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dis
[p. 70]


35a. Is anyone in the family (that is you, your -- etc.) limited in the kind or amount of their activities because of an emotional or nervous condition?

[] Y
[] N (36)

b. Who is this? ____

Mark "Condition" box in person's column.

[] Condition Mark D box, THEN 35c

c. Would you say this is an emotional or nervous condition? Mark appropriate box in each person's column.

1 [] Emotional (Item C THEN 35d)
2 [] Nervous (Item C THEN 35d)
3 [] Reported earlier

d. Does anyone else in the family have an emotional or nervous condition that limits them in the kind or amount of their activities?

[] Y (Reask 35b and c)
[] N


36a. Because of a disability or health problem, does anyone in the family (that is you, your -- etc.) --


1. Need the help of another person in getting around outside of this neighborhood? ____


2. Need the help of another person in getting around in this neighborhood? ____


3. Need the help of another person in getting around inside of this house (apartment)? ____


b. Who is this? ____

Mark appropriate box in person's column

1 [] Needs help outside neighborhood
2 [] Needs help inside neighborhood
3 [] Needs help inside house

c. Anyone else? ____


37a. Because of disability or health problem, does anyone in the family stay in bed all or most of the day?

[] Y
[] N (38)

b. Who is this? ____
Mark "Stays in bed" in person's column

4 [] Stays in bed

c. Anyone else?

[] Y (Reask 37b and c)
[] N


For each person with "Needs help" or "Stays in bed," ask 38-40; otherwise go to next page.

38. How long has -- (needed help in getting around/had to stay in bed)?

000 [] Less than 1 month
1 [] Mos. ____
2 [] Yrs. ____


39a. How often does -- (need help in getting around/need help because he has to stay in bed) - most of the time, some of the time, or once in a while?

1 [] All/most
2 [] Some
3 [] Once
[] Other -- Specify ____


b. Does -- receive the needed help - most of the time, some of the time, or once in a while?

1 [] All/most
2 [] Some
3 [] Once
0 [] Never (40)
[] Other -- Specify ____


c. When -- receives help who provides it - a relative, friend, nurse, or some other person? Anyone else? ____

1 [] Relative
2 [] Friend
3 [] Nurse
[] Other -- Specify ____


40a. What disability or health problem causes -- to (need help in getting around/stay in bed)?

1 [] Reported earlier (Mark D box THEN 40b)
Condition ____
2 [] Enter Cond. in C2
3 [] Old age only

b. Does any other condition cause -- to (need help in getting around/stay in bed)?

[] Y
[] N (40d)

c. What other disability or health problem causes -- to (need help in getting around/stay in bed)? ____
Enter condition in C2. Reask 40b and c.

Mark box or ask:
d. Which of these conditions would you say is the main cause of this disability or health problem?

[] Only 1 condition
Enter main condition ____

[p. 71]


[MK Note: Page 71 appears to be a response sheet for questions asked on page 70. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

35b.

[] Condition Mark D box, THEN 35c

c.

1 [] Emotional (Item C THEN 35d)
2 [] Nervous (Item C THEN 35d)
3 [] Reported earlier

d. Does anyone else in the family have an emotional or nervous condition that limits them in the kind or amount of their activities?

[] Y (Reask 35b and c)
[] N

36b.

1 [] Needs help outside neighborhood
2 [] Needs help inside neighborhood
3 [] Needs help inside house

37b.

4 [] Stays in bed

38.

000 [] Less than 1 month
1 [] Mos. ____
2 [] Yrs. ____

39a.

1 [] All/most
2 [] Some
3 [] Once
[] Other -- Specify ____

b.

1 [] All/most
2 [] Some
3 [] Once
0 [] Never (40)
[] Other -- Specify ____

c.

1 [] Relative
2 [] Friend
3 [] Nurse
[] Other -- Specify ____

40a.

1 [] Reported earlier (Mark D box THEN 40b)
Condition ____
2 [] Enter Cond. in C2
3 [] Old age only

b.

[] Y
[] N (40d)

c. Enter condition in C2. Reask 40b and c.

d.

[] Only 1 condition
Enter main condition ____

[p. 72]


41a. Because of disability or health problems, does anyone in the family (that is, you, your --, etc.) need help --

1. Bathing? ____
2. Dressing? ____
3. Eating? ____
4. Using the toilet? ____

If "Yes," ask 41b and c

b. Who is this? ____

Mark appropriate box in person's column

1 [] Bathing
2 [] Dressing
3 [] Eating
4 [] Toilet

c. Anyone else? ____

For each person with an entry in 41, ask 42-44, otherwise go to next page.


42. How long has -- needed help


bathing?
Mos. ____
Yrs. ____


dressing?
Mos. ____
Yrs. ____


eating?
Mos. ____
Yrs. ____


using the toilet?
Mos. ____
Yrs. ____


43a. How often does -- need help

[bathing
dressing
eating
using the toilet]

most of the time, some of the time, or once in a while?

Bathing ____
Dressing ____
Eating ____
Toilet ____


b. How often does he receive the needed help

[bathing
dressing
eating
using the toilet]

most of the time, some of the time, or once in a while?

Bathing ____
Dressing ____
Eating ____
Toilet ____


c. When -- receives help, who provides it -- a relative, friend, nurse, or some other person? Anyone else?

1 [] Relative
2 [] Friend
3 [] Nurse
[] Other -- Specify ____


44a. What disability or health problem causes -- to need help

[bathing,
dressing,
eating,
using the toilet?]
1 [] Reported earlier ____ (Mark D box THEN 44b)
2 [] Enter Cond. in C2 (Mark D box THEN 44b)
3 [] Old age only (Mark D box THEN 44b)

b. Does any other condition cause this need?

