Questionnaire Text

Questionnaire form view entire document:  text  image

For all individuals [applies to questions 1 to 6]


4. Do you have any of the following characteristics?

[] 1 Total blindness
[] 2 Total deafness
[] 3 Muteness
[] 4 Paralyzed or injured
[] 5 Mental deficiency

Questionnaire instructions view entire document:  text  image

4. Do you have any of the following characteristics?

Read alternatives 1 to 5 to the person being surveyed and fill in the corresponding circles. If the person doesn't have any of the characteristics listed, fill in circle 6. none.

[The above directions refer to a picture of question 4 in this section of the enumeration form.]