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Rehab Measures: Dizziness Handicap Inventory

Link to instrument

Availabe on Southhampton Hospital's website (other languages available below) 

Title of Assessment

Dizziness Handicap Inventory 

Acronym

DHI

Instrument Reviewer(s)

Initially reviewed by Amy M. Yorke, PT, NCS and the MS EDGE task force and Irene Ward, PT, DPT, NCS and the TBI EDGE taskforce of the Neurology Section of the APTA; Updated by Salomi R. Vora in 10/2012. Updated with references for individuals with vestibular disorders by Tracy Rice, PT, MPH, NCS and Jenny Fay, PT, DPT, NCS and the Vestibular EDGE task force of the Neurology Section of the APTA (2013)
 

Summary Date

7/29/2013 

Purpose

A 25-item self-assessment inventory designed to evaluate the self-perceived handicapping effects imposed by dizziness.

Description

  • 25 items
  • Self-report questionnaire
  • Quantifies the impact of dizziness on daily life by measuring self-perceived handicap
  • Three domains: functional (9 questions, 36 points), emotional (9 questions, 36 points), and physical (7 questions, 28 points)
  • Maximum score of 100 (28 points for physical, 36 points for emotional and 36 points for functional) to Minimum score of 0. The higher the score, the greater the perceived handicap due to dizziness
  • Item scores are summed
  • Answers are graded 0 (no), 2 (sometimes) and 4 (yes)
  • Jacobson, G.P., Newman, C.W. (1990). The development of the dizziness handicap inventory. Arch Otolaryngol Head Neck Surg, 116, 424-427.

Area of Assessment

Balance Vestibular; Gait; Quality of Life; Social Relationships; Vestibular 

Body Part

Not Applicable 

ICF Domain

Body Structure; Body Function; Participation 

Domain

 

Assessment Type

Patient Reported Outcomes 

Length of Test

06 to 30 Minutes 

Time to Administer

10 minutes

Number of Items

25 items 

Equipment Required

Score sheet and pen

Training Required

No Training

Type of training required

No Training 

Cost

Free 

Actual Cost

Available online at multiple sites, Copyrighted 1990, American Medical Association.

Age Range

 

Administration Mode

Paper/Pencil 

Diagnosis

Geriatrics; Multiple Sclerosis; Traumatic Brain Injury; Vestibular Disorders 

Populations Tested

  • Vestibular disorders
  • Benign Paroxysmal Positional Vertigo (BPPV)
  • Individuals with dizziness
  • Multiple Sclerosis (MS)
  • Brain Injury
  • Geriatrics

Standard Error of Measurement (SEM)

Multiple sclerosis (Cattaneo et al, 2007; n = 25 males = 8 & females = 17; mean age = 41.7 (12.5) years; onset of pathology = 8.7 (8.8) years of relapsing remitting/ secondary progressive type of multiple sclerosis)

Peripheral and central vestibular pathology:

(Jacobson & Newman, 1990; n = 14, mean age 45 (13.48) years)

  • SEM = 6.23

Minimal Detectable Change (MDC)

Multiple sclerosis (calculated from Cattaneo et al, 2007)

  • MDC = 22.50

Peripheral and central vestibular pathology. (Calculated from Jacobson & Newman, 1990)

  • MDC = 17.18

Minimally Clinically Important Difference (MCID)

Benign Paroxysmal Positional Vertigo:

(Lopez-Escamez, et al, 2003;  n = 40 individuals with pSCC BPPV)

  • Dizziness Handicap Inventory Short Form total score significantly decreased from 18.05 ± 9.91 (mean ± standard deviation) at the first day to 9.54 ± 9.94 at 30 days (p < 0.001)
  • All 36-Item Short Form Health Survey scale scores were correlated significantly with Dizziness Handicap Inventory Short Form total scores at 30 days after treatment

 

Vestibular Dysfunction:

(Jacobson and Newman, 1990; n = 14; mean age = 45 (13.48) years)

