Occupational Questionnaire Form – Fill Out and Use This PDF

OCCUPATIONAL QUESTIONNAIRE

Developed by N. Riopel Smith with assistance from G. Kielhofner and J. Hawkins Watts (1986).1

INSTRUCTIONS:

In this questionnaire youwill be asked to record your usual daily activities, and to answer some questions about these activities.

PART ONE:

Please think about how you have been spendingyour days the past few weeks. Try to decide what you do on a usual weekday (Monday - Friday). Usingthe worksheet that begins below, recordyour activities from the time you wake up. Each row represents a half hour. For each half hour record the main activity that you wouldbe doing during that half hour. An activity can be anythingfrom talking to a friend, to cooking, to bathing. If you do an activity for longer than a half hour, write it down again for as long as you continue to do that activity.

PART TWO:

After you have listed your activities, answer all four of the questions for each activity by circling the number of the most appropriate answer. Notice that the questions ask you to consider whether your activities are work, daily living tasks, recreation, or rest, andto consider how well you do the activities, how important they are to you, and howmuch you enjoy them. In the first question, work does not necessarily mean that youare paidfor the activity. Work can include productive activities that are useful to other people, like volunteering at a hospital. Daily living tasks are activities that are related to your own self care, such as housekeeping andshopping. Rest includes taking a nap and not doing anythingin particular. Even if a question does not seem appropriate for some of your activities, please try to respond to each one as accurately as possible. Your answers to every question are important!

1This instrument was first published in: Smith, N.R., Kielhofner, G., & Watts, J.H. (1986). The relationships between volition, activity pattern, and life satisfaction in the elderly. American Journal of Occupational Therapy, 40, 278-283.

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OCCUPATIONAL QUESTIONNAIRE

Developed by N. Riopel Smith with assistance from G. Kielhofner and J. Hawkins Watts (1986).

Today's date

Name

Age

TYPICAL ACTIVITIES	QUESTION 1				QUESTION 2						QUESTION 3						QUESTION 4
	I consider this activityto be:				I think that I do this:						For me this activity is:						How much do youenjoy this activity:
	1 - work				1	- Very well					1	- Extremely important					1	- Like it very much
	2 - daily living work				2	- Well					2	- Important					2	- Like it
	3 - recreation				3	- About average					3	- Take it or leave it					3	- Neither like it nor dislike it
	4 - rest				4	- Poorly					4	- Rather notdo it					4	- Dislike it
For the half hour beginning at:					5	- Very poorly					5	- Total waste of time					5	- Strongly dislike it
5:00am	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
5:30	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
6:00	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
6:30	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
7:00	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
7:30	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
8:00	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
8:30	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
9:00	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
9:30	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
10:00	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
10:30	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
11:00	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
11:30	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5
12:00	1	2	3	4		1	2	3	4	5		1	2	3	4	5		1	2	3	4	5

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OCCUPATIONAL QUESTIONNAIRE (CONTINUED)

	TYPICAL ACTIVITIES	QUESTION 1				QUESTION 2					QUESTION 3					QUESTION 4
		I consider this activityto be:				I think that I do this:					For me this activity is:					How much do youenjoy this activity:
		1 - work				1 - Very well					1 - Extremely important					1 - Like it very much
		2 - daily living work				2 - Well					2 - Important					2 - Like it
		3 - recreation				3 - About average					3 - Take it or leave it					3 - Neither like it nor dislike it
		4 - rest				4 - Poorly					4 - Rather notdo it					4 - Dislike it
	For the half hour beginning at:					5 - Very poorly					5 - Total waste of time					5 - Strongly dislike it
	12:30pm	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	1:00	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	1:30	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	2:00	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	2:30	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	3:00	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	3:30	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	4:00	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	4:30	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	5:00	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	5:30	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	6:00	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	6:30	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	7:00	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	7:30	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	8:00	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	8:30	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	9:00	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	9:30	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	10:00	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	10:30	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	11:00	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5
	11:30	1	2	3	4	1	2	3	4	5	1	2	3	4	5	1	2	3	4	5

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Bibliography on the Model of Human Occupation

(Published Works on Instruments)

The Occupational Questionnaire

Barris, R., Kielhofner, G., Burch, R.M., Gelinas, I., Klement, M., & Schultz, B. (1986). Occupational function and dysfunction in three groups of adolescents. Occupational Therapy Journal of Research, 6, 301-317.

Ebb, E.W., Coster, W., & Duncombe, L. (1989). Comparison of normal and psychosocially dysfunctional male adolescents. Occupational Therapy in Mental Health, 9(2), 53-74.

Kielhofner, G., & Brinson, M. (1989). Development and evaluation of an aftercare program for young and chronic psychiatrically disabled adults. Occupational Therapy in Mental Health, 9(2), 1-25.

Rust, K., Barris, R., & Hooper, F. (1987). Use of the model of human occupation to predict women’s exercise behavior. Occupational Therapy Journal of Research, 7, 23-35.

Smith, N., Kielhofner, G. & Watts, J. (1986). The relationship between volition, activity pattern and life satisfaction in the elderly. American Journal of Occupational Therapy, 40, 278-283.

Smyntek, L. Barris, R., & Kielhofner, G. (1985). The model of human occupation applied to psychosocially functional and dysfunctional adolescents. Occupational Therapy in Mental Health, 5(1), 21-40.

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