These questionnaires/interviews were developed by the Outcomes Committee of the AIDS Clinical Trials Group, sponsored by the NIH/NIAID. The Outcomes Committee promotes the use of these tools in other projects. To cite the original forms, use the statement quoted above.
ACTG Outcomes - List of References for Self Assessments (.pdf)
ACTG QOL 601-602 Health Survey Manual (.pdf) - This is a 31-page document submitted by Albert Wu, chair of the Quality of Life Subcommittee of the Outcomes Committee. If you have problems printing this document, try printing 10 pages at a time.
The date following the form name is the date the form was last modified (this is the date found in the lower left corner of the form). If the date in the lower left corner of your form copy does not match the date on this web page, please download the latest version of the form. NOTE: The date in the upper right corner of a form is the date the form was added to a CRF notebook.
To view these files, a PDF reader such as Adobe Reader is required.
Form Number | Form Name | Form Date | English | Spanish |
---|---|---|---|---|
F0450 | Electronic Monitoring System Tracking - II | 13-JUN-2002 |
f0450.pdf
|
|
QLW0044 | Supplemental Antepartum Adherence Questionnaire | 22-OCT-2001 |
qlw0044.pdf
|
qlw0044_spa.pdf
|
QLW0045 | Supplemental Postpartum Adherence Questionnaire | 22-OCT-2001 |
qlw0045.pdf
|
qlw0045_spa.pdf
|
QLW0060 | Adherence/Quality of Life/Psychosocial Interview | 15-JUN-2006 |
qlw0060.pdf
|
qlw0060_spa.pdf
|
QLW0061 | Adherence Interview | 15-JUN-2006 |
qlw0061.pdf
|
qlw0061_spa.pdf
|
QLW0067 | CES-D10 | 05-DEC-2003 |
qlw0067.pdf
|
qlw0067_spa.pdf
|
QLW0068 | Adherence to HCV Therapy | 05-DEC-2003 |
qlw0068.pdf
|
|
QLW0077 | Resource Interview | 21-JUN-2004 |
qlw0077.pdf
|
|
QL0601 | Overall Health Status Assessment | 05-MAR-1997 |
ql0601.pdf
|
ql0601_spa.pdf
|
QL0602 | Multidimensional Health Status Assessment | 05-MAR-1997 |
ql0602.pdf
|
ql0602_spa.pdf
|
QL0603 | Multidimensional Health Status Assessment (For CMV Retinitis) | 17-NOV-1995 |
ql0603.pdf
|
ql0603_spa.pdf
|
QL0701 | ACTG Baseline Adherence Questionnaire II | 19-JAN-2001 |
ql0701.pdf
|
ql0701_spa.pdf
|
QL0702 | ACTG Adherence Follow-up Questionnaire | 05-APR-2001 |
ql0702.pdf
|
ql0702_spa.pdf
|
QL0720 | Baseline Body Image Questionnaire | 18-SEP-1998 |
ql0720.pdf
|
ql0720_spa.pdf
|
QL0721 | Follow-up Body Image Questionnaire | 18-SEP-1998 |
ql0721.pdf
|
ql0721_spa.pdf
|
QL0725 | Assessment of Body Change and Distress | 17-APR-2001 |
ql0725.pdf
|
ql0725_spa.pdf
|
QL0730 | Symptoms Distress Module | 22-APR-1999 |
ql0730.pdf
|
ql0730_spa.pdf
|
QL0742 | ACTG Self Report | 22-APR-2002 |
ql0742.pdf
|
ql0742_spa.pdf
|
QL0743 | ACTG Abbreviated Adherence Module | 17-DEC-2002 |
ql0743.pdf
|
ql0743_spa.pdf
|
QL0744 | ACTG Self Report - Revised | 27-JUN-2007 |
ql0744.pdf
|
ql0744_spa.pdf
|
QL0745 | Abbreviated Adherence/Quality of Life Factors Questionnaire | 21-NOV-2008 |
ql0745.pdf
|
ql0745_spa.pdf
|
QL0746 | Personal Safety Questionnaire | 21-NOV-2008 |
ql0746.pdf
|
ql0746_spa.pdf
|
QL0747 | Brief Adherence Self-Report Questionnaire | 21-NOV-2008 |
ql0747.pdf
|
ql0747_spa.pdf
|
QL0748 | Adherence/Psychosocial Factors Questionnaire | 13-MAY-2009 |
ql0748.pdf
|
ql0748_spa.pdf
|
QL0749 | Sociodemographic Questionnaire | 21-NOV-2008 |
ql0749.pdf
|
ql0749_spa.pdf
|
QL0751 | Adherence Barriers Questionnaire | 08-DEC-2008 |
ql0751.pdf
|
ql0751_spa.pdf
|
QL0752 | Adherence Barriers Follow-up Questionnaire | 08-DEC-2008 |
ql0752.pdf
|
ql0752_spa.pdf
|
QL0753 | Reproductive Choices | 08-DEC-2008 |
ql0753.pdf
|
ql0753_spa.pdf
|
QL0754 | Reproductive Choices Follow-up Questionnaire | 08-DEC-2008 |
ql0754.pdf
|
ql0754_spa.pdf
|
QL0755 | Substance Use Self Report | 13-MAY-2009 |
ql0755.pdf
|
ql0755_spa.pdf
|
QL0756 | ACTG Self Report - III | 17-DEC-2009 |
ql0756.pdf
|
ql0756_spa.pdf
|
QL0757 | ACTG Adherence Self Report | 13-SEP-2013 |
ql0757.pdf
|
ql0757_spa.pdf
|
QL0770 | Attitudes About HIV | 05-JUN-2000 |
ql0770.pdf
|
ql0770_spa.pdf
|
QL0771 | Comorbidity Conditions | 05-JUN-2000 |
ql0771.pdf
|
|
QL0772 | Dealing with Illness | 05-JUN-2000 |
ql0772.pdf
|
ql0772_spa.pdf
|
QL0773 | Emotional Responses to Illness | 05-JUN-2000 |
ql0773.pdf
|
ql0773_spa.pdf
|
QL0774 | Social Support | 18-JUL-2000 |
ql0774.pdf
|
ql0774_spa.pdf
|
QL0775 | ACTG Baseline Psychosocial Assessment | 23-JUN-2003 |
ql0775.pdf
|
ql0775_spa.pdf
|
QL0776 | Baseline Substance Use Self Report | 23-JUN-2003 |
ql0776.pdf
|
ql0776_spa.pdf
|
QL0777 | Adherence Barriers Self Report | 23-JUN-2003 |
ql0777.pdf
|
ql0777_spa.pdf
|
QL0778 | Baseline Sociodemographics Self Report | 23-JUN-2003 |
ql0778.pdf
|
ql0778_spa.pdf
|
QL0800 | Electonic Monitoring System Questionnaire | 12-SEP-2001 |
ql0800.pdf
|
ql0800_spa.pdf
|
QL7000 | Maternal Baseline Behavioral Self Report | 20-DEC-2002 |
ql7000.pdf
|
ql7000_spa.pdf
|
QL7001 | Maternal Behavioral Self Report | 20-DEC-2002 |
ql7001.pdf
|
ql7001_spa.pdf
|