[p.72]
VISION IMPAIRMENT AND USE OF CORRECTIVE LENSES
Name of person ________
Age ________
PSU ________
Segment ________
Serial No _______
Sample B-
Column number of person ________
[] Responded for self or
Column number of respondent ________
Interviewer: Complete either section A or B
a. Both "Yes" and "No" in answer to columns (c), (d) and (e) of table B OR
b. "Great deal" or "some" in answer to column (J) of table B
Complete section B (blue pages 7-10) if:
"No" in answer to all of columns (c), (d) and (e) of table B.
Respondent rules for vision supplement:
If the person is not an eligible respondent, or is unable to respond for himself because of disability or illness, complete the interview with any eligible respondent for him.
Exception to respondent rules for vision supplement
Footnotes and comments: ___________________________________________
Record of return calls to complete supplement:
1. Date ____
Time ____
Completed ____
2. Date ____
Time ____
Completed ____
Name of interviewer ________
Code ____
[p.73]
1a. Did your trouble with seeing come suddenly or did it come gradually?
Definition: "Suddenly" would be either instantaneously or in a very short time, usually associated with an injury.
[] Gradually
[] At birth (go to question 2)
b. If "suddenly" or "gradually" ask:
How old were you when your trouble with seeing first began to interfere with your daily activities, that is, your work, recreation, education, or travel?
Definition: "Daily activities" means the person's usual activities, depending on the age of the person at the time.
[] Never interfered (go to question 2)
If age in 1b is 17 or over, ask:
c. Were you working at a job or business before you began to have trouble with seeing?
[] No
2. When were your eyes last examined by a physician eye specialist?
If over 12 months, round to nearest year; round 1/2 years upward, e.g "1 1/2" years should be recorded as "2" years.
Years ____
[] Never
If person is wearing glasses mark this box [] and ask 3b.
If person is not wearing glasses ,ask:
3a. At the present time do you use any glasses -- that is, ordinary glasses or special glasses or lenses?
[] No (go to question 4)
If "Yes" or if person is wearing glasses, ask:
b. What types of glasses do you use or wear?
Mark each type reported. if unable to classify by type, mark last box and describe.
[] Ordinary glasses for distance alone
[] Ordinary glasses for reading alone
[] Spectacles with strong reading additions (such as bifocals)
[] Hand magnifying lenses
[] Protection glasses (dark or frosted)
[] Any other type (specify) ________
[p.74]
4. Do you see things as if you were looking through a tube or a gun barrel?
Persons with this type of visual defect ("tunnel vision") will understand the question.
[] No
5a. Because of your trouble seeing, do you ever use any aids either in getting around the house or in traveling outside the house; such as a cane, guide dog, or a person with sight?
[] No (go to question 6)
If "Yes" ask:
b. Which do you use? (mark each one mentioned)
[] A guide dog (if marked ask question 5b(2))
[] A person with sight
[] Other (specify) ________
(1) have you ever had any special instructions in using or getting around with a cane? Definition: "special instructions" means training by a trained instructor.
[] No
(2) have you ever had any special instructions in traveling with guide dogs?
Definition: "special instructions" means training by a trained instructor.
[] No
6a. Have you ever heard of talking book records?
If the supplement person is a child, 6a refers to whether the respondent ever heard of talking book records; 6b to whether the child is receiving them.
[] No (go to question 7)
If "Yes" ask:
b. At the present time are you getting talking book records of any kind through the bill?
If the supplement person is a child, 6a refers to whether the respondent ever heard of talking book records; 6b to whether the child is receiving them.
[] No
7a. Have you ever had any instruction in reading braille?
[] No (go to question 8)
If "yes" ask:
b. Can you read braille?
[] No (go to question 8)
If "Yes" ask:
c. At the present time are you reading books in braille?
[] No
[p.75]
8a. During an average week, about how many hours do you spend watching or listening to television?
If answer is not reported in hours, convert to hours. "An average week" is whatever the person considers to be a typical week.
[] Don't watch or listen (go to question 9)
If some hours reported, ask:
b. When you are watching television, how close to the screen do you have to sit in order to see the pictures?
If the answer is "quite close" or something similar, ask about how many feet that would be.
[] Only listen
9. During an average week, about how many hours do you spend listening to the radio?
If answer is not reported in hours, convert to hours. "An average week" is whatever the person considers to be a typical week.
