Questionnaire Text

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Section A:

To be completed for each person in the household in a separate column. Remember to include babies. Please include yourself.


13. Does (the person) have a serious sight, hearing, physical or mental disability?

[] 1 = Yes
[] 2 = No
(If "Yes") Circle all applicable disabilities for the person.

[] 1 = Sight (serious eye defects)
[] 2 = Hearing/speech
[] 3 = Physical disability (e.g. paralysis)
[] 4 = Mental disability