QOL/Adherence Forms

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.

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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