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[p.161]

ITEM X1
Enter conditions reported in Disability supplement in X1
If insufficient space to enter multiple sources, continue in a footnote

X1
PERSON 1
A __
C __
D __
E __
F __
G __


A __
C __
D __
E __
F __
G __


A __
C __
D __
E __
F __
G __


A __
C __
D __
E __
F __
G __


A __
C __
D __
E __
F __
G __

ITEM X2
Indicate ADL Limitations in X2.

X2
Bathing
Help/Remind __
Spec. equip. __
Difficulty/Doesn't do __


Dressing
Help/Remind __
Spec. equip. __
Difficulty/Doesn't do __


Eating
Help/Remind __
Spec. equip. __
Difficulty/Doesn't do __


Bed/chair
Help/Remind __
Spec. equip. __
Difficulty/Doesn't do __


Toilet
Help/Remind __
Spec. equip. __
Difficulty/Doesn't do __


Getting around
Help/Remind __
Spec. equip. __
Difficulty/Doesn't do __

ITEM X3
Indicate IADL Limitations in X3

X3
Prep. meals
Help/Supv. __
Difficulty/Doesn't do __


Shopping
Help/Supv. __
Difficulty/Doesn't do __


Managing money
Help/Supv. __
Difficulty/Doesn't do __


Telephone
Help/Supv. __
Difficulty/Doesn't do __


Heavy work
Help/Supv. __
Difficulty/Doesn't do __


Light work
Help/Supv. __
Difficulty/Doesn't do __

[p.170]

Section II- Disability

Part A- Sensory, Communication and Mobility

These next questions refer to everyone in the family, that is (read names of all nondeleted family members).
1a. Does anyone in the family have SERIOUS difficulty seeing, even when wearing glasses or contact lenses?

1[] Yes (1b)
2[] No (2 on page 14)
9[] DK (2 on page 14)

b. Who is this? (Anyone else?)
Mark (x) "Difficulty seeing" box in person's column.

1[] Difficulty seeing.

Ask 1c-f for each person with box marked in 1b.
c. What is the MAIN problem or condition which causes -- serious difficulty seeing?
(Enter condition on X1 and mark box)

1[] In C2
2[] Not in C2

d. Is -- legally blind?

1[] Yes (1f)
2[] No (1e)
9[] DK (1e)

e. [Do you expect/is -- expected] to have SERIOUS difficulty seeing for at least the next 12 months?

1[] Yes (1f)
2[] No (1c for NP in 1b, or 2 on page 14)
9[] DK (1c for NP in 1b, or 2 on page 14)

f. Does -- NOW use telescopic lenses, braille, reader, a guide dog, white cane, or any other equipment for people with visual impairment?
If "No", mark (x) box 0.
If "Yes", ask "Which?" Mark (x) all that apply.

0[] Does not use any (1c for NP in 1b, or 2 on page 14)
1[] Telescopic lenses (1c for NP in 1b, or 2 on page 14)
2[] Braille (1c for NP in 1b, or 2 on page 14)
3[] Readers (1c for NP in 1b, or 2 on page 14)
4[] Guide dog (1c for NP in 1b, or 2 on page 14)
5[] White cane (1c for NP in 1b, or 2 on page 14)
6[] Computer equipment (1c for NP in 1b, or 2 on page 14)
7[] Other (1c for NP in 1b, or 2 on page 14)

[p.171]

Section II- Disability - Continued

Part A- Sensory, Communication and Mobility - Continued

2a. Does anyone in the family now use a hearing aid?

1[] Yes (2b)
2[] No (2d)
9[] DK (2d)

b. Who is this?
Mark (x) "Hearing aid" box in person's column.

1[] Hearing aid

c. Anyone else?

[] Yes (Reask 2b and c)
[] No (2d)

d. Does anyone in the family have any trouble hearing what is said in normal conversation (even when wearing a hearing aid)?

1[] Yes (2e)
2[] No (4 on page 16)
9[] DK (4 on page 16)

e. Who is this? (Anyone else?)
Mark (x) "Trouble hearing" box in person's column

1[] Trouble hearing

Ask 2f-h and 3 for each person with box marked in 2e.
f. What is the MAIN problem or condition which causes -- to have trouble hearing?
(Enter condition in X1 and mark box)

1[] In C2
2[] Not in C2

g. Is -- able to hear loud noises?

1[] Yes
2[] No
9[] DK

h. [Do you expect/is -- expecting] to have this trouble hearing for at least the next 12 months?

1[] Yes (3)
2[] No (2f for NP in 2e, or 4 on page 16)
9[] DK (2f for NP in 2e, or 4 on page 16)

3. (Besides a hearing aid,) Does -- now use an amplifier for the telephone, a TDD, TTY or teletype, closed caption TV, assistive listening or signaling devices, an interpreter, or any other equipment for people with hearing impairment?
Read if necessary: Assistive listening devices include a loop, FM systems, and direct input devices that connect to a TV. Assistive signaling devices indicate that a door, telephone or fire bells are ringing.
If "No", mark (x) box 0.
If "Yes", ask "Which"? Mark (x) all that apply.

0[] Does not use any
1[] Amplifier for telephone
2[] TDD, TTY, or teletype
3[] Closed caption TV
4[] Assistive listening devices
5[] Assistive signaling devices
6[] Interpreter
7[] Other
(2f for NP in 2e, or 4 on page 16)

[p.172]

Section II- Disability - Continued

Part A- Sensory, Communication and Mobility - Continued

The next few questions refer only to family members who are 5 years old or older, that is (read names of family members 5 years old or older)

4a. Do (read names of persons 5+) have SERIOUS difficulty communicating so that PEOPLE OUTSIDE the family understand?
Read if necessary: Do not include language problems

1[] Yes (4b)
2[] No (4f)
9[] DK (4f)

b. Who is this?
Mark (x) "Difficulty communicating" box in person's column

1[] Difficulty communicating

c. Anyone else?

[] Yes (Reask 4b and c)
[] No

Ask 4d-e for each person with "Difficulty communicating" marked in 4b.
d. Does -- have any difficulty communicating so that FAMILY MEMBERS understand?

1[] Yes (4e)
2[] No (NP in 4b, or 4f)
9[] DK (NP in 4b, or 4f)

e. Does -- have difficulty communicating -- basic needs, such as hunger and thirst, to family members?

1[] Yes (4d for NP in 4b, or 4f)
2[] No (4d for NP in 4b, or 4f)
9[] DK (4d for NP in 4b, or 4f)

f. Do (read names of person 5+) have SERIOUS difficulty understanding other people when they talk or ask questions?
Read if necessary: Do not include language problems.

1[] Yes (4g)
2[] No (A1)
9[] DK (A1)

g. Who is this?
Mark (x) "Difficulty understanding" box in person's column.

1[] Difficulty understanding

h. Anyone else?

[] Yes (Reask 4g and h)
[] No (A1)

ITEM A1
Refer to age or questions 4b and 4g for each person.

2[] Under 5 (NP, or 4n on page 18)
1[] "Difficulty communicating" in 4b and/or "Difficulty understanding" in 4g (4i on page 18)
2[] All others (NP, or 4n on page 18)
[p.173]

Section II- Disability - Continued

Part A- Sensory, Communication and Mobility - Continued

4i. How old was -- when -- first had difficulty [communicating with/(and) understanding] other people?

______ Years old (4l)
96[] At birth (4l)
99[] DK (4j)

j. Was it before -- was 18 years old?

