Questionnaire Text

Questionnaire form view entire document:  text  image

5. Do you have any of the following disabilities?
Circle one or more numbers, as appropriate:

[] 1 Total blindness
[] 2 Total deafness
[] 3 Muteness
[] 4 Mental retardation
[] 5 Mental illness
[] 6 Polio
[] 7 Loss or paralysis of upper extremity
[] 8 Loss or paralysis of lower extremity
[] 9 Other (specify) ____
[] 0 No disability
Questionnaire instructions view entire document:  text  image

For All People
[Applies to questions 1 - 6]


Question No. 5: Do you have any of the following disabilities:
Read the question and each one of the options. Then, circle one or more numbers, based on the informant's answers.
[There is a picture of question 5 in this section of the Enumeration Form.]
If the informant reports having a physical handicap that is not included in any of the alternatives, you should circle number 9 (Other) and write it on the corresponding line.
If the informant reports not having any handicap, circle number 0.