  • Pretreatment and post-treatment scores would have to differ by at least 18 points (95% confidence interval for a true change before the intervention could be said to have effected a significant change in a self-perceived handicap)

Vestibular Rehabilitation:

 

(Cohen & Kimball, 2003; n = 53 individuals with chronic vertigo due to a peripheral vestibular impairment; mean age = 51.1 years)

  • DHI scores decreased from pretest to posttest and then continued to decline over the 6-month follow- up period (P = 0.001) Changes on the DHI Total score were highly associated with VADL Total score (P = 0.001) and with VADL Ambulation score (P = 0.001)

 

(Cowand, et al, 1998;  n = 37; mean age = 69.8 (SD = 16.2) years)

  • The Sign test identified a significant difference between pre-rehabilitation and post-rehabilitation total DHI scores (p < 0.0001).  Significant before and after differences were found for the physical (p < 0.0001) and functional subscores (p < 0.0015)

 

(Jacobson & Calder, 1998).

  • A four-point change in the DHI-S would be statistically significant at the p = 0.05 level

 

Cut-Off Scores

Multiple Sclerosis (MS):

(Cattaneo et al, 2006; n = 51 patients with MS; mean number of falls month prior to evaluation = 0.98 (1.8) falls; 16 males, 35 females; mean age = 45.3 (18.1) years; mean onset of pathology = 15.6 (7.6) years)

  • Cut off score < 59  

Vestibular Dysfunction:

(Whitney et al, 2004; n = 85 participants with a variety of vestibular diagnoses; mean age = 61 years)

  • Mild: 0 - 30
  • Moderate: 31 - 60
  • Severe: 61 - 100
  • Individuals who perceive greater handicap as measured by the DHI demonstrate greater functional impairment

Normative Data

Multiple Sclerosis:

(Cattaneo et al, 2006)

  • Mean = 38.5 (Non-fallers)
  • Mean = 56.0 (Fallers)
  • Statistically significant differences between mean scores of fallers and non-fallers

Traumatic Brain Injury:

(Kaufman et al., 2006; n = 10; 6 men and 4 women; community living individuals with normal gait and balance before pathology; average duration since TBI = 2.8 (0.4 - 14.4) years)

  • Mean = 32 (23)

Test-retest Reliability

Multiple Sclerosis (MS):

(Cattaneo et al, 2007; n = 25 patients with MS; 8 males, 17 females; mean age = 41.7(12.5) years; mean onset = 8.7 (8.8) years)

  • Excellent test-retest reliability (ICC = 0.90, 95% CI 0.77 - 0.96)

Vestibular Dysfunction:

(Jacobson and Newman, 1990)

  • Excellent  test-retest reliability for total score (r = 0.97, df = 12, p < 0.0001)
  • Excellent  test-retest reliability for sub-scales scores (r = 0.92-0.97, p < 0.001)

(Jacobson & Calder, 1998)

  • Excellent test-retest reliability of the DHI-S (r = 0.95, p < 0.001)
  • Found the 95% confidence interval for test-retest reliability difference was 2.44 points.

(Perez et al., 2001)

  • Cronbach's alpha = 0.9226 for the Spanish version of the questionnaire

(Tamber et al., 2009)

  • Excellent test-retest reliability of the Norwegian version (ICC 1,1 = 0.90)

(Jarlsäter & Mattsson, 2003)

  • Good test-retest reliability for the Swedish version of the DHI (k = 0.63)

(Kurre et al., 2009)

  • Cronbach's a value for the DHI-German and the function, physical, and emotional subscales were 0.90, 0.80, 0.71, and 0.82 respectively

(Poon et al., 2004)

  • The Chinese DHI has been shown to retain good test-retest reliability (intraclass correlation coefficient range, 0.64 to 0.87) and internal consistency (Cronbach alpha coefficient > 0.7)

Interrater/Intrarater Reliability

Not Established

Internal Consistency

Multiple Sclerosis:

