Aiuto alla compilazione in lingua inglese
English guide to the completion of the Census form
9th October Law No. 122 of 30th July 2010, Art. 50
15th General Population and Housing Census
[Background information for the enumerator is omitted here]
We may need to contact you if we have questions about your information. To make it easier to contact you and avoid the inconvenience of a personal visit by one of our staff, please provide the following information:
Telephone: _ _ _ _ _ _ _ _ _ _ _ _ _ _
Preferred time of day to be contacted
From _ _ hour: _ _ minutes to _ _ hour: _ _ minutes
Password: xxxxxxxxxxxxxx
Problems with the password? Contact the free phone number 800.069.701
Completing the lists
List A should list each individual who is both a household member and:
- foreign citizen using this dwelling as a usual place of residence and who is either registered in the Public Records Office or in possession of regular documentation for staying in Italy, even if physically absent on the date of the Census (for citizens of countries outside the European Union, valid entitlement to stay in Italy includes waivers on entry (nulla osta all'ingresso) into Italy for work or family reunification, requests for residency permit renewals and requests for first-time residency permits.)
Household members should be entered in List A:
[] Spouse or cohabiting partner ('partner') of the head of household;
[] Unmarried children (from oldest to youngest);
[] Married children and their family members;
[] Other relatives or kin of the head of household on the Household form (father/mother, father-/mother-in-law, brother/sister, brother-/sister-in-law, grandchildren, grandfather/grandmother, uncle, aunt);
[] Other cohabitants with no personal ties, kinship or affinity.
Each household member will be assigned a 2-digit number (person code) corresponding to their position on the list (01 - 08). The Individual forms in Section II should be filled out in the same order.
If the household consists of one individual only (one-person household), only the first line (person code 01) of List A needs to be filled in.
List B should list any individuals who do not use this dwelling as their usual place of residence, but who are present in this dwelling on 09th October 2011 on a temporary or occasional basis (e.g. visiting tourists, short vacations, short-term medical treatments, visiting friends or relatives, etc.).
N.B. For these individuals, the questionnaire concludes with the completion of List B.
[Instructions to enumerator omitted]
List A: Individuals for whom the dwelling is the usual place of residence
[Space for up to eight individuals to answer is provided]
____ First name
[] 1 Male
[] 2 Female
Day _ _
Month _ _
Year _ _ _ _
Place of birth ____
Specify the municipality of birth. If born abroad, specify the foreign country
Citizenship:
[] 2 Foreign or stateless
Individual Information:
Important: Households with more than three members should contact the nearest Municipal Collection Centre
List B: Individuals for whom the dwelling is not the usual place of residence and who are temporarily or occasionally present in the dwelling on the date of the Census, October 9th, 2011
[Space for up to three individuals to answer is provided]
[] 2 Female
Day _ _
Month _ _
Year _ _ _ _
Place of Birth:
[] 1 Italy
[] 2 Abroad
Usual residence:
[] 1 Italy
[] 2 Abroad
Citizenships:
[] 1 Italian
[] 2 Foreign or stateless
Important: If more than three individuals are present for whom the dwelling is not the usual place of residence, contact the nearest Municipal Collection Centre.
Month _ _
Year 201_
Signature of individual who filled the form: ____
Continue by filling in the section
1. Fill in Section I by answering the household and dwelling questions.
2. Fill in Section II. An Individual form should be filled in for each household member from List A.
The Individual forms in Section II should be filled in the same order that the household members are listed in List A.
[Other specific instructions on filling out the census form omitted]
Section I: Information about household and dwelling
1. Type of dwelling and household
1.1 Indicate the type of dwelling
[] 2 Other type of dwelling (shed, trailer, camper, etc.)
[] 3 Accommodation at diplomatic or consular centers
[] 4 Collective residential structure (hotel, rest home, etc.) (go to question 1.4)
1.2 The dwelling is inhabited by
[] 2 Two or more households that cohabit
1.3 Enter the information for the other cohabiting households
_ _ _ _ _ _ _ _ _ _ _ _ _ _Questionnaire code (cohabiting household(s)) (this code is found on the first page of the questionnaire)
_____Last name - head of household
_____ First name - head of household
1.4 In what capacity does your household occupy the dwelling?
[] 2 Rental
[] 3 Other right (free of charge, in exchange for services, etc.)
