Personal Capacities Questionnaire

1.    LEARNING ABIUTY
0. I learn just as fast as other people.
1. I can learn difficult things‚ but I need extra time.
2. In school I was in special classes for students who needed extra help.
3. Learning is very hard for me. I need extra time and help to learn most new things.
2.    READING AND WRITING IN ENGLISH (in print or in braille)
0. I have no trouble reading and writing English.
1. I have a little trouble reading or writing English (for any reason; for example lack of good schooling or because the first language I learned was not English.) (If I am visually impaired I cannot see regular print but I can use large print or Braille.
2. It is very hard for me to read or write English.
3. I cannot read or write English.
3.    MEMORYO
0. My memory is good.
1. Forgetting things is often a problem for me.
2. Memory problems often make it hard for me to learn new things. I usually need to have directions and information repeated to me.
3. My memory is very poor. I often feel confused. It is hard to me to remember things from one day to the next.
4.    PERCEPTIONO
0. When I look at things‚ they never seem confused or mixed-up.
1. I don’t do well at work that requires looking closely at details.
2. It is very hard for me to follow maps to put together jigsaw puzzles‚ or to do other things that require me to see how things fit together.
3. The world seems confusing or mixed-up to me. I often get lost‚ even in places that I know
5.    VISION (with eyeglasses or contact lenses if you wear them)
0. I have no trouble seeing.
1. It is hard for me to see small print.
2. I cannot do some important activities (for example‚ reading or driving) because I cannot see well enough.
3. I have little or no vision.
6.    HEARING (with a hearing aid if you use one)
0. I have no trouble hearing.
1. I sometimes have trouble understanding conversations or using the phone.
2. My hearing is so poor that I cannot use the telephone.
3. I cannot hear conversation well enough to understand it.
7.    SPEECH
0. I have no difficulty speaking.
1. People can understand my speech most of the time‚ but it may sound unusual.
2. My speech is difficult for other people to understand. I often have to repeat myself.
3. Most people cannot understand my speech.
8.    SPOKEN COMMUNICATION
0. I understand and speak English without any difficulty.
1. I have some problem communicating in English with other people. (If I am hearing impaired‚ I can use lip-reading and speech to communicate.)
2. It is hard for me to communicate in English with most people. I cannot say more than a few words. (If I am hearing impaired‚ I use sign language but cannot communicate through lip-reading and speech.)
3. I cannot communicate through spoken English with other people.
9.    USE OF ARMS
0.  Both of my arms work normally.
1.  My preferred arm (my right if I am right-handed or my left if I am left-handed) works well‚ but the other does not.
2. Both of my arms are a little limited in how well they work.
OR
My preferred arm does not work well‚ but the other is okay.
3. I have little or no use of either of my arms.
10.USE OF HANDS
0. Both of my hands work normally.
1. My hands are a little clumsy or slow.
2. Use of my hands is quite limited‚ but (with or without aids or devices) I can write‚ feed myself‚ and do most or all ordinary self- care tasks.
3. My hands work so poorly that I cannot do my own self-care.
11.SPEED
0. I move as quickly as most people.
1. I move a little more slowly than most people.
2. I move quite slowly.
3. I move very slowly.
12.ABILITY TO GET AROUND
0. I am able to walk and to travel around town without difficulty.
1. I do walk‚ but I have some difficulty getting around. (For example‚ because of physical limitations or other problems that affect ability to travel in unfamiliar parts of town.).
2. Mobility is a significant challenge for me. (Either you use a wheelchair independently‚ or else you walk but often need assistance from someone in order to get from place to place.)
3. I need the help of other people in order to get around. (For example‚ you use a wheelchair and need help getting into and out of it‚ or you have any impairment that requires help from others to get around when you are away from home.)
13.ABIUTY TO DO HEAVY WORK
0. I can do as much heavy work as most people of my age and sex.
1. I am capable of a medium amount of physical activity‚ but I have to avoid hard work such as frequent lifting of more than 25 pounds or a lot of bending‚ walking‚ etc.
2. I must avoid even a medium amount of heavy work (such as housework). I could only handle a light job (lifting of 10-20 pounds and some walking or standing).
3. I need a job that will allow me to sit all or most of the time and that involves little or no lifting.
14.ENDURANCE AND AVAILABLITY FOR WORK
0. I can work a regular full-time job.
1. I can work a full-time job if special rest periods are provided.
2. I can work only a part-time job (about 16-32 hours per week).
3. I can work only an hour or two per day (15 hours per week or less).
15.ABSENCE FROM WORK
0. I rarely miss work because of illness‚ medical appointments‚ or personal reasons.
1. I need to take a day or two per month off work.
2. I am likely to miss about a day per week from work.
3. I am frequently absent from work for medical or personal reasons.
16.STABILITY OF CONDMON
0.  My disability is stable. (In other words‚ it will not become worse.)
1. My disability could become worse unless I keep it under control with diet‚ treatment‚ or exercise.
2. My disability is slowly getting worse.
OR
It is hard to predict how my disability will change. It could stay the same‚ or it might get quite a bit worse.
3. My disability is likely to become much worse in the future.
17.WORK RECORD
0. I have a good‚ steady work record.
1. I had a good work record until I became disabled. However‚ since then I have been out of work for more than a year‚
OR
I have not had much opportunity to work in the past (for a good reason‚ such as being too young.)
2. My job record is only fair. It includes some drawbacks such as frequent job changes or periods of unemployment.
3. My work record is poor. I have been out of work a lot‚ or my raferences are poor.
18.ACCEPTABILITY TO EMPLOYERS