(Hebert et al, 2011; n = 38; 18 - 65 years; Intervention = vestibular rehabilitation (6 weeks); follow-up (4 weeks); able to walk 100 m; ≥ 45 on the Modified Fatigue Impact Scale Questionnaire and < 72 on the computerized Sensory Organization test)

  • Excellent internal consistency (Cronbach’s alpha = 0.91)
Vestibular Dysfunction:
(Jacobson and Newman, 1990)
  • Excellent internal consistency for total score (alpha = 0.89)
  • Adequate to excellent internal consistency for the 3 sub-scales (alpha = 0.72 - 0.85)

(Tamber et al., 2009)

  • Excellent internal consistency fr the Norwegian Version of the DHI (Cronbach's alpha = 0.88-0.95)

 

Criterion Validity (Predictive/Concurrent)

Benign Paroxysmal Positional Vertigo (BPPV):

(Whitney et al., 2005; n = 383 patients with a variety of vestibular diagnoses; mean age = 61 years)

  • 5 item BPPV subscale developed from current DHI is a significant predictor of likelihood of having BPPV

Mild Traumatic Brain Injury:

(Gottshall et al., 2003; n = 53 male active duty individuals who suffered mild TBI and 46 control subjects without TBI; Glascow Coma Scale score of 14-15; mean age = 22 years)

  • Statistically significant correlation between all Dynamic Visual Acuity Test results measured and the DHI and the 1 week time point (p < 0.01)
  • There was no significant or consistent correlation between the two tests after the 1 week period

Multiple Sclerosis (MS):

(Cattaneo et al., 2006)

  • Adequate correlation with Berg Balance Scale (r = -0.32)
  • Adequate correlation with Dynamic Gait Index (r = -0.39)
  • Adequate correlation with Timed Up and Go (r = 0.35)
  • Adequate correlation with Hauser Ambulation Index (r = 0.32)
  • Excellent correlation with Activities Specific Based Confidence Scale (ABC) (r = -0.70)

Traumatic Brain Injury:

(Kaufman et al., 2006; n = 20; 10 patients with TBI (6 men and 4 women) and 10 matched controls for age, gender, weight, and height; mean age = 41 (11) years; Average duration since the TBI was 2.8 years (range 0.4-14.4); 6 subjects with TBI had abnormal imaging studies)

  • Excellent correlation between physical aspects of the subject's complaints of dizziness on the DHI were related to SOT 6 (platform and surround sway referenced) (r = 0.72, p = 0.02)
  • Excellent correlation between the physical aspect of the DHI and the A/P motion of the subject (r = 0.83, p = 0.003)
  • Excellent correlation between the functional aspect of the DHI and the COM M/L velocity (r = 0.65, p = 0.04)
  • Excellent correlation between the total DHI and the M/L velocity (r = 0.71, p = 0.02)

Vestibular Dysfunction:

(Whitney et al., 1999; n = 71 subjects from a local balance and vestibular clinic; 15 males, 56 females; mean age = 65 (16.8) years)

  • Excellent correlation with ABC (r = -0.64)

(Fielder et al., 1996; n = 42)

  • Good to Excellent correlation with SF-36 (r = 0.53-0.72; p < 0.001)

(Jacobson et al., 1991)

  • Total score DHI demonstrated a moderate statistically significant negative correlation with SOT conditions 2(r = -0.39, p = 0.001); 4(r = -0.36, p = 0.004); 5(r = -0.42, p = 0.0005); and 6(r = -0.35, p = 0.004)
  • The functional subscale demonstrated a moderate statistically significant negative correlation with SOT conditions 2(r = -0.39, p = 0.001); 3(r = -0.29, p = 0.02); 4(r = -0.40, p = 0.001); 5(r = -0.48, p = 0.0001); and 6(r = -0.41, p = 0.0007)
  • The emotional subscale demonstrated a moderate statistically significant negative correlation with SOT conditions 2(r = -0.35, p = 0.004); 4(r = -0.30, p = 0.01); 5(r = -0.39, p = 0.001); and 6(r = -0.37, p = 0.003)
  • The physical subscale demonstrated a moderate statistically significant negative correlation with the equilibrium score on condition 2 of the SOT (r = -0.28, p = 0.02)

(Jacobson & Calder, 1998).

