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spaid
[p. 52]

SPECIAL AIDS SUPPLEMENT

37a. Does anyone in the family now use any of the following special aids --


1. An artificial arm?

[] Yes
[] No



2. An artificial leg?

[] Yes
[] No



3. A brace of any kind?

[] Yes
[] No



4. Crutches?

[] Yes
[] No



5. A cane or walking stick?

[] Yes
[] No



6. Special shoes?

[] Yes
[] No



7. A wheel chair?

[] Yes
[] No



8. A walker?

[] Yes
[] No



9. Any other kind of aid for getting around?

[] Yes
[] No

If "Yes" specify: _____

b. Who is this? Enter in table SA ________

c. Anyone else? ________

Table SA

a. Person No. ________

b. Type of aid. ________

c. If 1-6 in (b), ASK: Does he use one or two ____ (at a time)?

1[]
2[]
[] Other _______


d. If 3-9 in (b) ASK: For what condition does he need this ________? (Item C)

R
Q's 5-37
For persons 19 years old or over, show who responded for (or was present during the asking of) Q's 5-37. If persons responded for self, show whether entirely or partly. For persons under 19 show who responded for them. If eligible respondent is "at home" but did not respond for self, enter the reason in a footnote.

1[] Responded for self-entirely
2[] Responded for self-partly
Person ____ was resp

Table 5A -Continued

e. Is the -- used all the time, most of the time or only occasionally?

1[]A1l
2[]Most
3[]Occasionally


f. How long has he used --?

[]Less than 1 month
__Months __Years




g. How was the __ obtained? Was it purchased, rented, borrowed or a gift?
1[]Purchased
2[]Rented
3[]Borrowed
4[]Gift