Dear participant:IF YOU HAD COMPLETED THIS QUESTIONNAIRE BEFORE,PLEASE DON'T COMPLETE IT AGAIN. I am a doctoral nursing student at the University of Connecticut conducting a research study entitled “Development of the Client Empowerment Scale”. The intent of my study is to test the reliability and validity of the Client Empowerment Scale, which measures the degree to which patients with chronic health conditions are empowered. The results of this study will be used to improve the care provided to clients with chronic conditions. Participation in this study is voluntary. You don not have to be in this study if you do not want to. If you agree to be in the study, but later change your mind, you may drop out at any time. You have the right to decline or withdraw from participation in the study at any time you feel uncomfortable.

There are no risks associated with participation in this study. You will be asked to complete the demographic data sheet, and a questionnaire called “The Client Empowerment Scale”. The approximate time required to complete the questionnaires is 25-30 minutes. All information will be kept confidential and stored in secured servers at FormSite.com. The data collected will be coded and will be destroyed upon completion of the study. The UCONN Institutional Review Board (IRB) and the Office of Research Compliance may inspect study records. Your contribution in this study will help build the limited body of knowledge regarding empowerment of patients with chronic health conditions. Completing the questionnaire and the demographic sheet is a valid consent of your participation. Take as long as you like before you make a decision.

Should you have any questions or concerns regarding this study, please contact the Principal Investigator of this project Dr.Carolyn D’Avanzo who can be reached at phone # (860) 486-0540 or via E-mail Address: Carolyn.Davanzo@uconn.edu. If you have any questions concerning your rights as a research participant, you may contact the University of Connecticut Institutional Review Board (IRB) at (860) 486-8802. An IRB is a group of people that reviews research studies and protects the rights of people involved in research. Thank you for your participation. Project Director Ismat Mikky, BSN, MSN, PhDc, RN Doctoral nursing student University of Connecticut School of Nursing

Directions: Please read each item carefully then circle the number that corresponds to your level of agreement (how much you agree or disagree) with each of the given below statements. Click on the circle next to the ONE response that best describes your CURRENT feelings and perceptions of being empowered while living with a chronic illness (chronic health condition). Note: “Provider” in the statements refers to your health care provider includes physicians and nurses