2. Ownership and structure of the dwelling
[] 2 Business or corporation (insurance company, bank, property investment company, construction company, commercial venture, etc.)
[] 3 Residential building cooperative
[] 4 State, Region or Province
[] 5 Municipality
[] 6 Social Security Agency (INPS, INPDAP, etc.)
[] 7 Istituto Autonomo Case Popolari (IACP), Azienda per il Territorio (ATER) or similar
[] 8 Other
2.2 What is the size of the dwelling?
Round to the nearest whole number
_ _ _ square meters
2.3 How many rooms are in the dwelling?
Number of rooms _ _
2.4 How many of the rooms indicated in question 2.3 are dedicated exclusively to a vocation?
[] 0
[] 1
[] 2
[] 3
If more than 3, specify how many _ _
2.5 Indicate whether the dwelling has the following
[] 1 A full kitchen [a space that qualifies as a full room and is designed and equipped for meal preparation]
[] 2 A kitchenette [a space designed and equipped for meal preparation that does not qualify as a room]
[] 3 A kitchen corner in a multi-purpose room [a space designed and equipped for meal preparation and that forms part of a room that serves multiple functions (living room, family room, etc.)]
[] 4 No kitchen, kitchenette or kitchen corner
If more than 1 kitchen, specify how many _ _
3 Water and sanitation systems
3.1 Is water available inside the dwelling?
[] 1 Yes, drinkable water from the public water mains
[] 2 Yes, drinkable water from a well
[] 3 Yes, drinkable water from another source
[] 4 Yes, but it is not drinkable
[] 5 No, no water is available inside [skip to question 3.5]
3.2 Is hot water available in the dwelling (in the bathroom and/or kitchen)?
[] 2 No [skip to question 3.5]
3.3 Is this hot water produced by the same system that is used to heat the dwelling itself?
[] 2 No
3.4 What type of fuel or energy source is used to heat your water? (Multiple responses allowed)
[] 2 Electricity
[] 3 Solar power
[] 4 Other
3.5 How many showers and/or bathtubs are there in the dwelling?
[] 1
[] 2
[] 3
If more than 3, indicate how many _ _
3.6 How many toilets are in the dwelling?
[] 1
[] 2
[] 3
If more than 3, indicate how many _ _
4. Climate control systems (heating, air conditioning, renewable energy)
4.1 Does the dwelling have a heating system?
[] 2 No (go to question 4.3)
4.2 Indicate the type(s) of heating system(s) used in the dwelling and the fuel or energy source that powers each system
Centralized system used by multiple dwellings:
[] 2 Gas oil
[] 3 LPG (liquid petroleum gas)
[] 4 Solid fuel (wood, coal, etc.)
[] 5 Fuel oil
[] 6 Electricity
[] 7 Other fuel or power source
[] 9 Gas oil
[] 10 LPG (liquid petroleum gas)
[] 11 Solid fuel (wood, coal, etc.)
[] 12 Fuel oil
[] 13 Electricity
[] 14 Other fuel or power source
[] 16 Gas oil
[] 17 LPG (liquid petroleum gas)
[] 18 Solid fuel (wood, coal, etc.)
[] 19 Fuel oil
[] 20 Electricity
[] 21 Other fuel or power source
[] 23 Gas oil
[] 24 LPG (liquid petroleum gas)
[] 25 Solid fuel (wood, coal, etc.)
[] 26 Fuel oil
[] 27 Electricity
[] 28 Other fuel or power source
4.3 Does the dwelling have a renewable energy system for generating electricity?
[] 1 Yes
[] 2 No
4.4 Does the dwelling have a permanent air conditioning system?
[] 2 No
5.1 Does your household have a car?
[] 2 Yes, two or more
[] 3 No
5.2 Does your household have one or more private parking spaces? (garage, parking space in a communal garage, reserved uncovered parking space, etc.)
If more than one, specify how many _ _
[] 2 No
6. Telephone and internet connection
6.1 Does your household have at least one active landline telephone in the dwelling?
[] 2 No
6.2 Does at least one household member have a cellular phone with active telephone service?
[] 2 No [skip to question 6.4]
6.3 How many household members have at least one cellular phone? _ _
6.4 Does your household have an internet connection in the dwelling?
[] 2 No [Skip to Section II]
6.5 Specify the type of internet connection in the dwelling
[] 2 DSL (ADSL, SHDSL, etc.)