[] Don't listen
10a. During an average week, about how many hours do you spend reading or listening to books?
Include printed books, books in braille and recorded books. Do not include time spent reading comic books, magazines, or newspaper . If answer is not reported in hours, convert to hours.
[] None (ask 10b)
If "None" ask:
b. Is this because of your trouble with seeing?
[] No
11. Do you attend any school or take any courses?
Include correspondence courses and night school. Report students on summer vacation as "Yes"
[] No
[] Person is 17 years old or over (continue with question 12)
12. Because of your trouble with seeing have you ever had any special vocational or job training? Training received through any formal program designed to aid or rehabilitate persons with visual defects.
[] No
13a. Do you have a job or business?
[] No (go to question 14)
Accept the person's answer's to questions 13 b and c without probing.
If "Yes" ask:
b. What kind of work are you doing?
Examples: farmer, seamstress, sales clerk
c. What kind of business or industry is this?
Examples: farm, dress manufacturing, candy and tobacco stand.
d. Class of worker: (mark one box) If not indicated by entries in (b) and (c) ask additional questions.
[] Own (owns or shares ownership in own business)
[] Federal government
[] Government -other than federal
[] Non-paid (works only for room and board, etc)
e. On the whole, would you say you are very satisfied with your present job, fairly satisfied or not satisfied at all?
Mark the box for the statement most nearly corresponding to the person's answer.
[] Fairly satisfied
[] Not satisfied at all
[p.76]
14a. On the average, about how many hours a week do you spend visiting with friends, either in your home or theirs?
Includes time spent in physical visits only, not telephone conversations. If answer is not in hours, convert to hours.
[] Don't visit
b. Has your trouble with seeing made any difference at all in how often you get together with friends?
[] No
15a. Do you belong to any clubs or organizations?
Include any social, civic, fraternal or religious organizations.
[] No (ask 15c)
If "Yes" to question 15a, ask:
b. Has you trouble with seeing made any difference at all in your activity in clubs or organizations?
[] No
If "No" to questions 15a, ask:
c. Is this because of your trouble with seeing?
[] No
16. Do you go to stores to do any shopping for yourself or your household?
Either alone or with someone else.
[] No
If person lives with related member(s), skip to question 18.
If person does not live with any related member(s) ask:
17a. Do you have any relatives who live within ten miles of your home?
[] No
b. About how often do you visit with your relatives, either in your home or theirs?
[] At least once a week
[] At least once a month
[] Other (specify) ____
c. Do you own your own home, rent or board?
17c refers to sample unit, i.e person's present living quarters.
[] Rents
[] Boards
[] Other (Specify) ____
18. How long have you lived at your present address?
[] One year but less than two
[] Two years but less than five
[] Five years but less than ten
[] Ten years or over
[p.77]
19. How long have you lived in (city or town) ____ (this are)?
Insert name of city or town-if in rural areas, substitute "this area".
[] One year but less than two
[] Two years but less than five
[] Five years but less than ten
[] Ten years or over
20. Because of your trouble with seeing, are you presently receiving any financial help or other services from public or private agencies?
Include all types of services, such as aid in shopping, receipt of free recorded books, etc.
[] No
[p.78]
1. Can you see well enough to tell if a light is on or off?
[] No
2a. Did your trouble with seeing come suddenly or did it come gradually?
Definition: "suddenly" would be either instantaneously or in a very short time, usually associated with an injury.
[] Gradually
[] At birth (skip to question 5)
If "suddenly" or "gradually" ask:
b. how old were you when your trouble with seeing first began to interfere with your daily activities, that is, your work, recreation ,education, or travel?
Definition: "Daily activities" means the person's usual activities, depending on the age of the person at the time. If age in question 2b is: under 6, go to question 3; 17 or over, skip to question 4; 6-16 skip to question 5.
If age in question 2b is under 6, ask:
3a. Could you see anything besides light when you were an infant?
[] No (skip to question 5)
If "Yes" ask:
b. Do you remember seeing colours?
[] No
c. Do you remember seeing moving objects or people's features?
[] No
If age in question 2b is 17 or over, ask:
4. Were you working at a job or business before you began to have trouble with seeing?
[] No
5. When were your eyes last examined by a physician eye specialist?
If over 12 months, round to nearest year; round 1/2 years upward. e.g "1 1/2" years should be recorded as "2" years.