1[] Yes (4l)
2[] No (4k)
9[] DK (4l)

k. Was it before -- was 22 years old?

1[] Yes (4l)
2[] No (4l)
9[] DK (4l)

If obvious, mark without asking; otherwise ask:
l. Is -- expected to have this difficulty with [communication/(and) understanding other people] for at least 12 months longer?

1[] Yes (4m)
2[] No (4m)
9[] DK (4m)

m. What condition causes -- difficulty [communicating with/(and) understanding] other people?
Accept up to 2 conditions; then go to A1 on page 16 for next person, or 4n.
(Enter condition in X1 and mark box)

1[] In C2
2[] Not in C2

4n. Do (read names of persons 5+) have SERIOUS difficulty learning how to do things that most people their age are able to learn?

1[] Yes (4o)
2[] No (5 on page 20)
9[] DK (5 on page 20)

o. Who is this?
Mark (x) "Difficulty learning" box in person's column.

1[] Difficulty learning

p. Anyone else?

[] Yes (Reask 4o and p)
[] No (5 on page 20)

[p.174]

Section II- Disability - Continued

Part A- Sensory, Communication and Mobility - Continued

Hand card DA1. Read parenthetical if telephone interview.
CARD DA1

1. A cane
2. Crutches
3. A walker
4. Medically prescribed shoes
5. A manual wheelchair
6. An electric wheelchair
7. A scooter
5a. Does ANYONE in the family now use any of these aids to get around? (A cane, crutches, walker, medically prescribed shoes, a wheelchair, or a scooter?)

1[] Yes (5b)
2[] No (6 on page 22)
9[] DK (6 on page 22)

b. Who is this?
Mark (X) "Mobility aid" box in person's column

1[] Mobility

c. Anyone else?

[] Yes (Reask 5b and c)
[] No

Ask 5d and e for each person with "Mobility aid" in 5b.
d. Which aids does -- use?
Any others?
Mark (x) all that apply.
If "Wheelchair", ask: Does -- use an electric or manual wheelchair?

1[] Cane
2[] Crutches
3[] Walker
4[] Medically prescribed shoes
5[] Manual wheelchair
6[] Electric wheelchair
7[] Scooter

Ask only about each aid marked in 5d. Then 5d for next person with 5b; otherwise 6 on page 22.
e. Has -- used or is -- expected to use (aid in 5d) for 12 months or longer?

(1) A cane
1[] Yes
2[] No
9[] DK


(2) Crutches
1[] Yes
2[] No
9[] DK


(3) Walker
1[] Yes
2[] No
9[] DK


(4) Medically prescribed shoes
1[] Yes
2[] No
9[] DK


(5) A manual wheelchair
1[] Yes
2[] No
9[] DK


(6) An electric wheelchair
1[] Yes
2[] No
9[] DK


(7) A scooter
1[] Yes
2[] No
9[] DK

[p.175]

Section II- Disability - Continued

Part A- Sensory, Communication and Mobility - Continued

6a. Does anyone in the family now use a brace of any kind?

1[] Yes (6b)
2[] No (7)
9[] DK (7)

b. Who is this?
Ask if necessary: On what part of the body is the brace worn? Is it worn on the back, neck, arm, hand, leg, foot or knee?
Mark (x) appropriate box(es) in person's column.

1[] Back
2[] Neck
3[] Arm
4[] Hand
5[] Leg
6[] Foot
7[] Knee
8[] Other

c. Does anyone else now use a brace?

[] Yes (Reask 6b and c)
[] No

Ask 6d for each person with an entry in 6b.
d. Has -- used or is -- expected to use [this brace/any of these braces] for 12 months or longer?

1[] Yes (6d for NP with entry in 6b, or 7)
2[] No (6d for NP with entry in 6b, or 7)
9[] DK (6d for NP with entry in 6b, or 7)

7a. (Does anyone in the family now use) an artificial leg, foot, arm or hand?

1[] Yes (7b)
2[] No (A2 on page 24)
9[] DK (A2 on page 24)

b. Who is this?
Ask if necessary: Which does -- use - an artificial leg, foot, arm or hand?
Mark (x) appropriate box(es) in person's column.

1[] Artificial leg or foot
2[] Artificial arm or hand

c. Does anyone else now use an artificial limb?

[] Yes (Reask 7b and c)
[] No (A2 on page 24)

[p.176]

Section II- Disability - Continued

Part A- Sensory, Communication and Mobility - Continued

ITEM A2
Refer to ages of all family members.

1[] All under 18 (Part B on page 28)
2[] Any 18+ (8)
8a. Do (names of persons 18+) now have any problem with dizziness that has lasted for at least three months?

1[] Yes (8b)
2[] No (8d)
9[] DK (8d)

b. Who is this?
Mark (x) "Dizziness" box in person's column

1[] Dizziness

c. Anyone else?

[] Yes (reask 8b and c)
[] No (8d)

d. Do (names of persons 18+) have any problem with balance that has lasted for at least three months?

1[] Yes (8e)
2[] No (9)
9[] DK (9)

e. Who is this?
Mark (x) "Problem with balance" box in person's column.

1[] Problem with balance

f. Anyone else?

[] Yes (Reask 8e and f)
[] No

g. Does -- need support or touch walls when walking due to balance problem?

1[] Yes (NP in 8e, or 9)
2[] No (NP in 8e, or 9)
9[] DK (NP in 8e, or 9)

9a. Do (names of persons 18+) now have ringing, roaring, or buzzing in the ears that has lasted for at least three months?

1[] Yes (9b)
2[] No (10 on page 26)
9[] DK (10 on page 26)

b. Who is this?
Mark (x) "Noise in ears" box in person's column

1[] Noise in ears

c. Anyone else?

[] Yes (Reask 9b and c)
[] No (10 on page 26)

[p.177]

Section II- Disability - Continued

Part A- Sensory, Communication and Mobility - Continued

10a. Do (names of persons 18+) now have any problems with their smell, such as not being able to smell things or things not smelling the way they are supposed to?

1[] Yes (10b)
2[] No (11)
9[] DK (11)

b. Who is this?
Mark (x) "Problem with smell" box in person's column

1[] Problem with smell

c. Anyone else?

[] Yes (Reask 10b and c)
[] No

Ask 10d-f for each person with box marked in 10b.
d. Which problem does -- have, not being able to smell things, or things not smelling the way they are supposed to?

1[] Loss of smell (10e)
2[] Things don't smell right (10f)
9[] DK (10f)

e. Is -- loss of smell complete or partial?

1[] Complete
2[] Partial
9[] DK

f. Has -- had problems with -- sense of smell for at least three months?

1[] Yes (10d for NP in 10b, or 11)
2[] No (10d for NP in 10b, or 11)
9[] DK (10d for NP in 10b, or 11)

11a. Do (names of persons 18+) have a problem with their sense of taste, such as not being able to taste salt or sugar or with tastes in the mouth that shouldn't be there, like bitter, salty, sour or sweet tastes?

1[] Yes (11b)
2[] No (Part B on page 28)
9[] DK (Part B on page 28)

b. Who is this?
Mark (x) "Problem with taste" box in person's column

1[] Problem with taste

c. Anyone else?

[] Yes (Reask 11b and c)
[] No

Ask 11d-e for each person with box marked in 11b
d. Which problem does -- have, not being able to taste salt or sugar, tastes in the mouth that shouldn't be there, or some other problem?
Mark (x) all that apply.