[] Y
[] N (44d)

c. What other disability or health problem causes -- to need help (bathing, dressing, eating, using the toilet?) ____

Enter condition in C2. Reask 44b and c.

Mark box or ask:

d. Which of these conditions would you say is the main reason -- needs help

bathing? ____
dressing? ____
eating? ____
using the toilet? ____
1 [] Only 1 condition (NP)

[p. 73]


[MK Note: Page 73 appears to be a response sheet for questions asked on page 72. It contains five identical columns in which to enter responses; only one is represented here since all columns contain the same information.]

41b.

1 [] Bathing
2 [] Dressing
3 [] Eating
4 [] Toilet

42.

bathing
Mos. ____
Yrs. ____
dressing
Mos. ____
Yrs. ____
eating
Mos. ____
Yrs. ____
using the toilet
Mos. ____
Yrs. ____

43a.

Bathing ____
Dressing ____
Eating ____
Toilet ____

b.

Bathing ____
Dressing ____
Eating ____
Toilet ____

c.

1 [] Relative
2 [] Friend
3 [] Nurse
[] Other -- Specify ____

44a.

1 [] Reported earlier ____ (Mark D box THEN 44b)
2 [] Enter Cond. in C2 (Mark D box THEN 44b)
3 [] Old age only (Mark D box THEN 44b)

b.

[] Y
[] N (44d)

c. Enter condition in C2. Reask 44b and c.

d.

1 [] Only 1 condition (NP)
Bathing ____
Dressing ____
Eating ____
Toilet ____

[p. 89]

SD PAGE

Complete for each person age 3 and over with D box marked

Person number _____


DS

1 [] 3-18 (1)
2 [] 19+, respondent available (5)
3 [] 19+, return call required (NP)

1. Is -- now attending or enrolled in school?

1 [] Y
2 [] N (4)

2. Is it a public or private school?

1 [] Public
2 [] Private


3. Does -- receive special educational services or attend special classes at school because of a disability or health problem?

1 [] Y
2 [] N


4. Does -- now take any medicine prescribed by a doctor because he is more active or more restless than other children?

1 [] Y
2 [] N


5. Is -- covered by a health insurance plan that pays any part of a hospital bill?

1 [] Y
2 [] N


6. During the past 12 months, has -- had a general physical examination?

1 [] Y
2 [] N


7. During the past 12 months, did -- receive --


A. Physical therapy?


1. Received service past 12 months
1 [] Y (Col. 2)
2 [] N (Col. 4)
2. Is -- now receiving this service?
1 [] Y (B)
2 [] N


3. Was -- helped by this ____?
1 [] Y
2 [] N


4. Does -- need ____?
1 [] Y
2 [] N (B)


5. Has -- tried to get this service?
1 [] Y
2 [] N


B. Psychological counseling?


1. Received service past 12 months
1 [] Y (Col. 2)
2 [] N (Col. 4)
2. Is -- now receiving this service?
1 [] Y (B)
2 [] N


3. Was -- helped by this ____?
1 [] Y
2 [] N


4. Does -- need ____?
1 [] Y
2 [] N (B)


5. Has -- tried to get this service?
1 [] Y
2 [] N


Ask if 16+:
Because of disability or health problem, during the past 12 months, did -- receive --


C. Job counseling or guidance?


1. Received service past 12 months
1 [] Y (Col. 2)
2 [] N (Col. 4)
2. Is -- now receiving this service?
1 [] Y (B)
2 [] N


3. Was -- helped by this ____?
1 [] Y
2 [] N


4. Does -- need ____?
1 [] Y
2 [] N (B)


5. Has -- tried to get this service?
1 [] Y
2 [] N


D. Job training or vocational training?


1. Received service past 12 months
1 [] Y (Col. 2)
2 [] N (Col. 4)
2. Is -- now receiving this service?
1 [] Y (B)
2 [] N


3. Was -- helped by this ____?
1 [] Y
2 [] N


4. Does -- need ____?
1 [] Y
2 [] N (B)


5. Has -- tried to get this service?
1 [] Y
2 [] N


E. Job placement services?


1. Received service past 12 months
1 [] Y (Col. 2)
2 [] N (Col. 4)
2. Is -- now receiving this service?
1 [] Y (B)
2 [] N


3. Was -- helped by this ____?
1 [] Y
2 [] N


4. Does -- need ____?
1 [] Y
2 [] N (B)


5. Has -- tried to get this service?
1 [] Y
2 [] N


If "Yes," in column (1), question 7, ask: otherwise go to 9

8a. Was a government agency involved in arranging or providing (services) for --?

1 [] Y
2 [] N (9)

b. What is the name of the agency? Any other agency? ____


9a. During the past 12 months, have you tried to get information related to --'s health problem or disability?

1 [] Y
2 [] N (9e)

b. Did you get the information?

1 [] Y
2 [] N (9e)


c. Did you get the information from --'s doctor, a government agency, or some other source?

1 [] Doctor (9e)
2 [] Government
8 [] Other

d. For whom did you receive the information? ____


e. Do you need (additional) information related to --'s health problem or disability?

1 [] Y
2 [] N


10a. Have any changes been made to this house (apartment) because of --'s health problem or disability?

1 [] Y
2 [] N (10c)


b. What changes have been made? ________


c. Do any (additional) changes need to be made because of --'s health problem or disability?

1 [] Y
2 [] N (NP)


d. What (additional) changes need to be made? ________