Community Integration Questionnaire – CIQ

Who usually does shopping for groceries or other necessities in your household? (Options: Yourself alone, Yourself and someone else, Someone else)

Who usually prepares meals in your household? (Options: Yourself alone, Yourself and someone else, Someone else)

In your home, who usually does everyday housework? (Options: Yourself alone, Yourself and someone else, Someone else)

Who usually cares for the children in your home? (Options: Yourself alone, Yourself and someone else, Someone else, Not applicable/no children under 17 in the home)

Who usually plans social arrangements such as get-togethers with family and friends? (Options: Yourself alone, Yourself and someone else, Someone else)

Who usually looks after your personal finances, such as banking or paying bills? (Options: Yourself alone, Yourself and someone else, Someone else)

Approximately how many times a month do you usually participate in shopping outside your home? (Options: Never, 1-4 times, 5 times or more)

Approximately how many times a month do you usually participate in leisure activities such as movies, sports, restaurants, etc.? (Options: Never, 1-4 times, 5 times or more)

Approximately how many times a month do you usually visit your friends or relatives? (Options: Never, 1-4 times, 5 times or more)

When you participate in leisure activities, do you usually do this alone or with others? (Options: Mostly alone, Mostly with friends who have head injuries, Mostly with family members, Mostly with friends who do not have head injuries, With a combination of family and friends)

Do you have a best friend with whom you can confide? (Options: Yes, No)

How often do you travel outside the home? (Options: Almost every day, Almost every week, Seldom/never [less than once/month])

Please choose the answer below that best corresponds to your current work situation during the past month: (Options: Full-time [more than 20 hours/week], Part-time [less than or equal to 20 hours/week], Not working but actively looking for work, Not working and not looking for work, Not applicable/retired due to age)

Please choose the answer below that best corresponds to your current (during the past month) school or training program situation: (Options: Full-time, Part-time, Not attending school or training program)

In the past month, how often do you engage in volunteer activities? (Options: Never, 1-4 times, 5 times or more)