Questionnaire Text

Questionnaire form view entire document:  text  image

G. Answer question 17 only if this person is 15 years old or over. Otherwise, skip to the questions for Person 2 on page 10.
17. Because of a physical, mental, or emotional condition lasting 6 months or more, does this person have any difficulty in doing any of the following activities:


b) Working at a job or business?

[] Yes
[] No

Questionnaire instructions view entire document:  text  image

[Housing Question 17-42 should be asked only of individuals 15 and older.]


17. Mark the "Yes" or "No" box for parts 17a. and 17b. of question 17 to indicate if the person has any difficulty doing any of the activities listed.