Questionnaire Text

Questionnaire form view entire document:  text  image
Housing
Please answer the following questions about the house, apartment, or mobile home at the address on the mailing label.

[B] - Answer questions 18a and b if this house, apartment, or mobile home is rented. Otherwise, skip to question 19.

18. a) What is the monthly rent for this house, apartment, or mobile home?

Monthly amount (USD) _________
Questionnaire instructions view entire document:  text  image
Answer person questions 18a through 18c if this person is 5 years old or over.

18a-18c. Mark the "Yes" or "No" box to indicate if the person has serious difficulty with any of the activities listed in parts a, b, and c because of a physical, mental, or emotional condition.