Questionnaire Text

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Disability
[Questions C1-C2.]


C1. Does anyone in this household have difficulty with seeing, hearing, speaking, learning, behavior, mobility, personal care, etc.

Tick appropriate box.
[ ] 1 Yes (go to C2)
[ ] 2 No (end of questions)


C2. If "yes", which type of difficulty does this/do [person(s)] have?

Person No. ____
Type
[ ] 1 Seeing
[ ] 2 Hearing
[ ] 3 Speaking
[ ] 4 Learning
[ ] 5 Behavior
[ ] 6 Mobility
[ ] 7 Personal care
[ ] 8 Other: Specify ____