Questionnaire Text

Questionnaire form view entire document:  text  image
C. Disability

3. Does any listed persons (from section A or B) have any of the following disabilities:

[] 11 Partial sighted
[] 12 Total blindness
[] 21 Partial hearing
[] 22 Deafness
[] 31 Partial speech impairment
[] 32 Inability to speak
[] 41 Inability to use 1 leg
[] 42 Inability to use 2 legs
[] 43 Inability to use 1 arm
[] 44 Inability to use 2 arms
[] 45 Inability to use the whole body
[] 51 Intellectual impairment
[] 61 Mental health disorder
[] 71 Missing 1 leg
[] 72 Missing 2 legs
[] 73 Missing 1 arm
[] 74 Missing 2 arms
Questionnaire instructions view entire document:  text  image
Part C of the questionnaire: Disability

Disability is any restriction or lack (resulting from an impairment) of the ability to perform an activity within the range considered normal for a human being.

177. Columns C1/C2/C3: Disability
Q. Does any person(s) listed in A1 or B1 suffer from any of the following disabilities?

11. Partial sighted
12. Total blindness
21. Partial hearing
22. Deafness
31. Partial speech impairment
32. Inability to speak
23. Inability to use 1 leg
24. Inability to use 2 legs
43. Inability to use 1 arm
44. Inability to use 2 arms
45. Inability to use the whole body
51. Intellectual impairment
61. Mental health disorder
71. Missing 1 leg
72. Missing 2 legs
73. Missing 1 arm
74. Missing 2 arms

You should read out the list of disabilities to the respondent as a guide on the types of disabilities you are referring to. Be very tactful in asking these questions so as not to cause offense of embarrassment.

If anyone does have a disability, enter the person's first name in column C1, then enter in column C2 the same serial number that you assigned to this person in column A2 or B2. A person from Part A will have serial numbers 01, 02 or 03, etc., whilst a person from Part B will have serial numbers 91, 92 or 93, etc.

A disabled person has incapacities as a result of physical or mental deficiencies such as bodily abnormalities, defects and impairments. Impairments are defects of structure or functions of the body which give rise to personal inabilities to perform necessary activities. The defects and impairments might occur from birth, or may be brought about by disease, injury or just old age.

Enter the stated disabilities a person has from any of the following codes.

11. Partial sighted
This refers to a person who cannot count fingers from a distance of three meters.
12. Total blindness
This refers to a person who cannot see completely.
21. Partial hearing
This refers to a person who cannot hear a whisper at a distance of two meters even with hearing aids.
22. Deafness
This refers to a person who cannot hear completely
31. Partial speech impairment
This refers to a person who makes unintelligible/unclear speech or stammers and whose speech is not easy to hear.
32. Inability to speak
This refers to a person who cannot speak at all (i.e. completely dumb or mute).
41. Inability to use 1 leg
This refers to a person who has one lame leg.
42. Inability to use 2 legs
This refers to a person who has two lame legs.
43. Inability to use 1 arm
This refers to a person who has one lame hand/arm.
44. Inability to use 2 arms
This refers to a person who has two lame hands/arms.
45. Inability to use the whole body
This refers to a person who cannot use their entire body.
51. Intellectual impairment
This refers to a person with a normal IQ level who begins to show strange behavior, thinking, acting, or talking in a different way than other people. The onset occurs later in life after a period of normal development.
61. Mental health disorder
This refers to a handicap of abnormal intellectual functioning with onset during the developmental period associated with impaired maturation, learning, and social maladjustment. The Intelligence Quotient (IQ) is below normal.
71. Missing 1 leg
This refers to a person who has one missing leg.
72. Missing 2 legs
This refers to a person who has two missing legs.
73. Missing 1 arm
This refers to a person who has one missing arm.
74. Missing 2 arms
This refers to a person who has two missing arms.

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