no Somewhat difficult; A little difficulty for you to write? difficulty to Very difficult; because of vision; extreme)? Unable to do Moderate difficulty because of because of vision; eyesight; Extreme difficulty Unable to write because of vision. because of another reason. E.8 Because of How much NEI-RQL-42 Not difficult at all; No difficulty at all; your eyesight, difficulty do you A little bit difficult; A little difficulty; how difficult is it have doing work Somewhat difficult; Moderate for you to do or hobbies that Very difficult; difficulty; work or hobbies require you to Unable to do A lot of difficulty; that require you see up close, because of Never try to do to see up close such as cooking, eyesight; these activities such as cooking, fixing things Unable to do work because of vision; or fixing things around the or hobbies that Never do these around the house, sewing, require me to see activities for other house? using hand tools, up close because reasons. or working with a of another reason. computer?

E.9 How Do you have any VF14 Not difficult at all; Yes; difficult is it for difficulty, even A little bit difficult; No; NA. you to recognize with glasses, Somewhat difficult; If yes, how much people when recognizing Very difficult; difficulty do you they are standing people when they Unable to do currently have: or sitting near are close to you? because of A little ; you? eyesight. A moderate amount; A great deal; Are you unable to do the activity.

F: Ocular Symptoms

F.1 In the last 7 How much LVQOL No problem at all; Scale: 5-1 days, how much problem do you A little bit of a (5-None; of a problem did have with glare problem; 4-2- Moderate; you have with (e.g. dazzled by Somewhat of a 1- Great). glare from bright car light or the problem; lights? sun)? Very much of a problem.

F.2 In the last 7 Over the last 2 IDEEL No problem at all; I did not have this days, how much weeks, how A little bit of a symptom, NA; Not of a problem did much did each of problem; at all; you have with the following Somewhat of a Slightly; burning or symptoms bother problem; Moderately; stinging eyes? you? Burning or Very much of a Very much. stinging eyes. problem.

F.3 In the last 7 Over the last 2 IDEEL No problem at all. I did not have this

Revision February 10, 2010 Page 10 Appendix B: Toolbox Vision Survey - Item and Response Option Sources days, how much weeks, how A little bit of a symptom, NA; Not of a problem did much did each of problem; at all; you have with the following Somewhat of a Slightly; redness in your symptoms bother problem; Moderately; eyes? you? Eye Very much of a Very much. redness. problem.

F.4 In the last 7 How often do you NEI-RQL-42 No problem at all; Never; days, how much have headaches A little bit of a Rarely; of a problem did that you think are problem; Occasionally; you have with related to your Somewhat of a Sometimes; headaches vision or vision problem; All of the time. because of your correction? Very much of a vision, or problem. because of your glasses or contact lenses?

F.5 In the last 7 During the past RSVP No problem at all; With glasses, with days, how much month, how A little bit of a contact lenses, of a problem did bothered have problem; with no correction: you have with you been by eyes Somewhat of a 1 No trouble at all; your eyes being being sensitive to problem; 2 A little trouble; 3 sensitive to light? light? Very much of a Moderate trouble; problem. 4 Severe trouble; 5 So much trouble that I don't use this type of correction.

F.6 In the last 7 Over the last 2 IDEEL No problem at all; I did not have this days, how much weeks, how A little bit of a symptom, NA; Not of a problem did much did each of problem; at all; you have with the following Somewhat of a Slightly; blurry vision? symptoms bother problem; Moderately; you? Blurry Very much of a Very much. vision. problem.

F.7 In the last 7 Have you NEI-RQL-42 No problem at all; Yes; days, how much experienced any A little bit of a No. of a problem did of the following problem; If yes, how you have with problems in the Somewhat of a bothersome has it itching in or last 4 weeks? problem; been? around your Itching in or Very much of a Very; eyes? around your problem. Somewhat; eyes. A little; Not at all.

G. Psycho/Social

G.1 In the last Have you felt IVI Did not feel Not at all; 7 days, how frustrated or frustrated or upset Very rarely; frustrated or annoyed because at all; A little of the time; upset did you of your eyesight? Felt a little bit A fair amount of