[] 3 Other type of broadband connection (fiber optic, local area network, etc.)
[] 4 Internet dongle, PC card, cell phone (GPRS, UMTS, HSDPA, HSUPA, etc.)
[For persons in List A]
1.1 Kinship or cohabitation relationship with the head of household on the household form
[] 2 Spouse of the head of household
[] 3 Cohabiting partner (partner) of the head of household
[] 4 Son/daughter of the head of household and spouse/partner
[] 5 Son/daughter of the head of household only
[] 6 Son/daughter of the spouse/partner only
[] 7 Parent (or spouse/partner of a parent) of the head of household
[] 8 Father-/mother-in-law of the head of household
[] 9 Brother/sister of the head of household
[] 10 Brother/sister of the spouse/partner
[] 11 Spouse/partner of a brother/sister of the head of household or of the brother/sister of the spouse/partner
[] 12 Son-/daughter-in-law (spouse/partner of a son/daughter) of the head of household and/or the spouse/partner
[] 13 Grandchild (son/daughter of a son/daughter) of the head of household and/or spouse/partner
[] 14 Nephew/niece (son/daughter of a brother/sister) of the head of household and/or spouse/partner
[] 15 Grandmother/grandfather of the head of household or spouse/partner
[] 16 Other relative of the head of household and/or spouse/partner
[] 17 Other cohabitant without any personal or kinship ties or affinities
[] 2 Female
Month _ _
Year _ _ _ _
[] 2 In a different Italian municipality
Specify the municipality and the abbreviation for the province
Municipality ____
Province _ _
[] 3 Abroad
Specify the foreign country ____
1.5 Are you registered in the Public Records Office of this municipality?
The municipality of registration is where your identification documents and basic public records (e.g. birth certificate, civil status, etc.) can be retrieved
[] 1 Yes, in this dwelling
[] 2 Yes, but in a different dwelling or cohabitation
[] 3 No, in a different municipality
Specify the municipality and the abbreviation for the province
Municipality ____
Province _ _
[] 4 No, not in any Italian municipality
2. Marital status and marriages
[] 2 Married
[] 3 De facto separated
[] 4 De jure separated
[] 5 Divorced
[] 6 Widow(er)
2.2 Month and year the marriage took place
Month _ _
Year _ _ _ _
2.3 Marital status prior to the most recent marriage
[] 2 Divorced
[] 3 Widow(er)
3.1 What citizenship do you have?
[] 1 Italian (go to question 3.2)
[] 2 Foreign
Specify the foreign country of citizenship and skip to question 3.4
Municipality ____
Province _ _
[] 3 Stateless (no citizenship) [skip to question 3.4]
[Questions 3.2 and 3.3 were asked of persons with Italian citizenship]
3.2 Have you had Italian citizenship since birth?
[] 2 No [go to question 3.3]
3.3 How did you obtain Italian citizenship?
[] 2 Other
Specify the foreign country of your previous citizenship ____
3.4 Where was your mother born?
[] 1 In Italy
[] 2 Abroad
Specify the foreign country of birth ____
3.4 Where was your father born?
[] 1 In Italy
[] 2 Abroad
Specify the foreign country of birth ____
4. Presence and prior dwelling
4.1 Where were you living as of the date of the census, October 9th, 2011?
[] 2 In this municipality, but in a different dwelling or cohabitation (e.g. at a friend's/relative's house, military barracks, hospital)
[] 3 In a different Italian municipality
[] 4 Abroad
4.2 Have you ever had residency abroad?
[] 2 No [skip to question 4.6]
4.3 Indicate the month and year of your most recent transfer to Italy
Year _ _ _ _
4.4 In what foreign country did you last have residence?
4.5 Where was your usual place of residence one year ago on October 9th, 2010?
[] 1 In this dwelling
[] 2 In this municipality, but in a different dwelling or cohabitation (e.g. at a friend's/relative's house, military barracks, hospital)