1[] Not tasting salt
2[] Not tasting sugar
3[] Tastes that shouldn't be there
4[] Other problem

e. Has -- had [any of these/this] problem(s) with taste for at least three months?

1[] Yes (11d for NP in 11b, or part B on page 28)
2[] No (11d for NP in 11b, or part B on page 28)
9[] DK (11d for NP in 11b, or part B on page 28)

[p.177]

Section II- Disability - Continued

Part B - Conditions

(I am going to read a list of medical conditions. Tell me if anyone in the family has any of these conditions, even if you have mentioned them before.)
1a. Does anyone in the family, that is (read names) have-

(1) A learning disability?
1[] Yes (1b)
2[] No
9[] DK


(2) Cerebral palsy (ce Re' bral pawl'zee)?
1[] Yes (1b)
2[] No
9[] DK


(3) Cystic fibrosis (sis'tic fi bro'sis)?
1[] Yes (1b)
2[] No
9[] DK


(4) Down syndrome?
1[] Yes (1b)
2[] No
9[] DK


(5) Mental syndrome?
1[] Yes (1b)
2[] No
9[] DK


(6) Muscular dystrophy (dis' tro fee)?
1[] Yes (1b)
2[] No
9[] DK


(7) Spina bifida (spin' ah bif i dah)?
1[] Yes (1b)
2[] No
9[] DK


(8) Autism (aw'tism)?
1[] Yes (1b)
2[] No
9[] DK


(9) Hydrocephalus (hi dro sef'ah lus)?
1[] Yes (1b)
2[] No (2)
9[] DK (2)

b. Who is this?
Mark (x) appropriate box in person's column

1[] Learning disability
2[] Cerebral palsy
3[] Cystic fibrosis
4[] Down syndrome
5[] Mental Retardation
6[] Muscular dystrophy
7[] Spina bifida
8[] Autism
9[] Hydrocephalus

c. Anyone else?

If "Yes " (Reask 1b and c)
If "No" (1a for NC, or 2)

2a. Was anyone in the family EVER told by a doctor that they had polio, whether or not it resulted in physical disability?

1[] Yes (2b)
2[] No (Part C on page 30)
9[] DK (Part C on page 30)

b. Who is this? (Anyone else?)
Mark (x) "Polio" box in person's column

1[] Polio

Ask 2c for each person with "Polio" box marked in 2b
c. Did -- EVER have paralysis of any kind caused by polio?

1[] Yes
2[] No
9[] DK

[p.179]

Section II- Disability - Continued

PART C-ADL/IADL

Hand card DC1.
CARD DC1

1. Bathing or showering
2. Dressing
3. Eating
4. Getting in and out of bed or chairs
5. Using the toilet, including getting to the toilet
6. Getting around inside your home

These next questions refer only to (read names of persons 5+).
1a. Because of a physical, mental, or emotional problem, do (read names of persons 5+) get HELP FROM ANOTHER PERSON in

(1) Bathing or showering?
1[] Yes (1b)
2[] No
9[] DK


(2) Dressing?
1[] Yes (1b)
2[] No
9[] DK


(3) Eating?
1[] Yes (1b)
2[] No
9[] DK


(4) Getting in and out of bed or chairs?
1[] Yes (1b)
2[] No
9[] DK


(5) Using the toilet, including getting to the toilet?
1[] Yes (1b)
2[] No
9[] DK


(6) Getting around inside the home?
1[] Yes (1b)
2[] No (2)
9[] DK (2)

b. Who is this? (Anyone else?)
Mark (x) appropriate box in person's column and in "Help/Remind" column in X2, then continue with 1a for next activity, or 2.

1[] Bathing or showering
2[] Dressing
3[] Eating
4[] Getting in/out of bed or chairs
5[] Using the toilet, including getting to the toilet
6[] Getting around inside the home
(Mark (x) appropriate box(es) in X2)

Refer to Card DC1. Read all categories in 2c if telephone interview.
CARD DC1

1. Bathing or showering
2. Dressing
3. Eating
4. Getting in and out of bed or chairs
5. Using the toilet, including getting to the toilet
6. Getting around inside your home
2a. Because of a physical, mental, or emotional problem, do (read names of persons 5+) need to be reminded to do [any of these/any of the following] activities, or need to have someone close by when they do them?

1[] Yes (2b)
2[] No (3 on page 32)
9[] DK (3 on page 32)

b. Who is this? (Anyone else?)
Mark (x) "remind/close" box in person's column

1[] Remind/close

Ask 2c for each person with "Remind/close" in 2b, then 3 on page 32
Refer to Card DC1. Read each category if telephone interview.
c. For which activities does -- need to be reminded or to have someone close by? (Any others?)
Mark (x) all that apply in person's column and in "Help/Remind" column in X2.

1[] Bathing or showering
2[] Dressing
3[] Eating
4[] Getting in/out or chairs
5[] Using the toilet, including getting to the toilet
6[] Getting around inside the home
(Mark (x) appropriate box(es) in X2)

[p.180]

Section II- Disability - Continued

PART C-ADL/IADL - Continued

Refer to Card DC1. Read all categories in 3c if telephone interview.
CARD DC1

1. Bathing or showering
2. Dressing
3. Eating
4. Getting in and out of bed or chairs
5. Using the toilet, including getting to the toilet
6. Getting around inside your home
3a. Do (read names of persons 5+) use any SPECIAL EQUIPMENT to do any of [these/the following] activities?

1[] Yes (3b)
2[] No (Item C1)
9[] DK (Item C1)

b. Who is this? (Anyone else?)
Mark (x) "Equipment" box in person's column

1[] Equipment

Ask 3c for each person with "Equipment" in 3b,then go to C1.
Refer to Card DC1. Read each category if telephone interview.
CARD DC1

1. Bathing or showering
2. Dressing
3. Eating
4. Getting in and out of bed or chairs
5. Using the toilet, including getting to the toilet
6. Getting around inside your home

c. For which activities does -- use special equipment? (Any others?)
Mark (x) all that apply in person's column and in "Spec. Equip" column in X2.

1[] Bathing or showering
2[] Dressing
3[] Eating
4[] Getting in/out bed or chairs
5[] Using the toilet, including getting to the toilet
6[] Getting around inside the home
(Mark (x) appropriate box(es) in X2)

ITEM C1
Read to age and Item X2. Mark (x) first appropriate box.

0[] Under 5 (NP, or C2 on page 38)
1[] One or more activities marked in X2 (4)
2[] No activities in X2 (5 on page 36)

Mark (x) box 0 or ask:
4a. Does -- have any difficulty bathing?
If doesn't do, Ask: Is this because of a physical, mental, or emotional problem?
If "Yes", mark (x) box 3 "Doesn't do/health"
If "No", mark (x) box 2 "No"

0[] Bathing in X2 (4c)
1[] Yes (Mark X2 then 4b)
2[] No (4c)
3[] Doesn't do/health (Mark X2, then 4c)
9[] DK (4c)

b. How much difficulty does -- have bathing -- some, a lot, or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Mark (x) box 0 or ask:
c. Does -- have any difficulty dressing?
If doesn't do, Ask: Is this because of a physical, mental, or emotional problem?
If "Yes", mark (x) box 3 "Doesn't do/health"
If "No" , mark (x) box 2 "No"

0[] Dressing in X2 (4e on page 34)
1[] Yes (Mark X2 then 4d on page 34)
2[] No (4e on page 34)
3[] Doesn't do/health (Mark X2, then 4e on page 34)
9[] DK (4e on page 34)

[p.181]

Section II- Disability - Continued

PART C-ADL/IADL - Continued

4d. How much difficulty does -- have dressing -- some, a lot, or is -- unable to do?

