Questionnaire Text

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For all persons, regardless of age:

18a. If you have an impairment or permanent physical disability, please state it here:


Examples: blind, almost blind, deaf-mute; characterized deafness [surdite caracteriseee]. For Amputation, maiming [mutilation], paralysis: please specify. For other impairment: please specify.

18b. Is it the result of:

[] 1 A war injury
[] 2 A work accident
[] 3 Other accident
[] 4 Illness or other reason

18c. If necessary, indicate the corresponding percentage of disability: ____ %