[] 3 In a different Italian municipality
[] 4 Abroad
4.6 Where was your usual place of residence five years ago on October 9th, 2006?
[] 1 In this dwelling
[] 2 In this municipality, but in a different dwelling or cohabitation (e.g. at a friend's/relative's house, military barracks, hospital)
[] 3 In a different Italian municipality
[] 4 Abroad
Specify the foreign country _____
Questions 5.1 and 5.2 are for children ages 6 years and under
[] 1 Daycare, micro crèches, drop-in/ short-term child care, etc. (3-36 months) (go to question 5.2)
[] 2 Nursery school (go to question 7.1)
[] 3 First year (go to question 7.1)
[] 4 Neither daycare nor nursery school nor first year (If this is selected, section is done)
5.2 Specify the type of daycare
[] 1 Public
[] 2 Private
Go to question 7.1 after completing question 5.2
Questions 5.3 through 5.9 are asked for those persons ages 6 years or more
5.3 What is the highest educational qualification you have attained from among those listed below?
[] 2 No formal education but can both read and write [skip to question 5.11]
[] 3 Elementary school qualification (or equivalent) [skip to question 5.9]
[] 4 Middle school (or vocational school) qualification [skip to question 5.7]
[] 5 Completion of lower/middle level of the Music Conservatory or National Academy of Dance (2-3 years) [skip to question 5.5]
[] 6 Vocational school diploma [go to question 5.4]
[] 7 Teacher training school diploma [go to question 5.4]
[] 8 Art school diploma [go to question 5.4]
[] 9 Technical institute diploma [skip to question 5.5]
[] 10 Teacher training institute diploma [skip to question 5.5]
[] 11 High school diploma (classical, scientific, etc.) [skip to question 5.5]
[] 12 Diploma from the Academy of Fine Arts, Dramatic Arts, ISIA, etc., Conservatory (former system) [skip to question 5.5]
[] 13 University degree (2-3 years) under the former system (including schools dedicated to specialized programs and vocationally-oriented community colleges [skip to question 5.5]
[] 14 Academic diploma of Higher Artistic, Music and Dance Training (A.F.A.M.), level I [skip to question 5.5]
[] 15 Three-year degree (level I) under the new system [skip to question 5.5]
[] 16 Academic degree of Higher Artistic, Music or Dance Training (A.F.A.M.), level II [skip to question 5.5]
[] 17 Degree (4-6 years) under the former system, single-cycle specialized Level II degrees or specialistica or magistrale under the new system, two-year specialized degree (level II) under the new system [skip to question 5.5]
5.4 The duration of the course was
[] 1 2-3 years
[] 2 4-5 years
5.5 Enter the full title of the educational qualification indicated in question 5.3 ____
5.6 Did you complete any regional/provincial vocational training courses lasting 6 months or longer and requiring an upper secondary school diploma for admission? (level II programs, Higher Technical Education and Training courses)
[] 2 No [skip to question 5.9]
5.7 Did you complete any regional/provincial vocational training courses lasting 24 months or longer and requiring a middle school certificate for admission?
[] 2 No [skip to question 5.9]
5.8 Specify the program listed in question 5.7
[] 2 Other regional/provincial vocational training course
5.9 Was the educational qualification awarded abroad?
[] 2 No [skip to question 5.11]
5.10 How many years of schooling were required to attain the qualification abroad? _ _
5.11 Are you presently enrolled in a regular course of studies?
[] 1 Yes
[] 2 No
5.12 In the week preceding the date of the census (October 02nd -- 08th), did you attend any vocational training/continuing education courses (free of charge or otherwise)?
Questions 5.13 and 5.14 is for those who checked one of the boxes 12 through 17 in question 5.3
[Question 5.13 and 5.14 were asked of persons who indicated they had a degree higher than a high school diploma (code 11 in question 5.3)]
5.13 Have you obtained any post-graduate or post-diploma A.F.A.M. qualifications?
[] 2 No [go to Section 6]
5.14 Specify the qualifications attained if question 5.13 indicates "1 Yes"
[] 1 Level I master's degree
[] 2 Level II master's degree
[] 3 Specialization school
[] 4 Research doctorate
Individuals aged 15 years and over proceed with question 6.1. Individuals aged 15 years and under, proceed with question 7.1.
6. Vocational or non-vocational status
[These questions are asked of individuals aged 15 years and over]
6.1 During the week preceding the date of the census, October 2nd -- October 8th, did you work for at least one hour?
[] 1 Yes [skip to question 6.6]
[] 2 No
6.2 During the week of October 2nd - October 8th, did you have a job from which you were absent?
[] 1 Yes [skip to question 6.6]
[] 2 No
6.3 During the period from September 11th - October 08th, were you actively seeking employment or did you set up the means to start your own business?