1[] Some
2[] A lot
3[] Unable
9[] DK

Mark (x) box 0 or ask:
e. Does -- have any difficulty eating?
If doesn't do, Ask: Is this because of a physical, mental, or emotional problem?
If "Yes", mark (x) box 3 "Doesn't do/health"
If "No", mark (x) box 2 "No"

0[] Eating in X2 (4g)
1[] Yes (Mark X2 then 4f)
2[] No (4g)
3[] Doesn't do/health (Mark X2, then 4g)
9[] DK (4g)

f. How much difficulty does -- have eating -- some, a lot, or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Mark (X) box 0 or ask:
g. Does -- have any difficulty getting in and out of bed or chairs?
If doesn't do, Ask : Is this because of a physical, mental, or emotional problem?
If "Yes", mark (x) box 3 "Doesn't do/health"
If "No", mark (x) box 2 "No"

0[] Bed/ chair in X2 (4i)
1[] Yes (Mark X2 then 4h)
2[] No (4i)
3[] Doesn't do/health (Mark X2, then 4i)
9[] DK (4i)

h. How much difficulty does -- have getting in and out of beds or chairs - some, a lot, or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Mark (x) box 0 or ask:
i. Does -- have any difficulty using the toilet, including getting to the toilet?
If doesn't do, Ask: Is this because of a physical, mental, or emotional problem?
If "Yes", mark (X) box 3 "Doesn't do/health"
If "No", mark (X) box 2 "No"

0[] Toilet in X2 (4k on page 36)
1[] Yes (Mark X2 then 4j)
2[] No (4k on page 36)
3[] Doesn't do/health (Mark X2, then 4k on page 36)
9[] DK (4k on page 36)

j. How much difficulty does -- have using the toilet, including getting to the toilet- some, a lot, or is -- unable to do it?

1[] Some (4k on page 36)
2[] A lot (4k on page 36)
3[] Unable (4k on page 36)
9[] DK (4k on page 36)

[p.182]

Section II- Disability - Continued

PART C-ADL/IADL - Continued

Mark (x) box 0 or ask:
4k. Does -- have any difficulty getting around inside the home?
If doesn't do, Ask: Is this because of a physical, mental, or emotional problem?
If "Yes", mark (x) box 3 "Doesn't do/health"
If "No", mark (x) box 2 "No"

0[] Getting around in X2 (C1 on page 32 for NP, or C2 on page 38)
1[] Yes (Mark X2 then 4l)
2[] No (C1 on page 32 for NP, or C2 on page 38)
3[] Doesn't do/health (Mark X2, then C1 on page 32 for NP, or C2 on page 38)
9[] DK (C1 on page 32 for NP or C2 on page 38)

l. How much difficulty does -- have getting around inside the home - some, a lot, or is -- unable to do it?

1[] Some (C1 on page 32 for NP, or C2 on page 38)
2[] A lot (C1 on page 32 for NP, or C2 on page 38)
3[] Unable (C1 on page 32 for NP, or C2 on page 38)
9[] DK (C1 on page 32 for NP, or C2 on page 38)

Hand card DC1. Read categories if telephone interview.
CARD DC1

1. Bathing or showering
2. Dressing
3. Eating
4. Getting in and out of bed or chairs
5. Using the toilet, including getting to the toilet
6. Getting around inside your home
5a. Because of a physical, mental, or emotional problem, does -- have any difficulty with any of [these/the following] activities?
If "Yes", ask "Which"? and mark the appropriate box(es) in person's column AND in "Difficulty/Doesn't do" column in X2.
If doesn't do, ask: Is this because of a physical, mental, or emotional problem?
If "Yes", mark (x) box for that activity
If "No", do not mark the box for that activity
Mark (x) box 0 only if no other boxes are marked

0[] No difficulty (C1 on page 32 for NP, or C2 on page 38)
1[] Bathing or showering
2[] Dressing
3[] Eating
4[] Getting in/out of bed or chairs
5[] Using the toilet, including getting to the toilet
6[] Getting around inside the home
Mark (x) appropriate box(es) in X2

Ask only of box 1 "Bathing" in 5a; otherwise, skip to 5c.
b. How much difficulty does -- have bathing or showering -some, a lot, or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Ask only if 2 "Dressing" in 5a; otherwise, skip to 5d
c. How much difficulty does -- have dressing - some, a lot, or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Ask only if 3 "Eating" in 5a; otherwise, skip to 5e.
d. How much difficulty does -- have eating - some, a lot, or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Ask only if 4"Gettin in/out of bed or chairs" in 5a; otherwise, skip to 5f on page 38
e. How much difficulty does -- have getting in and out of bed or chairs- some, a lot, or is -- unable to do it?

1[] Some (5f on page 38)
2[] A lot (5f on page 38)
3[] Unable (5f on page 38)
9[] DK (5f on page 38)

[p.183]

Section II- Disability - Continued

PART C-ADL/IADL - Continued

Ask only if box 5 "Using the toilet" in 5a; otherwise, skip to 5g.
5f. How much difficulty does -- have using the toilet, including getting to the toilet - some, a lot, or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Ask only if box 6 "Getting around inside" in 5a; otherwise, go to C1 on page 32 for NP, or C2.
g. How much difficulty does -- have getting around inside the home- some, a lot, or is -- unable to do it?

1[] Some (C1 on page 32 for NP, or C2)
2[] A lot (C1 on page 32 for NP, or C2)
3[] Unable (C1 on page 32 for NP, or C2)
9[] DK (C1 on page 32 for NP, or C2)

ITEM C2
Refer to age and Item X2. Mark (x) first appropriate box.

0[] Under 5 (NP, or 10 on page 56)
1[] One or more activities marked in X2 (ADL table)
2[] No activities in X2 (NP, or 10 on page 56)

If no more persons in family, skip to 10 on page 56.

[p.184]

Section II- Disability - Continued

PART C-ADL/IADL - Continued

ADL TABLE 1

ITEM C3
Enter person's number and name.

Person number _____
Name ________

ITEM C4
Refer to X2 for this person. Mark (x) first appropriate box

1[] "Help/Remind" (6)
2[] "Special equip" (7)
3[] "Difficulty/doesn't do" (8 on page 42)
6a. You said that -- gets help, needs to be reminded, or needs someone close by when (activities with "help/remind" in X2).
Who gives this help?
Anyone else?
Mark (x) all that apply

Household members
1[] Relative(s)
2[] Nonrelative(s)

Nonhousehold members
3[] Relative(s)
4[] Nonrelative(s)

If ONLY help is from spouse/child(ren)/parent, mark (x) box 0; otherwise, ask:
b. Is any of this help paid for?

0[] Spouse/child(ren)/parent only (7)
1[] Yes (6c)
2[] No (7)
9[] DK (7)

c. Which helpers are paid?
Anyone else?
Mark (x) all that apply

Household members
1[] Relative(s)
2[] Nonrelative(s)

Nonhousehold members
3[] Relative(s)
4[] Nonrelative(s)

Ask 7a and b only if "Help/remind" and/or "Special equip" for Bathing; otherwise, skip to 7c.
7a. If -- did not [get help from another person/(and) use special equipment], how much difficulty would -- have bathing - some, a lot, or would -- be completely unable to do this?

