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:


a) Learning, remembering, or concentrating?

[] Yes
[] No

Questionnaire instructions view entire document:  text  image

[Housing Question 15 and 16 should only be asked of individuals 5 years and older]


16. Mark the "Yes" or "No" box for parts 16a. and 16b. of question 16 to indicate whether the person has any difficulty doing any of the activities listed.