Years ____
[] Never
[p.79]
6a. Because of your trouble seeing, do you ever use any aid either in getting around the house or in traveling outside the house; such as a cane, guide dog, or a person with sight?
[] No (go to question 7)
If "Yes" ask:
b. Which do you use? (Mark each one mentioned)
[] A guide dog (if marked, ask question 6b(2))
[] A person with sight
[] Other (specify) ____
(1) Have you ever had any special instructions in using or getting around with a cane? Definition: "Special instructions" means training by a trained instructor.
[] No
(2) Have you ever had any special instructions in traveling with guide dogs?
Definition: "Special instructions" means training by a trained instructor.
[] No
7a. Have you ever heard of talking book records?
If the supplement person is a child, 7a refers to whether the respondent ever heard of talking book records; 7b to whether the child is receiving them.
[] No (go to question 8)
If "Yes" ask:
b. At the present time are you getting talking book records of any kind through the mail?
If the supplement person is a child, 7a refers to whether the respondent ever heard of talking book records; 7b to whether the child is receiving them.
[] No
8a. Have you ever had any instructions in reading braille?
[] No (go to questions 9)
If "Yes" ask:
b. Can you read braille?
[] No (go to question 9)
If "Yes" ask:
c. At the present time are you reading books in braille?
[] No
9. During an average week, about how many hours do you spend reading or listening to books?
"An average week" is whatever the person considers to by a typical week. Include books in braille, recorded books and printed books read by or to the person, but not including magazines or newspapers. If answer not reported in hours, convert to hours.
[] None
10. During an average week, about how many hours do you spend listening to the radio or television?
If answer not reported in hours, convert to hours.
[] Don't listen
[p.80]
11. Do you attend any school or take any courses?
Include correspondence course and night school. Report students on summer vacation as "Yes".
[] No
[] Person is 17 years old or over (continue with question 12)
12. Because of your trouble with seeing have you ever had any special vocational or job training?
Training received through any formal program designed to aid or rehabilitate persons with visual defects.
[] No
13a. Do you have a job or business?
[] No (go to question 14)
Accept the person's answers to questions 13b and c without probing.
If "Yes" ask:
b. What kind of work are you doing?
Examples: farmer, seamstress, sales clerk
c. What kind of business or industry is this?
Examples: Farm, dress manufacturing, candy, and tobacco stand.
d. Class of worker: (mark one box) If not indicated by entries in (b) and (c) ask additional questions:
[] Own (owns or shares ownership in own business)
[] Federal government
[] Government -other than federal
[] Non-paid (works only for room and board, etc)
e. On the whole, would you say you are very satisfied with your present job, fairly satisfied or not satisfied at all?
Mark the box for the statement most nearly corresponding to the person's answer.
[] Fairly satisfied
[] Not satisfied at all.
14a. On the average, about how many hours a week do you stand visiting with friends, either in your home or theirs?
Include time spent in physical visits only, not telephone conversations.
[] Don't visit
b. Has your trouble with seeing made any difference at all in how often you get together with friends?
[] No
15a. Do you belong to any clubs or organizations?
Include any social, civic, fraternal, or religious organizations.
[] No (ask 15c)
If "Yes" to questions 15a, ask:
b. Has your trouble with seeing made any difference at all in your activity in clubs or organizations?
[] No
If "No" to question 15a, ask:
c. Is this because of your trouble with seeing?
[] No
[p.81]
16. Do you go to stores to do any shopping for yourself or your household? Either alone or with someone else.
[] No
If person lives with related members(s), skip to question 18.
If person does not live with any related member(s) ask:
17a. Do you have any relatives who live within ten miles of your home?
[] No
b. About how often do you visit with your relatives, either in your home or theirs?
[] At least once a week
[] At least once a month
[] Other (Specify) ____
c. Do you own your own home, rent or board?
17c refers to sample unit, i.e person's present living quarters.
[] Rents
[] Boards
[] Other (specify) ____
18. How long have you lived at your present address?
[] One year but less than two
[] Two years but less than five
[] Five years but less than ten
[] Ten years or over
19. How long have you lived in (city or town) ________ (this area)?
Insert name of city or town--if in rural area, substitute "this area"
[] One year but less than two
[] Two years but less than five
[] Five years but less than ten
[] Ten years or over
20. Because of your trouble with seeing, are you presently receiving any financial help or other services from public or private agencies?
Include all types of services such as, aid in shopping, receipt of free recorded books etc.
[] No