1[] Some
2[] A lot
3[] Completely unable
9[] DK

b. WITH [help from another person/(and) special equipment], how much difficulty does - - have bathing - some, a lot, or is -- completely unable to do this?

0[] No difficulty
1[] Some
2[] A lot
3[] Completely unable
9[] DK

Ask 7c and d only if "Help/remind" and/or "Special equip" for Dressing; otherwise, skip to 7e.
7c. If -- did not [get help from another person/(and) use special equipment], how much difficulty would -- have dressing - some, a lot, or would -- be completely unable to do this?

1[] Some
2[] A lot
3[] Completely unable
9[] DK

d. WITH [help from another person/(and) special equipment], how much difficulty does - - have dressing - some, a lot, or is -- completely unable to do this?

0[] No difficulty
1[] Some
2[] A lot
3[] Completely unable
9[] DK

[p.185]

Section II- Disability - Continued

PART C-ADL/IADL - Continued

ADL TABLE 1 - Continued

Ask 7e and f only if "Help/remind" and/or "Special equip" for Eating; otherwise, skip to 7g.
7e. If -- did not [get help from another person/(and) use special equipment], how much difficulty would -- have eating - some, a lot, or would -- be completely unable to do this?

1[] Some
2[] A lot
3[] Completely unable
9[] DK

f. WITH [help from another person/(and) special equipment], how much difficulty does - - have eating - some, a lot, or is -- completely unable to do this?

0[] No difficulty
1[] Some
2[] A lot
3[] Completely unable
9[] DK

Ask 7g and h only if "Help/remind" and/or "Special equip" for Bed or Chair; otherwise, skip to 7i.
g. If -- did not [get help from another person/(and) use special equipment], how much difficulty would -- have getting in and out of bed or chairs - some, a lot, or would -- be completely unable to do this?

1[] Some
2[] A lot
3[] Completely unable
9[] DK

h. WITH [help from another person/(and) special equipment], how much difficulty does - - have getting in and out of bed or chairs - some, a lot, or is -- completely unable to do this?

0[] No difficulty
1[] Some
2[] A lot
3[] Completely unable
9[] DK

Ask 7i and j only if "Help/remind" and/or "Special equip" for Toilet; otherwise, skip to 7k.
7i. If -- did not [get help from another person/(and) use special equipment], how much difficulty would -- have using the toilet, including getting to the toilet - some, a lot, or would -- be completely unable to do this?

1[] Some
2[] A lot
3[] Completely unable
9[] DK

j. WITH [help from another person/(and) special equipment], how much difficulty does - - have using the toilet, including getting to the toilet - some, a lot, or is -- completely unable to do this?

0[] No difficulty
1[] Some
2[] A lot
3[] Completely unable
9[] DK

Ask 7k and l only if "Help/remind" and/or "Special equip" for Getting around; otherwise, skip to 8 on page 42.
k. If -- did not [get help from another person/(and) use special equipment], how much difficulty would -- have getting around inside the home - some, a lot, or would -- be completely unable to do this?

1[] Some
2[] A lot
3[] Completely unable
9[] DK

l. WITH [help from another person/(and) special equipment], how much difficulty does - - have getting around inside the house - some, a lot, or is -- completely unable to do this?

0[] No difficulty
1[] Some
2[] A lot
3[] Completely unable
9[] DK

(Go to 8 on page 42)

[p.186]

Section II- Disability - Continued

PART C-ADL/IADL - Continued

ADL TABLE 1 - Continued

Ask only if "Bathing" marked in X2; otherwise, 8a for next activity.
8a. How old was -- when -- first had a problem with bathing or showering?

_____ Years old (8d)

96[] At birth (8d)
99[] DK (8b)

b. Was it before-- was 18 years old?

1[] Yes (8d)
2[] No (8c)
0[] DK (8d)

c. Was it before -- was 22 years old?

1[] Yes
2[] No
9[] DK

If obvious, mark without asking; otherwise ask:
d. Is -- expected to have this problem with bathing or showering for at least 12 months longer?

1[] Yes (8a for next activity)
2[] No (8a for next activity)
9[] DK (8a for next activity)

Ask only if "Eating" marked in X2; otherwise, 8a for next activity
8a. How old was -- when -- first had a problem with eating?

______Years old (8d)

96[] At birth (8d)
99[] DK (8b)

b. Was it before-- was 18 years old?

1[] Yes (8d)
2[] No (8c)
0[] DK (8d)

c. Was it before -- was 22 years old?

1[] Yes
2[] No
9[] DK

If obvious, mark without asking; otherwise ask:
d. Is -- expected to have this problem with eating for at least 12 months longer?

1[] Yes (8a for next activity)
2[] No (8a for next activity)
9[] DK (8a for next activity)

Ask only if "Dressing" marked in X2; otherwise, 8a for next activity.
8a. How old was -- when -- first had a problem with dressing?

______ Years old (8d)

96[] At birth (8d)
99[] DK (8b)

b. Was it before-- was 18 years old?

1[] Yes (8d)
2[] No (8c)
0[] DK (8d)

c. Was it before -- was 22 years old?

1[] Yes
2[] No
9[] DK

If obvious, mark without asking; otherwise ask:
d. Is -- expected to have this problem with dressing for at least 12 months longer?

1[] Yes (8a for next activity)
2[] No (8a for next activity)
9[] DK (8a for next activity)

Ask only if "Bed or Chairs" marked in X2; otherwise, 8a for next activity.
8a. How old was -- when -- first had a problem with getting in and out of bed or chairs?

_______ Years old (8d)

96[] At birth (8d)
99[] DK (8b)

b. Was it before-- was 18 years old?

1[] Yes (8d)
2[] No (8c)
0[] DK (8d)

c. Was it before -- was 22 years old?

1[] Yes
2[] No
9[] DK

If obvious, mark without asking; otherwise ask:
d. Is -- expected to have this problem with getting in and out of bed or chairs for at least 12 months longer?

1[] Yes (8a for next activity)
2[] No (8a for next activity)
9[] DK (8a for next activity)

[p.187]

Section II- Disability - Continued

PART C-ADL/IADL - Continued

ADL TABLE 1 - Continued

Ask only if "Toilet" marked in X2; otherwise, 8a for next activity.
8a. How old was -- when -- first had a problem with toilet?

______Years old (8d)

96[] At birth (8d)
99[] DK (8b)

b. Was it before-- was 18 years old?

1[] Yes (8d)
2[] No (8c)
0[] DK (8d)

c. Was it before -- was 22 years old?

1[] Yes
2[] No
9[] DK

If obvious, mark without asking; otherwise ask:
d. Is -- expected to have this problem with toilet for at least 12 months longer?

1[] Yes (8a for next activity)
2[] No (8a for next activity)
9[] DK (8a for next activity)

Ask only if "Getting around" marked in X2; otherwise, 9 below.
8a. How old was -- when -- first had a problem with getting around inside the home?

________Years old (8d)

96[] At birth (8d)
99[] DK (8b)

b. Was it before-- was 18 years old?

1[] Yes (8d)
2[] No (8c)
0[] DK (8d)

c. Was it before -- was 22 years old?

1[] Yes
2[] No
9[] DK

If obvious, mark without asking; otherwise ask:
d. Is -- expected to have this problem with getting around inside the home for at least 12 months longer?

