Questionnaire Text

Questionnaire form view entire document:  text  image

Other characteristics

For those of the age indicated.


20. Permanent physical disabilities:

(For those affected, of any age.) Mark the box as appropriate.

[] 1 Blind
[] 2 Deaf
[] 3 Deaf-mute


Questionnaire instructions view entire document:  text  image


Item XX: Permanent physical disabilities

227 - Annotate the permanent physical impediment(s) of the affected person (of any age) by marking an (x) in the corresponding box.