  • DHI-S highly correlated to the total score on the DHI (r = 0.86, p < 0.001)

(Lim et al., 2012; n = 32; mean age = 55.6 years individuals with vestibular neuritis)

  • Discovered varying level of correlation between the DHI and the composite score of the SOT and the equilibrium scores of the HS-SOT conditions 2 and 5 depending on the level of acuity
    • Excellent correlation between DHI and SOT composite score at initial assessment (r = -0.787, p < 0.05)
    • Excellent correlation between DHI and SOT composite score at one week follow-up (r = -0.679, p < 0.05)
    • Adequate correlation between DHI and equilibrium score ratio of the HS-SOT condition 2 at initial assessment (r = -0.559, p < 0.05)
    • Excellent  correlation between DHI and equilibrium score ratio of the HS-SOT condition 2 at one week follow-up (r = -0.695, p < 0.05)
    • Adequate correlation between DHI and equilibrium score ratio of the HS-SOT condition 2 at one month follow-up (r = -0.385, p < 0.05)
    • Adequate correlation between DHI and equilibrium score ratio of the HS-SOT condition 2 at 2 month follow-up (r = -0.401, p < 0.05)
    • Adequate correlation between DHI and equilibrium score ratio of the HS-SOT condition 5 at initial assessment (r = -0.402, p < 0.05)
    • Adequate correlation between DHI and equilibrium score ratio of the HS-SOT condition 5 at one week follow-up (r = -0.539, p < 0.05)
    • Excellent correlation between DHI and equilibrium score ratio of the HS-SOT condition 5 at one month follow-up (r = -0.625, p < 0.05)
    • Adequate correlation between DHI and equilibrium score ratio of the HS-SOT condition 5 at 2 month follow-up (r = -0.461, p < 0.05)

(Perez et al., 2003; n = 226, mean age = 45.3 ± 9.4 years, individuals with vestibular pathology) 

  • Adequate correlation between DHI and equilibrium score ratio of the HS-SOT condition 5 at 6 month follow-up (r = -0.394, p < 0.05)
  • Adequate correlation between DHI total score and UCLA-DQ (r = 0.416; p < 0.01)
  • Adequate correlation between DHI total score and SOT composite score (r = -0.345; p < 0.01)

 

Construct Validity (Convergent/Discriminant)

Vestibular Dysfunction: 

(Jacobson and Newman, 1990)

  • Adequate relationship between the number of dizzy spells per year and score on DHI (< 12, > 12, and permanent)

(Perez et al., 2001)

  • Excellent correlation between vestibular handicap factor and DHI emotional (DHIe)  subscale r = 0.927 p < 0.001, and DHI functional subscale (DHIf) r = 0.743 p < 0.001
  • Adequate correlation between vestibular handicap factor and the DHI physical (DHIp) subscale r = 0.317 p < 0.001
  • Excellent correlation between vestibular disability factor and the DHI emotional r = 0.912 p < 0.001
  • Poor correlation between vestibular disability factor and the DHIf subscale 0.425 p < 0.001
  • Adequate correlation between vestibular disability factor and DHI physical subscale r = 0.714, p < 0.001

Vestibular Disorders:

(Alghwiri et al., 2012; n = 17 experts; and n = 58 patients with vestibular disorders)

  • Adequate to excellent correlation of 0.54 to 0.74 (DHI vs. VAP)

Peripheral and Central Vestibular Pathology:

(Fielder et al, 1996; n = 42; Participants with dizziness n = 21 with males = 3 and females = 18; mean age = 55.6 (17.2) years; duration of symptoms = 15.8 (16) months)

  • Adequate to excellent correlation between scores of DHI and SF- 36 (r = 0.53 to 0.72)
  • Directly proportional to the number of episodes of dizziness with validity increasing with seriousness.