1[] Yes (9)
2[] No (9)
9[] DK (9)

9. What is the MAIN problem or condition which causes -- trouble in (activities marked in X2)?
(Enter condition in X1 and mark box)

1[] In C2 (C2 on page 38 for NP; or 10 on page 56)
2[] Not in C2 (C2 on page 38 for NP; or 10 on page 56)

[p.188]

Section II - Disability - Continued

Part C - ADL/IADL

Skip to Part D, page 80 if no family members 18+ years old.
Hand card DC2
CARD DC2

1. Preparing their own meals
2. Shopping for personal items, such as toilet items or medicines
3. Managing money, such as keeping track of expenses or paying bills
4. Using the telephone
5. Doing heavy work around the house like scrubbing floors, washing windows, doing heavy yard work
6. Doing light work around the house like doing dishes, straightening up , light cleaning, or taking out the trash

(Now I will ask about some other activities. These next few questions refer only to (read names of persons 18+))
10a. Because of a physical, mental, or emotional problem, do (read names of persons 18+) GET HELP OR SUPERVISON FROM ANOTHER PERSON with-

(1) Preparing their own meals?
1[] Yes (10b)
2[] No
9[] DK


(2) Shopping for personal items, such as toilet items or medicine?
1[] Yes (10b)
2[] No
9[] DK


(3) Managing money, such as keeping track of expenses or paying bills?
1[] Yes (10b)
2[] No
9[] DK


(4) Using the telephone?
1[] Yes (10b)
2[] No
9[] DK


(5) Doing heavy work around the house like scrubbing floors, washing windows, and doing heavy yard work?
1[] Yes (10b)
2[] No
9[] DK


(6) Doing light work around the house like doing dishes, straightening up, light cleaning, or taking out the trash?
1[] Yes (10b)
2[] No (C5)
9[] DK (C5)

b. Who is this?
(Anyone else?)
Mark (x) appropriate box in person's column AND in "Help/supv" column in X3, then continue with 10a, or go to C5.

1[] Preparing meals
2[] Shopping
3[] Managing money
4[] Using telephone
5[] Heavy housework
6[] Light housework
(Mark (x) appropriate box(es) in X3)

ITEM C5
Refer to age and item X3 for each person. Mark (x) first appropriate box.

0[] Under 18 (NP, or C6 on page 62)
1[] One or more activities marked in X3 (11)
2[] No activities in X3 (12 on page 60)

Mark (x) box 0 or ask:
11a. Does -- have any difficulty preparing -- own meals?
If doesn't do, ask: Is this because of a physical, mental, or emotional problem?
If "Yes", mark (x) box 3 "Doesn't do/health"
If "No", mark (x) box 2 "No"

0[] Preparing meals in X3 (11c on page 58)
1[] Yes (Mark X3, then 11b)
2[] No (11c on page 58)
3[] Doesn't do/health (Mark X3, then 11c on page 58)
9[] DK (11c on page 58)

b. How much difficulty does -- have preparing -- own meals- some, a lot, or is -- unable to do it?

1[] Some (11c on page 58)
2[] A lot (11c on page 58)
3[] Unable (11c on page 58)
9[] DK (11c on page 58)

[p.189]

Section II - Disability - Continued

Part C - ADL/IADL - Continued

Mark (x) box 0 or ask:
11c. Does -- have any difficulty shopping for personal items?
If doesn't do, ask : Is this because of a physical, mental, or emotional problem?
If "Yes", mark (x) box 3 "Doesn't do/health"
If "No", mark (x) box 2 "No"

0[] Shopping in X3 (11e)
1[] Yes (Mark X3, then 11d)
2[] No (11e)
3[] Doesn't do/health (Mark X3, then 11e)
9[] DK (11e)

d. How much difficulty does -- have shopping for personal items - some, a lot, or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Mark (X) box 0 or ask:
e. Does -- have any difficulty managing money?
If doesn't do, ask: Is this because of a physical, mental, or emotional problem?
If "Yes", mark (x) box 3 "Doesn't do/health"
If "No", mark (x) box 2 "No"

0[] Managing money in X3 (11g)
1[] Yes (Mark X3, then 11f)
2[] No (11g)
3[] Doesn't do/health (Mark X3, then 11g)
9[] DK (11g)

f. How much difficulty does -- have managing money - some, a lot, or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Mark (x) box 0 or ask:
g. Does -- have any difficulty using the telephone?
If doesn't do, ask: Is this because of a physical, mental, or emotional problem?
If "Yes", mark (x) box 3 "Doesn't do/health"
If "No", mark (x) box 2 "No"

0[] Telephone in X3 (11i)
1[] Yes (Mark X3, then 11h)
2[] No (11i)
3[] Doesn't do/health (Mark X3, then 11i)
9[] DK (11i)

h. How much difficulty does -- have using the telephone - some, a lot, or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Mark (x) box 0 or ask:
i. Does -- have any difficulty doing heavy work around the house?
If doesn't do, ask: Is this because of a physical, mental, or emotional problem?
If "Yes", mark (x) box 3 "Doesn't do/health"
If "No", mark (x) box 2 "No"

0[] Heavy work in X3 (11k on page 60)
1[] Yes (Mark X3, then 11j)
2[] No (11k on page 60)
3[] Doesn't do/health (Mark X3, then 11k on page 60)
9[] DK (11k on page 60)

j. How much difficulty does -- have doing heavy work around the house - some, a lot, or is -- unable to do it?

1[] Some (11k on page 60)
2[] A lot (11k on page 60)
3[] Unable (11k on page 60)
9[] DK (11k on page 60)

[p.190]

Section II - Disability - Continued

Part C - ADL/IADL - Continued

Mark (x) box 0 or ask:
11k. Does -- have any difficulty doing light work around the house?
If doesn't do, ask: Is this because of a physical, mental, or emotional problem?
If "Yes", mark (x) box 3 "Doesn't do/health"
If "No", mark (x) box 2 "No"

0[] Light work in X3 (C5 on page 58 for NP, or C6 on page 62)
1[] Yes (Mark X3, then 11l)
2[] No (C5 on page 56 for NP, or C6 on page 62)
3[] Doesn't do/health (Mark X3, then C5 on page 56 for NP, or C6 on page 62)
9[] DK (C5 on page 56 for NP, or C6 on page 62)

l. How much difficulty does -- have doing light work around the house - some, a lot, or is -- unable to do it?

1[] Some (C5 on page 56 for NP, or C6 on page 62)
2[] A lot (C5 on page 56 for NP, or C6 on page 62)
3[] Unable (C5 on page 56 for NP, or C6 on page 62)
9[] DK (C5 on page 56 for NP, or C6 on page 62)

Hand card DC2.
CARD DC2

1. Preparing their own meals
2. Shopping for personal items, such as toilet items or medicines
3. Managing money, such as keeping track of expenses or paying bills
4. Using the telephone
5. Doing heavy work around the house like scrubbing floors, washing windows, doing heavy yard work
6. Doing light work around the house like doing dishes, straightening up, light cleaning, or taking out the trash.

12a. Because of a physical, mental, or emotional problem does -- have any difficulty with any of [these/the following] activities? Read categories if telephone interview.
If "Yes", ask "Which"? and mark the appropriate box(es), in person's column AND in "Difficulty/doesn't do" column in X3.
If doesn't do, ask: Is this because of a physical, mental, or emotional problem?
If "Yes" mark the box for that activity
If "No" do not make any entries
Mark (x) box 0 only if no other box(es) are marked.

