[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?
[] N (36)
b. Who is this? ____
Mark "Condition" box in person's column.
c. Would you say this is an emotional or nervous condition? Mark appropriate box in each person's column.
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?
[] N
36a. Because of a disability or health problem, does anyone in the family (that is you, your -- etc.) --
Mark appropriate box in person's column
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?
[] N (38)
b. Who is this? ____
Mark "Stays in bed" in person's column
c. Anyone else?
[] 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)?
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?
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?
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? ____
2 [] Friend
3 [] Nurse
[] Other -- Specify ____
40a. What disability or health problem causes -- to (need help in getting around/stay in bed)?
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)?
[] 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?
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.]
c.
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?
[] N
2 [] Needs help inside neighborhood
3 [] Needs help inside house
1 [] Mos. ____
2 [] Yrs. ____
2 [] Some
3 [] Once
[] Other -- Specify ____
b.
2 [] Some
3 [] Once
0 [] Never (40)
[] Other -- Specify ____
c.
2 [] Friend
3 [] Nurse
[] Other -- Specify ____
Condition ____
2 [] Enter Cond. in C2
3 [] Old age only
b.
[] N (40d)
c. Enter condition in C2. Reask 40b and c.
d.
Enter main condition ____
[p. 72]
41a. Because of disability or health problems, does anyone in the family (that is, you, your --, etc.) need help --
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
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
Yrs. ____
43a. How often does -- need help
dressing
eating
using the toilet]
most of the time, some of the time, or once in a while?
Dressing ____
Eating ____
Toilet ____
b. How often does he receive the needed help
dressing
eating
using the toilet]
most of the time, some of the time, or once in a while?
Dressing ____
Eating ____
Toilet ____
c. When -- receives help, who provides it -- a relative, friend, nurse, or some other person? Anyone else?
2 [] Friend
3 [] Nurse
[] Other -- Specify ____
44a. What disability or health problem causes -- to need help
dressing,
eating,
using the toilet?]
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?
[] 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
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.]
2 [] Dressing
3 [] Eating
4 [] Toilet
Yrs. ____
Yrs. ____
Yrs. ____
Yrs. ____
Dressing ____
Eating ____
Toilet ____
b.
Dressing ____
Eating ____
Toilet ____
c.
2 [] Friend
3 [] Nurse
[] Other -- Specify ____
2 [] Enter Cond. in C2 (Mark D box THEN 44b)
3 [] Old age only (Mark D box THEN 44b)
b.
[] N (44d)
c. Enter condition in C2. Reask 44b and c.
d.
Bathing ____
Dressing ____
Eating ____
Toilet ____
[p. 89]
SD PAGE
Complete for each person age 3 and over with D box marked
Person number _____
1. Is -- now attending or enrolled in school? 2. Is it a public or private school?
DS
2 [] 19+, respondent available (5)
3 [] 19+, return call required (NP)
2 [] N (4)
2 [] Private
3. Does -- receive special educational services or attend special classes at school because of a disability or health problem?
2 [] N
4. Does -- now take any medicine prescribed by a doctor because he is more active or more restless than other children?
2 [] N
5. Is -- covered by a health insurance plan that pays any part of a hospital bill?
2 [] N
6. During the past 12 months, has -- had a general physical examination?
2 [] N
7. During the past 12 months, did -- receive --
2 [] N (Col. 4)
2 [] N
2 [] N
2 [] N (B)
2 [] N
2 [] N (Col. 4)
2 [] N
2 [] N
2 [] N (B)
2 [] N
Ask if 16+:
Because of disability or health problem, during the past 12 months, did -- receive --
2 [] N (Col. 4)
2 [] N
2 [] N
2 [] N (B)
2 [] N
D. Job training or vocational training?
2 [] N (Col. 4)
2 [] N
2 [] N
2 [] N (B)
2 [] N
2 [] N (Col. 4)
2 [] N
2 [] N
2 [] N (B)
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 --?
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?
2 [] N (9e)
b. Did you get the information?
2 [] N (9e)
c. Did you get the information from --'s doctor, a government agency, or some other source?
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?
2 [] N
10a. Have any changes been made to this house (apartment) because of --'s health problem or disability?
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?
2 [] N (NP)