Multiple Sclerosis:

(Cattaneo et al., 2006)

  • Adequate correlation of DHI to Berg Balance (r = 0.32), to Dynamic Gait Index (r = 0.39), to Timed Up and Go (r = 0.35) and to Hauser Ambulation Index (r = 0.32).
  • Excellent correlation of DHI with Activities Specific Based Confidence Scale (r = ‐0.70)
  • Adequate relationship exists between the numbers of dizzy spells/year (< 12, > 12, and permanent) and score on the DHI.

Elderly:

(Whitney et al., 1999; n = 71, males = 15 & females = 56; age range = 26- 88 years)

  • Excellent negative correlation between scores of DHI and ABC (Activity specific Balance Confidence Scale) (r = 0.64)

Traumatic Brain Injury:

(Gotshall et al., 2003; n = 53 with mild traumatic brain injury)

  • DHI significantly correlated with Dynamic Visual Acuity testing (After one week)

Whiplash Associated Disorders:

(Treleaven et al., 2005; n = 100; 50 with dizziness including males = 12 & females = 38 having a mean age = 35.5 (19- 46) years and their time since injury = 1.4 (0.35- 3) years; 50 without dizziness including males = 12 & females = 38 having a mean age = 35 (18-46) years and their time since injury = 1.6 (0.3- 3) years; individuals had to refrain from medications 24 hours prior to study.)

  • Adequate correlation of DHI to Smooth Pursuit Neck Torsion Test (r = 0.31)

 

Content Validity

Vestibular Dysfunction:
(Jacobson and Newman, 1990)
  • The total score was show to be significantly poorer for patients reporting more frequent attacks of dizziness or unsteadiness.

(Jacobson & Calder, 2000)

  • Self perceived balance handicap (DHI-total and DHI –physical subscale) experienced by patients with bilateral reductions in peripheral vestibular function is significantly greater than that experienced by individuals with balance complaints that have normal balance function tests but is not greater than those individuals that demonstrate unilateral vestibular impairments.

Traumatic Brain Injury:

(Basford et al., 2003; n = 20, 10 with TBI and complaints on instability, and 10 without TBI; 6 men and 4 women, ranging in age from 18 to 65 years; age, height and gender matched with controls)

  • DHI scores were consistent with the subjects' complaints of unsteadiness and imbalance

Face Validity

Not Established

Floor/Ceiling Effects

Multiple Sclerosis (MS): (Cattaneo et al., 2006)

·         Adequate ceiling effect (1.9%)

Responsiveness

Multiple Sclerosis (MS): (Cattaneo et al., 2006)

·         Sensitivity = 50%

·         Specificity = 77%

(Hebert et al., 2011)

  • Highly responsive (Effect size of 1.03 & 1.12 for experimental group vs. exercise control group and wait listed control group respectively at 10 weeks)
  • Moderately responsive (Effect size of -0.35 and -0.84 for experimental group vs. exercise control group and wait listed control group respectively at 14 weeks.)

Peripheral and Central Vestibular Rehabilitation: (Enloe et al., 1997; n = 95; mean age = 25 - 88 (14.9) years)

  • DHI was found to be moderately responsive. It required 7.24 patients to measure change and had a responsiveness score of 1.66 

Vestibular Dysfunction

(Perez et al., 2001)

  • Performed a factor analysis on 337 individuals with dizziness and discovered that the DHI is a multidimensional questionnaire for the assessment of dizziness and has the ability to provide a good model for vestibular handicap and disability. 

