Questionnaire Text

Questionnaire form view entire document: text image

For all individuals [applies to questions 17 to 23]

20. Do you have any of the following disabilities?

[] 1 Total blindness
[] 2 Total deafness
[] 3 Muteness
[] 4 Paralyzed or injured
[] 5 Mental deficiency
[] 6 None of the above

Questionnaire instructions view entire document: text image

Question 20

If there is more than one type of impairment, mark all that apply. [These instructions refer to a graphic of question 20 on the census form.]