0[] No difficulty (C5 on page 56 for NP, or C6 on page 62)
1[] Preparing meals
2[] Shopping
3[] Managing money
4[] Using the telephone
5[] Heavy housework
6[] Light housework

(Mark (x) appropriate box(es) in X3)

Ask only if box 1 "Preparing meals" in 12a; otherwise, skip to 12c.
b. How much difficulty does -- have preparing -- own meals - some, a lot , or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Ask only if box 2 "Shopping" in 12a; otherwise, skip to 12d.
c. How much difficulty does -- have shopping for personal items- some, a lot , or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Ask only if box 3 "Managing money" in 12a; otherwise, skip to 12e
d. How much difficulty does -- have managing money- some, a lot, or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Ask only if box 4 "Using the telephone" in 12a; otherwise, skip to 12f on page 62
e. How much difficulty does -- have using the telephone- some, a lot , or is -- unable to do it?

1[] Some (12f on page 62)
2[] A lot (12f on page 62)
3[] Unable (12f on page 62)
9[] DK (12f on page 62)

[p.191]

Section II - Disability - Continued

Part C - ADL/IADL - Continued

Ask only if box 5 "Heavy housework" in 12a; otherwise, skip to 12g.
12f. How much difficulty does -- have doing heavy work around the house - some, a lot, or is -- unable to do it?

1[] Some
2[] A lot
3[] Unable
9[] DK

Ask only if box 6 "Light housework" in 12a; otherwise, go to C5 on page 56 for NP, or C6.
g. How much difficulty does -- have doing light work around the house - some, a lot, or is -- unable to do it?

1[] Some (C5 on page 56 for NP, or C6)
2[] A lot (C5 on page 56 for NP, or C6)
3[] Unable (C5 on page 56 for NP, or C6)
9[] DK (C5 on page 56 for NP, or C6)

ITEM C6
Refer to age and ITEM X3. Mark (x) first appropriate box

0[] Under 18 (NP, or Part D on page 80)
1[] One or more activities marked in X3 (IADL table)
2[] No activities in X3 (NP, or Part D on page 80)

If no more persons in family, skip to part D on page 80.

[p.192]

Section II - Disability - Continued

Part C - ADL/IADL - Continued

IADL Table 1

ITEM C7
Enter person's number and name.

Person number _____
Name _______
ITEM C8
Refer to X3 for this person. Mark (x) first appropriate box

1[] "Help/supv" (13)
2[] "Difficulty/doesn't do" (15 on page 66)
13a. You said that -- gets help or supervision with (activities with "help/supv" in X3).
Who gives this help?
Anyone else?
Mark (x) all that apply.

Household members
1[] Relative(s)
2[] Nonrelative(s)

Nonhousehold members
3[] Relative(s)
4[] Nonrelative(s)

If ONLY help is from spouse/child(ren)/parent, mark (x) box 0; otherwise, ask:
b. Is any of this help paid for?

0[] Spouse/chid(ren)/parents only (14)
1[] Yes (13c)
2[] No (14)
9[] DK (14)

c. Which helpers are paid?
Anyone else?
Mark (x) all that apply.

Household members
1[] Relative(s)
2[] Nonrelative(s)

Nonhousehold members
3[] Relative(s)
4[] Nonrelative(s)

Ask 14a and b only if "Help/supv" for "Preparing meals"; otherwise, skip to 14c.
14a. If -- did not get help or supervision from another person, how much difficulty would -- have preparing -- meals on -- own - some, a lot, or would -- be completely unable to do this?

1[] Some
2[] A lot
3[] Completely unable
9[] DK

b. WITH help or supervision, how much difficulty does -- have preparing -- meals - some, a lot, or is -- completely unable to do this?

0[] No difficulty
1[] Some
2[] A lot
3[] Completely unable
9[] DK

Ask 14c and d only if "Help/supv" for "Shopping"; otherwise, skip to 14e.
14c. If -- did not get help or supervision from another person, how much difficulty would -- have shopping for personal items on -- own - some, a lot, or would -- be completely unable to do this?

1[] Some
2[] A lot
3[] Completely unable
9[] DK

d. WITH help or supervision, how much difficulty does -- have shopping for personal items - some, a lot, or is -- completely unable to do this?

0[] No difficulty
1[] Some
2[] A lot
3[] Completely unable
9[] DK

[p.193]

Section II - Disability - Continued

Part C - ADL/IADL - Continued

IADL Table 1 - Continued

Ask 14e and f only if "Help/supv" for "Managing money"; otherwise, skip to 14g.
14e. If -- did not get help or supervision from another person, how much difficulty would -- have managing money on -- own - some, a lot, or would -- be completely unable to do this?

1[] Some
2[] A lot
3[] Completely unable
9[] DK

f. WITH help or supervision, how much difficulty does -- have managing money- some, a lot, or is -- completely unable to do this?

0[] No difficulty
1[] Some
2[] A lot
3[] Completely unable
9[] DK

Ask 14g and h only if "Help/supv" for "Telephone"; otherwise, skip to 14i.
g. If -- did not get help or supervision from another person, how much difficulty would -- have using the telephone - some, a lot, or would -- be completely unable to do this?

1[] Some
2[] A lot
3[] Completely unable
9[] DK

h. WITH help or supervision, how much difficulty does -- have using the telephone - some, a lot, or is -- completely unable to do this?

0[] No difficulty
1[] Some
2[] A lot
3[] Completely unable
9[] DK

Ask 14i and j only if "Help/supv" for "Heavy housework"; otherwise, skip to 14k.
14i. If -- did not get help or supervision from another person, how much difficulty would -- have doing heavy work around the house - some, a lot, or would -- be completely unable to do this?

1[] Some
2[] A lot
3[] Completely unable
9[] DK

j. WITH help or supervision, how much difficulty does -- have doing heavy work around the house - some, a lot, or is -- completely unable to do this?

0[] No difficulty
1[] Some
2[] A lot
3[] Completely unable
9[] DK

Ask 14k and l only if "Help/supv" for "Light Housework"; otherwise, skip to 15 on page 66.
14k. If -- did not get help or supervision from another person, how much difficulty would -- have doing light work around the house - some, a lot, or would -- be completely unable to do this?

1[] Some
2[] A lot
3[] Completely unable
9[] DK

l. WITH help or supervision, how much difficulty does -- have doing light work around the house - some, a lot, or is -- completely unable to do this?

0[] No difficulty
1[] Some
2[] A lot
3[] Completely unable
9[] DK

Go to 15 on page 66.

[p.194]

Section II - Disability - Continued

Part C - ADL/IADL - Continued

IADL Table 1 - Continued

Ask only if "Preparing meals" marked in X3; otherwise, 15a for next activity
15a. How old was -- when -- first had a problem with preparing -- own meals?

_______ Years old (15d)

96[] At birth (15d)
99[] DK (15b)

b. Was it before -- was 18 years old?

1[] Yes (15d)
2[] No (15c)
9[] DK (15d)

c. Was it before -- was 22 years old?

1[] Yes
2[] No
9[] DK

If obvious, mark without asking; otherwise ask:
d. Is -- expecting to have this problem with preparing --own meals for at least 12 months longer?

1[] Yes (15a for next activity)
2[] No (15a for next activity)
9[] DK (15a for next activity)

Ask only if "Managing money" marked in X3; otherwise, 15a for next activity
15a. How old was -- when -- first has a problem with managing money?

______Years old (15d)

96[] At birth (15d)
99[] DK (15b)

b. Was it before -- was 18 years old?

1[] Yes (15d)
2[] No (15c)
9[] DK (15d)

c. Was it before -- was 22 years old?