[] 2 No [skip to question 6.13]
6.4 If you had the chance, would you be willing to start working within the next two weeks?
[] 2 No [go to question 6.13]
6.5 Have you ever had a paying job or worked as a family worker?
[] 2 No [skip to question 7.1]
In your answers to question 6.6 through 6.12 refer to your primary work activity only. If you are not working at present, refer to your most recent job.
6.6 What type of work do (did) you do?
[] 2 Continuous coordinated collaboration (project-based or otherwise) [skip to question 6.9]
[] 3 Occasional work [skip to question 6.9]
[] 5 Freelance professional [skip to question 6.8]
[] 6 Self-employed worker [skip to question 6.8]
[] 7 Member of a cooperative [skip to question 6.9]
[] 8 Family worker [skip to question 6.9]
[] 2 Permanent
6.8 Did (do) you have paid employees?
[] 2 No
[] 2 Part time
6.10 What is (was) the nature of your work activity?
[] 1 Manual or unskilled labour (Farm hand, Custodian, Construction worker, Domestic assistant, Dishwasher, Usher, Porter, Hospital attendant, Refuse collector, Stablehand)
[] 2 Operation of manufacturing systems, machinery and assembly lines, driving vehicles (Forklift operator, Assembler of electric devices, Truck driver, Taxi driver, Automatic loom operator, Rolling mill operator, Oil mill operator)
[] 3 Skilled labor (Bricklayer, Mechanic, Heating system installer, Shoemaker, tailor, Carpenter, Blacksmith, Upholsterer)
[] 4 Plant cultivation and/or animal breeding (Farmer, Fruit grower, Stockman, Fish farmer, Reforester, Gardener, Fisherman)
[] 5 Retail sales and services (Shopkeeper, Police officer, Hairdresser, Cook, Waiter, Flight attendant, Baby sitter, Nanny, Salesperson)
[] 6 Administrative support (Secretary, Postal service counter worker, Switchboard operator, Administrative assistant, Service counter staff)
[] 7 Mid-level technical, administrative, athletic or artistic work (Nurse, Accountant, Surveyor, Electronic technician, Computer analyst, Athlete, Sales representative, Fire chief, Air traffic controller, Insurance agent)
[] 8 Highly-specialized managerial, technical, intellectual, scientific or artistic work (General or specialized physician, University professor, Actor, Musician, Elementary school teacher, Engineer, Chemist, Agricultural scientist, Pharmacist)
[] 9 Business management, administration of a private or public organization (Business owner, Party chief, Public official, CEO, Chief justice, School principal, Prefect)
[] 10 Military of any rank in the Armed Forces - Army, Navy, Air force, Military police (Carabinieri) (General, Medical colonel, Sergeant major, Military police agent (Carabinieri), Airman, Private first class)
6.11 What is the economic activity sector of the factory, organization, business, etc., where you work(ed) or that you own(ed)?
[] 2 Extractive activities in quarries or mines and mining support services (including the extraction of crude oil and natural gas)
[] 3 Manufacturing, processing and repairs, maintenance and installation of machinery and equipment (excluding the manufacture and repair of cars and motorcycles, computers and communications equipment and other personal and/or domestic goods)
[] 4 Supply of electricity, gas, steam or air conditioning
[] 5 Supply of water, sewer system management, waste management and reclamation
[] 6 Construction, public works and installation of facilities in buildings
[] 7 Wholesale and retail commerce, repair and maintenance of cars and motorcycles
[] 8 Transport (of passengers or goods by pipelines, road, water or air); storage/warehousing, postal and courier services
[] 9 Accommodation and immediate-consumption restaurant services
(including bars, cafes, pubs, ice cream parlours, etc.)
[] 10 Information and communication services
(including phone centers and internet points)
[] 11 Financial and insurance activities
[] 12 Real estate activities
(including condominium administration)
[] 13 Professional, scientific and technical activities
(including research and development, law offices, advertising agencies, veterinary services, etc.)
[] 14 Leasing, travel agencies, business support services
(including call centers, research services, personnel search and selection, etc.)
