Questionnaire Text

Questionnaire form view entire document:  text  image
39. Does the interviewed person have any of the following disabilities?
(More than one option may be marked)

[] 1 Blind
[] 2 Deaf
[] 3 Mute
[] 4 Physical disability
[] 5 Mental disability
[] 6 Doesn't have
Questionnaire instructions view entire document:  text  image
Question 39: Does the enumerated person have any of the following disabilities?

The person is asked if he has any of the disabilities found in the question. The alternatives are read and the corresponding circles are filled in.