0. Most employers would give me a fair chance if I were to apply for jobs.
1. Employers are likely to be prejudiced against me because of my disability.
2. Many employers would be reluctant to hire me because of my disability.
3. Most employers wouldn’t even consider hiring me.
19.PERSONAL ATTRACTIVENESS
0. I am at least as attractive and well-groomed as most people.
1. I have some problem with my appearance or hygiene‚ but people usually get used to it and accept me without much difficulty.
2. People find it hard to accept me because of my appearance or grooming.
3. Most people avoid me.
20.SKILLS
0. I have some special skills that would be useful on a job.
1. I do not have any special skills for working‚ but I have some education and can learn to do most jobs.
2. I had some special skills‚ but I can’t use them now that I am disabled.
3. I have very little in the way of special or personal skills to offer an employer.
21.FINANCES
0. My financial situation would improve if I got a job.
1. My financial situation would improve by working only if I got a job with a high salary or some special conditions.
2. I probably cannot afford to take a job that would cause me to lose my disability benefits. However‚ I would like to have some extra income from a part-time job or a low-paying‚ full-time job.
3. I probably cannot afford to work at all because I might lose my disability benefits‚
22.AVAILABILITY OF JOB OPPORTUNITIES
0. There are some suitable jobs within a reasonable distance from my home‚ and I could get to them.
1. Job opportunities are somewhat limited for me. (For example‚ because of transportation problems‚ location of my home‚ or a poor economy.)
2. Job opportunities are very limited. (For example‚ there are only a few suitable jobs or serious transportation problems.)
3. I have to work at home.
OR
There are almost no suitable jobs available in the community where I live.
23.SPECIAL JOB REQUIREMENTS
0. I do not need any special working conditions or accommodations from an employer.
1. The places I could work are limited to some extent by my disability. (For example‚ I may need an accessible workplace or a job that will allow me to stand up and move around occasionally.)
2. I need special working conditions or arrangements that will probably be difficult to find.
3. My disability puts strict requirements on the job I could take. (For example‚ I cannot tolerate most environments because of severe allergies‚ or I have to avoid all stress because of emotional problems.)
24.WORK HABITS
0. I have good work habits (for example‚ getting to work on time‚ keeping my mind on the job‚ dressing properly‚ etc.)
1. I have not had much opportunity to build work habits‚ but I am willing and able to develop them.
2. My work habits are not good‚ so I would need some special training and practice before starting a regular job.
3. My work habits are very poor‚ and I don’t think there is much hope that they can be changed.
25.ENCOURAGEMENT FROM FAMILY OR FRIENVS
0. I have family members or close friends who want to help me get back to work.
1. No one is either encouraging me or discouraging me aboutoing back to work.
2. I think my family or friends might be happier if I stayed home instead of going back to work.
3. My family or friends prefer that I not get a job.
26.AWARENESS OF ABILITIES AND UMITAT1ONS
0. I have a good understanding of what an employer would see as my strength and weaknesses.
1. I am not sure of just what I can or cannot do for work.
2. My disability has not affected my ability to find and do work.
OR
It seems that most kinds of work are ruled out by my disability.
3. It seems like there is nothing I can do because of my disability.
27.GEI7ING ALONG WITH SUPERVISORS AND CO-WORKERS
0. I have always gotten along well with people at work.
1. Getting along with people at work isn’t always easy for me‚ but I manage to do It.
2. I have had problems getting along with people at work.
3. I have lost job(s) because I didn’t get along with people at work.
28.JUDGMENT
0. I act wisely all of the time.
1. I sometimes make the wrong decision because I rush into things without thinking over the choices.
2. I often get into trouble because of unwise decisions.
3. I have caused accidental injury to myself or someone else either by doing something foolish or by forgetting to do something I should have done.
29.DESIRE TO WORK
0. I very much want to work‚ and I am willing to do anything the rehabilitation program requires in order to get a job.
1. I want to work‚ so I usually do what I am asked to do in the rehabilitation program.
2. I would like to work‚ but sometimes I don’t do the things that are required by the rehabilitation program.
3. I would be willing to work‚ but many times I don’t do the things required by the rehabilitation program.
30.INITIATIVE AND PROBLEM-SOLVING ABILJTY
0. I am good at seeing what needs to be done In a situation and going ahead to do it.
1. I can usually figure out a solution to problems‚ but I often need help or encouragement from someone else to take action.
2. I often need help from another person‚ both to see solutions to problems and to take action.
3. I usually need help from someone else to solve problems or to finish important tasks.
SPECIAL STRENGTH ITEMS (Put a check mark on the answer sheet for any that apply.)
31.I am very good looking.
32.I have a very pleasing personality.
33.I am unusually intelligent.
34.I have a work skill that is in great demand by employers.
35.I am very well trained or educated.
36.My family is extremely understanding and eager to help me get to work.
37.I have no financial worries that could interfere with my rehabilitation program.
38.I am absolutely determined to get a job.
39.An employer that I know is already holding a job open for me.
40.I have unusually good common sense.
Please answer these additional questions by circling the number on the answer sheet that best applies to y
41.Overall‚ how severely disabled do you think you are?
(1) slightly‚ (3) moderately‚ (5) severely‚ (7) very severely
42.What do you think are your chances of getting and holding a job?
(1) poor (0-25%)‚ (2) Fairy (26-50%) ‚ (3) good (51-75%)‚ (4) excellent (76-100 % )
 
 
This instrument can be found at:   http://files.eric.ed.gov/fulltext/ED277841.pdf
 

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