[] 15 Central and local public administration, Defence and compulsory social security
[] 16 Education and training, public and private
(including programs at military academies, conservatories, courses for sporting, recreational and cultural activities, driving schools)
[] 17 Healthcare and social welfare assistance (residential and non-residential)
(including daycare centers)
[] 18 Artistic, sports, entertainment and recreational activities
(including libraries and archives, museums, gambling halls and game rooms, etc.)
[] 19 Other maintenance and repair services for personal and household goods
(including the activities of associations, launderers, hairdressers, etc.)
[] 20 Family-oriented work and cohabitation as employers of domestic staff
[] 21 Overseas bodies and organizations (UN, FAO, embassies on Italian soil)
6.12 How many hours do (did) you usually work per week?
Skip to question 7.1
6.13 During the week of October 2nd -- October 8th, you were
If you fit more than one of these categories, check the first one that appears on the list. For example, if you are a both a housewife and you collect a retirement pension, check box 1
[] 1 A recipient of one or more pensions for previous work activity or recipient of unearned income (returns on property or equities)
[] 2 A student
[] 3 A homemaker
[] 4 Other
7.1 Do you go to your usual place of work or study every day?
[] 2 Yes, I go to a place of work (go to question 7.2)
[] 3 No, because I study at home [skip to question 8.1]
[] 4 No, because I work from home [skip to question 8.1]
[] 5 No, because I have no fixed workplace (fill-ins/substitutes, sales representatives, etc.) [skip to question 8.1]
[] 6 No, because I am neither working nor studying nor attending any vocational training courses [skip to question 8.1]
If persons are aged 6 years and under and choices 3 through 6 are selected, the individual form ends here.
7.2 Where is your usual place of work or study located?
[] 1 In this municipality [go to question 7.3]
[] 2 In a different Italian municipality
Specify the municipality and the abbreviation for the province
Municipality ____
Province _ _
[go to question 7.3]
[] 3 Abroad
Specify the foreign country ____
7.3 Write out the address without using any abbreviations ____
7.4 What dwelling do you leave from when you set out for your usual place of work or study each day?
[] 2 A different dwelling [skip to question 8.1]. If persons are aged 6 years and less, this individual form ends here.
7.5 After your work or study, is this the dwelling you return to on a daily basis?
[] 2 No [go to question 8.1]. If persons are aged 6 years and less, this individual form ends here.
In your answers to questions 7.6, 7.7, and 7.8, refer to last Wednesday. If you did not commute to your usual place of work or study on that particular day (regardless of the reason, e.g. strike, illness, holiday, etc.), refer instead to a typical day.
7.6 At what time did you leave home to go to your usual place of work or study?
_ _ Minutes
(e.g. 07:30)
7.7 How long did it take you (one way only) to get to your usual place of work or study? (in minutes)
Minutes _ _ _
(e.g. total travel time of 1 hour and 15 minutes should be written as 075)
7.8 What means of transportation did you use for the longest portion of the trip (in terms of distance, not time) to get to your usual place of work or study?
[] 2 Tram
[] 3 Underground/commuter train
[] 4 Bus (city bus, trolley bus)
[] 5 Bus (non-city bus)
[] 6 School or company bus
[] 7 Private car (as a driver)
[] 8 Private car (as a passenger)
[] 9 Motorcycle, moped, scooter
[] 10 Bicycle
[] 11 Other means (ferry, cable car, etc.)
[] 12 On foot
8. Difficulty with daily activities
[These questions are for persons ages 6 years old and over]
As provided for by law, responding to questions 8.1 through 8.4 is not compulsory.
The following questions address difficulties you might experience during any activities as the consequence of health problems. In the questions that follow, please do not consider any problems that are only temporary in nature.
8.1 Do you have difficulty with your vision?
[] 1 No, no difficulty
[] 2 Yes, some difficulty
[] 3 Yes, much difficulty
[] 4 I am unable to see
8.2 Do you have difficulty with your hearing?
[] 1 No, no difficulty
[] 2 Yes, some difficulty
[] 3 Yes, much difficulty
[] 4 I am unable to hear
8.3 Do you have difficulty walking or climbing up or down stairs?
[] 1 No, no difficulty
[] 2 Yes, some difficulty
[] 3 Yes, much difficulty
[] 4 I am unable to walk
8.4 Do you have difficulty with memory or concentration?
[] 2 Yes, some difficulty
[] 3 Yes, much difficulty
[] 4 I am unable to remember or concentrate