Revision February 10, 2010 Page 11 Appendix B: Toolbox Vision Survey - Item and Response Option Sources feel because of frustrated or upset; the time; your eyesight? Felt somewhat A lot of the time; frustrated or upset; All the time. Felt frustrated or upset a lot. G.2 In the last Have you felt IVI Did not feel Not at all; 7 days, how frustrated or annoyed or angry Very rarely; annoyed or annoyed because at all; A little of the time; angry did you of your eyesight? Felt a little bit A fair amount of feel because of annoyed or angry; the time; your eyesight? Felt somewhat A lot of the time; annoyed or angry; All the time. Felt annoyed or angry a lot. G.3 In the last Have you felt like IVI Did not feel like a Not at all; 7 days, how a nuisance or a burden at all; Very rarely; much did you burden because Felt a little bit like a A little of the time; feel like a burden of your eyesight? burden; A fair amount of on others Felt somewhat like the time; because of your a burden; A lot of the time; eyesight? Felt like a burden a All the time. lot. G.4 In the last Have you felt sad IVI Did not feel sad or Not at all; 7 days, how sad or low because of depressed at all; Very rarely; or depressed did your eyesight? Felt a little bit sad A little of the time; you feel because or depressed; A fair amount of of your eyesight? Felt somewhat sad the time; or depressed; A lot of the time; Felt sad or All the time. depressed a lot. G.5 In the last Do you feel Go-QOL Did not feel socially Yes, Very much 7 days, how socially isolated isolated at all; so; socially isolated because of your Felt a little bit Yes, a little; did you feel thyroid eye socially isolated; Not, not at all. because of your disease Felt somewhat eyesight? socially isolated; Felt socially isolated a lot. G.6 In the last In the PAST IVI Did not feel Not at all; 7 days, how MONTH, how concerned or Very rarely; concerned or often has YOUR worried at all; A little of the time; worried about EYESIGHT Felt a little bit A fair amount of your safety at MADE YOU concerned or the time; home did you CONCERNED worried; A lot of the time; feel because of OR WORRIED Felt somewhat All the time; your eyesight? about the concerned or following: Your worried; general safety at Felt concerned or home? worried a lot.

G.7 In the last In the past IVI Not worried at all; Not at all; 7 days, how month, how often A little bit worried; Very rarely; worried were you have you worried Somewhat worried; A little of the time; about your about your A lot worried. A fair amount of eyesight? eyesight getting the time;

worse? A lot of the time; All the time;

G.8 How much Because of my NEI-VFQ-25 Do not rely on Definitely true; do you have to eyesight, I have other people at all; Mostly true; rely on other to rely too much Rely a little bit on Not sure; people to do on what other other people; Mostly false; things because people tell me Rely somewhat on Definitely false; of your eyesight? other people; Rely a lot on other people. G.9 Because of In the PAST Not difficult at all; Not at all; your eyesight, MONTH, how IVI A little bit difficult; Hardly at all; how difficult is it much has YOUR Somewhat difficult; A little; for you to visit EYESIGHT Very difficult; A fair amount; with friends or INTERFERED Unable to do A lot; family? with the following because of Can't do because activities: Visiting eyesight; of eyesight; friends or family? Unable to visit with Don't do this for friends or family other reasons. because of another reason. H. Role Performance H.1 Because of Because of your NEI-RQL-42 Not limited at all; No difficulty at all, your eyesight, eyesight, how A little bit limited; A little difficulty, how limited are much difficulty do Somewhat limited; Moderate you in doing your you have with A lot limited; difficulty; a lot of daily activities? your daily Unable to do difficulty. activities? because of eyesight; Unable or limited in daily activities because of another reason.

H.2 Because of Are you limited in NEI-VFQ-25 Not limited at all; All of the time; your eyesight, how long you can A little bit limited; Most of the time; how limited are work or do other Somewhat limited; Some of the time; you in doing your activities because A lot limited; A little of the time; daily work of your vision? Unable to do None of the time. whether inside or because of outside the eyesight; house? Unable or limited in daily work because of another reason.

H.3 Because of Do you NEI-VFQ-25 Do not accomplish No difficulty at all; your eyesight, accomplish less less at all; A little difficulty; how much less than you would Accomplish a little Moderate do you like because of bit less; difficulty; accomplish than your vision? Accomplish Extreme difficulty; you would like? somewhat less; Stopped doing Accomplish a lot this because of less. your eyesight;

Stopped doing this for other reasons or not interested in doing this.

H.4 Because of Are you limited in NEI-VFQ-25 Not limited at all; All of the time; your eyesight, how long you can A little bit limited; Most of the time; how much are work or do other Somewhat limited; Some of the time; you limited in activities because A lot limited; A little of the time; how long you of your vision? Unable to do None of the time. can work or do because of other activities? eyesight; Unable or limited in work or other activities because of another reason.

H.5 Because of I need a lot of NEI-VFQ-25 Do not require help Definitely true; your eyesight, help from others from others at all; Mostly true; how much do because of my Require help from Not sure; you require help eyesight. others a little bit; Mostly false, from others with Require help from Definitely false; your work or others somewhat; other activities? Require help from others a lot; Unable to do because of eyesight; Unable or require help from others with work or other activities because of another reason.

Revision February 10, 2010 Page 14