Questionnaire Text

Questionnaire form view entire document: text image

F. Answer questions 15 and 16 only if this person is 5 years old or over. Otherwise, skip to the questions for Person 2 on page 10.

16. 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) Dressing, bathing, or getting around inside the home?

[] 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.