(Whitney et al., 2000; n = 39, mean age = 54 ± 16 years, individuals with a diagnosis of migraine-related vestibulopathy)

  • Demonstrated a 12 point average decrease in DHI score (P < 0.01) after a custom-designed physical therapy exercise program performed for a mean of 4.9 visits over a 4 month period

(Wackym et al., 2008; n = 55 individuals with sporadic vestibular schwannomas treated with gamma knife)  

  • Found a significant difference in total DHI score was seen only in the elderly (> 65 years old) patients pre-gamma knife surgery compared with post-gamma knife sugery  (t = 1.34, p = 0.05)

 

Professional Association Recommendations

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (VEDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

(Vestibular > 6 weeks post)

VEDGE

HR

HR

HR

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

NR

R

UR

HR

UR

TBI EDGE

LS

LS

LS

R

R

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

 

 

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

HR

HR

HR

UR

 

 

Recommendations based on vestibular diagnosis

 

Peripheral

Central

Benign Paroxysmal Positional Vertigo (BPPV)

Other

VEDGE

HR

HR

HR

HR

 

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

Yes

Yes

Yes

No

TBI EDGE

No

Yes

Yes

Not reported

VEDGE

Yes

Yes

Yes

Yes

Considerations

  • English language.
  • Spanish version (Perez et al., 2000)
  • Dutch version (Vereeck et al., 2007)
  • Norwegian version (Tamber et al., 2009)
  • Swedish version (Jarlsäter, S., & Mattsson, E. (2003)
  • Chinese version (Poon et al., 2004)
  • German version (Kurre et al., 2009)
  • The authors found that the frequency of dizziness attacks could not always reflect the perceived severity of the handicap.  Patients with fewer dizziness attacks would report that they were severely handicapped and those that had many attacks of dizziness did not necessarily report being severely handicapped. (Jacobson and Newman, 1990)
  • The Dizziness Handicap Inventory has become very important to diagnose the severity of handicap in the elderly since their post-fall complications are many, but it was still only moderately sensitive in identifying fallers in the population tested.
  • Since the DHI is a self-administered questionnaire, quantitative information regarding the instability episode cannot be recorded.
  • There was a higher prevalence of dizziness related episodes in women, whereas men were 2.26 times more depressed about their vertigo and dizziness problems.
  • The total score of DHI is more reliable than scores for any separate items recorded. (Kammerlind et al., 2005; n = 50, males = 26 & females = 24; mean age = 63 (13) years; onset of vestibular pathology 3 years.)
  • Elderly patients > 65 years have balance affections due to dizziness but a lower level of self perceived handicap and therefore need to treated more cautiously. (Hansson et al., 2005; n = 119; males = 46 & females = 73)
  • With high test-retest reliability and low error of measurement scores, the DHI has become a very useful tool for measurement of dizziness handicap in individuals.
  • Whitney at al., 2005 hypothesized that five items of the DHI were predictive of BPPV.  The scale is termed the five-item BPPV subscale of the DHI.  The five-item BPPV subscale is a summation of the following five items from the DHI: looking up, getting out of bed, quick head movements, rolling over in bed, and bending for a maximum score of 20 points. 
    • The BPPV five-item subscore was a significant predictor of likelihood of BPPV (×2 = 8.35; p<0.01)
    • Scores of 4 and 8 on the combined items of getting out of bed and rolling over in bed were significantly related to the probability of BPPV.  A score of 4 on the combined above stated items was approximately 2.7 times more likely to have BPPV than an individual that scored 0.  A score of 4 on the combined items was approximately 4.3 times more likely to have BPPV than an individual that scored 0.   

 Dizziness Handicap Inventory translations:

French (Appendix 1):
http://www.sciencedirect.com/science/article/pii/S0168605404000029

Spanish:
http://www.southamptonhospital.org/Resources/10355/FileRepository/Forms/Dizziness%20Handicap%20Inv%20%20(DHI)%20Spanish.pdf

These translations, and links to them, are subject to the Terms and Conditions of Use of the Rehab Measures Database. RIC is not responsible for and does not endorse the content, products or services of any third-party website, and does not make any representations regarding its quality, content or accuracy. If you would like to contribute a language translation to the RMD, please contact us at rehabmeasures@ric.org.

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Bibliography

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Year published

 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
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Created at 9/29/2012 8:45 PM  by Jason Raad 
Last modified at 9/3/2014 10:33 AM  by Jason Raad