1=Strongly Disagree 2=Disagree 3=Unsure 4=Agree 5=Strongly Agree 1- I am confident discussing my health concerns with my provider. 1 2 3 4 5 2- I would ask my provider to change my medication when it does not satisfy me. 1 2 3 4 5 3- I know how to reach the goals I set about my health problems. 1 2 3 4 5 4- I know my role versus the roles of my provider when solving problems associated with my chronic health condition. 1 2 3 4 5 5- I try to assist individuals who have chronic health conditions similar to mine. 1 2 3 4 5 6- I consider myself an equal partner when interacting with my provider. 1 2 3 4 5 7- I often request additional health resources from my provider when needed. 1 2 3 4 5 8- I would ask elected town and government officials to provide me with available community resources. 1 2 3 4 5 Page 8 / Page 9 1=Strongly Disagree, 2=Disagree, 3=Unsure, 4=Agree, 5=Strongly Agree 9- I am confident asking my provider questions related to my health problems. 1 2 3 4 5 10- I am responsible for the decisions I make about my health. 1 2 3 4 5 11- I have the right to discuss my use of medication with my provider. 1 2 3 4 5 12- I am comfortable expressing my feelings to my provider. 1 2 3 4 5 13- I participate in decisions concerning my health care regimen. 1 2 3 4 5 14- To improve the health care of patients like me, I would place a call to elected town and government officials. 1 2 3 4 5 15- I am confident performing the skills necessary for managing my chronic health condition. 1 2 3 4 5 16- I am comfortable choosing among different options related to my health care regimen. 1 2 3 4 5 Page 9 / Page 10 1=Strongly Disagree, 2=Disagree, 3=Unsure, 4=Agree, 5=Strongly Agree 17- I have the right to discuss my food preferences with my provider. 1 2 3 4 5 18- I would talk to my provider if I feel that a wrong therapy is prescribed for me. 1 2 3 4 5 19- My provider regards my knowledge and experience in taking care of my chronic health condition. 1 2 3 4 5 20- I try to share my health experiences with others who live with similar chronic health conditions. 1 2 3 4 5 21- I often adopt new skills important for managing my chronic health condition. 1 2 3 4 5 22- To improve the health care of patients like me, I would contact elected town and government officials by writing them a letter. 1 2 3 4 5 23- I am confident using my abilities to reach my health goals. 1 2 3 4 5 24- I feel having a voice when interacting with my provider. 1 2 3 4 5 Page 10 / Page 11 1=Strongly Disagree, 2=Disagree, 3=Unsure, 4=Agree, 5=Strongly Agree 25- I would ask my provider to change the dietary regimen if it does not satisfy me. 1 2 3 4 5 26- I would talk to my provider if I feel that a wrong procedure is to be performed on me. 1 2 3 4 5 27- My provider supports my health care choices even if it contradicts with his/her recommendations. 1 2 3 4 5 28- I am satisfied with my level of contribution in the decision-making process concerning my health care regimen. 1 2 3 4 5 29- I would attend an event or a public meeting to discuss problems related to my chronic health condition. 1 2 3 4 5 30- I am confident overcoming the obstacles that prevent me from achieving my health goals. 1 2 3 4 5 31- I am confident performing therapeutic exercises as prescribed. 1 2 3 4 5 32- I would refuse any decision made by my provider if it dose not satisfy me. 1 2 3 4 5 Page 11 / Page 12 1=Strongly Disagree, 2=Disagree, 3=Unsure, 4=Agree, 5=Strongly Agree 33- I depend mainly on myself in managing my chronic health condition. 1 2 3 4 5 34- I am aware of the barriers that prevent me from receiving certain health care services. 1 2 3 4 5 35- My provider spends a fair amount of time during a visit. 1 2 3 4 5 36- My provider encourages me to participate more in decisions related to my health care regimen. 1 2 3 4 5 37- I often learn new therapeutic activities to manage my chronic health condition more effectively. 1 2 3 4 5 38- I would state my opinion to elected town and government officials for the benefit of all patients who have similar chronic health conditions. 1 2 3 4 5 39- I am confident managing the pain associated with my chronic health condition. 1 2 3 4 5 40- I am confident taking my medications as prescribed. 1 2 3 4 5 Page 12 / Page 13 1=Strongly Disagree, 2=Disagree, 3=Unsure, 4=Agree, 5=Strongly Agree 41- Most of the time I make the final decision regarding my health care choices. 1 2 3 4 5 42- I have the right to stop taking my medication even if it contradicts my provider’s recommendations. 1 2 3 4 5 43- The positive attitudes of my provider motivate me to participate more in making decisions related to my health care regimen. 1 2 3 4 5 44- My provider listens attentively to me 1 2 3 4 5 45- I collaborate with my provider in planning my health care regimen. 1 2 3 4 5 46- I would identify problems related to my chronic health condition to elected town and government officials for the benefit of all patients. 1 2 3 4 5 47- I am confident following the health regimen as prescribed. 1 2 3 4 5 48- I feel in control when being able to manage the financial hardships associated with my chronic health condition. 1 2 3 4 5 Page 13 / Page 14 1=Strongly Disagree, 2=Disagree, 3=Unsure, 4=Agree, 5=Strongly Agree 49- I know where to find support for my health care needs. 1 2 3 4 5 50- I know what helps me stay motivated to better manage my chronic health condition. 1 2 3 4 5 51- I am satisfied with the support I get from loved ones. 1 2 3 4 5 52- I am satisfied with my level of self-care. 1 2 3 4 5 53- I would contact elected town and government officials to expand health coverage for alternative therapies. 1 2 3 4 5 54- I am confident managing the difficulties associated with my chronic health condition. 1 2 3 4 5 Page 14 / Page 15 1=Strongly Disagree, 2=Disagree, 3=Unsure, 4=Agree, 5=Strongly Agree 55- I have a positive outlook toward my chronic health condition. 1 2 3 4 5 56- I know my capabilities and strengths necessary for managing my chronic health condition. 1 2 3 4 5 57- I know the obstacles that prevent me from making decisions to reach my goals. 1 2 3 4 5 58- My religious practices are a source of support. 1 2 3 4 5 59- Having more knowledge about my chronic health condition increased my ability to participate in care. 1 2 3 4 5 60- I would ask elected town and government officials to consider including patients in the health policy process. 1 2 3 4 5 Page 15 / Page 16 Thank you very much for your participation in this study Powered by FormSite.com