1[] Yes
2[] No
9[] DK

If obvious, mark without asking; otherwise ask:
d. Is -- expecting to have this problem managing money for at least 12 months longer?

1[] Yes (15a for next activity)
2[] No (15a for next activity)
9[] DK (15a for next activity)

Ask only if "Shopping" marked in X3; otherwise, 15a for next activity
15a. How old was -- when -- first had a problem with shopping for personal items?

_______Years old (15d)

96[] At birth (15d)
99[] DK (15b)

b. Was it before -- was 18 years old?

1[] Yes (15d)
2[] No (15c)
9[] DK (15d)

c. Was it before -- was 22 years old?

1[] Yes
2[] No
9[] DK

If obvious, mark without asking; otherwise ask:
d. Is -- expecting to have this problem with shopping for personal items at least 12 months longer?

1[] Yes (15a for next activity)
2[] No (15a for next activity)
9[] DK (15a for next activity)

Ask only if "Telephone" marked in X3; otherwise, 15a for next activity
15a. How old was -- when -- first had a problem with using the telephone?

_______ Years old (15d)

96[] At birth (15d)
99[] DK (15b)

b. Was it before -- was 18 years old?

1[] Yes (15d)
2[] No (15c)
9[] DK (15d)

c. Was it before -- was 22 years old?

1[] Yes
2[] No
9[] DK

If obvious, mark without asking; otherwise ask:
d. Is -- expecting to have this problem using the telephone for at least 12 months longer?

1[] Yes (15a for next activity)
2[] No (15a for next activity)
9[] DK (15a for next activity)

[p.195]

Section II - Disability - Continued

Part C - ADL/IADL - Continued

IADL Table 1 - Continued

Ask only if "Heavy work" marked in X3; otherwise, 15a for next activity
15a. How old was -- when -- first had a problem with doing heavy work around the house?

_______Years old (15d)

96[] At birth (15d)
99[] DK (15b)

b. Was it before -- was 18 years old?

1[] Yes (15d)
2[] No (15c)
9[] DK (15d)

c. Was it before -- was 22 years old?

1[] Yes
2[] No
9[] DK

If obvious, mark without asking; otherwise ask:
d. Is -- expecting to have this problem doing heavy work around the house for at least for at least 12 months longer?

1[] Yes (15a for next activity)
2[] No (15a for next activity)
9[] DK (15a for next activity)

Ask only if "Light work" marked in X3; otherwise, 15a for next activity
15a. How old was -- when -- first had a problem with doing light work around the house?

_______ Years old (15d)

96[] At birth (15d)
99[] DK (15b)

b. Was it before -- was 18 years old?

1[] Yes (15d)
2[] No (15c)
9[] DK (15d)

c. Was it before -- was 22 years old?

1[] Yes
2[] No
9[] DK

If obvious, mark without asking; otherwise ask:
d. Is -- expecting to have this problem doing light work around the house for at least 12 months longer?

1[] Yes (16)
2[] No (16)
9[] DK (16)

16. What is the MAIN problem or condition which causes -- trouble in (activities marked in X3)?
(Enter condition in X1 and mark box)

1[] In C2 (C6 on page 62 for NP, or Part D on page 80)
2[] Not in C2 (C6 on page 62 for NP, or Part D on page 80)

[p.196]

Section II - Disability - Continued

Part D- Functional Limitation

ITEM D1
Refer to ages of all family members

1[] All under 18 (Section G on page 114)
2[] Any 18+ (1)

These next few questions also refer to family members who are 18 years old or older, that is (read names of nondeleted persons 18+).
1a. Do (names of persons 18+) have ANY difficulty lifting something as heavy as 10 pounds, such as a full bag of groceries?

1[] Yes (1b)
2[] No (2 on page 82)
9[] DK (2 on page 82)

b. Who is this?
Mark (x) "Difficulty lifting" box in person's column

1[] Difficulty lifting

c. Anyone else?

[] Yes (Reask 1b and c)
[] No

Ask 1d-g for each person with "Difficulty lifting" marked in 1b.
d. How much difficulty does -- have lifting 10 pounds, some, a lot, or is -- completely unable to do this?

1[] Some difficulty
2[] A lot of difficulty
3[] Completely unable
9[] DK

e. At what age did -- first have difficulty doing this?

_____ Years old
or
96[] Always had difficulty
97[] Never able
99[] DK

Ask only if "Completely unable" in 1d; otherwise, skip to 1g.
f. [Do you expect/is -- expected] to remain unable to do this for at least 12 months longer?

1[] Yes
2[] No
9[] DK

g. Did this difficulty result from a motor vehicle accident?

1[] Yes (1d for NP in 1b, or 2 on page 82)
2[] No (1d for NP in 1b, or 2 on page 82)
9[] DK (1d for NP in 1b, or 2 on page 82)

[p.197]

Section II - Disability - Continued

Part D- Functional Limitation - Continued

2a. Do (names of persons 18+) have any difficulty walking up 10 steps without resting?

1[] Yes (2b)
2[] No (3 on page 84)
9[] DK (3 on page 84)

b. Who is this?
Mark (x) "Difficulty walking up steps" box in person's column

1[] Difficulty walking up steps

c. Anyone else?

[] Yes (Reask 2b and c)
[] No

Ask 2d-g for each person with "Difficulty walking up steps" marked in 2b
d. How much difficulty does -- have walking up 10 steps without rest, some, a lot, or is -- completely unable to do this?

1[] Some difficulty
2[] A lot of difficulty
3[] Completely unable
9[] DK

e. At what age did -- first have difficulty doing this?

_____ Years old
or
96[] Always had difficulty
97[] Never able
99[] DK

Ask only if "Completely unable" in 2d; otherwise, skip to 2g.
f. [Do you expect/is -- expected] to remain unable to do this for at least 12 months longer?

1[] Yes
2[] No
9[] DK

g. Did this difficulty result from a motor vehicle accident?

1[] Yes (2d for NP in 2b, or 3 on page 84)
2[] No (2d for NP in 2b, or 3 on page 84)
9[] DK (2d for NP in 2b, or 3 on page 84)

[p.198]

Section II - Disability - Continued

Part D- Functional Limitation - Continued

3a. Do (names of persons 18+) have any difficulty walking a quarter of a mile -about 3 city blocks?

1[] Yes (3b)
2[] No (4 on page 86)
9[] DK (4 on page 86)

b. Who is this?
Mark (x) "Difficulty walking" box in person's column

1[] Difficulty walking

c. Anyone else?

[] Yes (Reask 3b and c)
[] No

Ask 3d-g for each person with "Difficulty walking" marked in 3b.
d. How much difficulty does -- have walking a quarter of a mile, some, a lot, or is -- completely unable to do this?

1[] Some difficulty
2[] A lot of difficulty
3[] Completely unable
9[] DK

e. At what age did -- first have difficulty doing this?

_____ Years old
or
96[] Always had difficulty
97[] Never able
99[] DK

Ask only if "Completely unable" in 3d; otherwise, skip to 3g
f. [Do you expect/is -- expected] to remain unable to do this for at least 12 months longer?

1[] Yes
2[] No
9[] DK

g. Did this difficulty result from a motor vehicle accident?

1[] Yes (3d for NP in 3b, or 4 on page 86)
2[] No (3d for NP in 3b, or 4 on page 86)
9[] DK (3d for NP in 3b, or 4 on page 86)

[p.199]

Section II - Disability - Continued

Part D- Functional Limitation - Continued

4a. Do (names of persons 18+) have any difficulty standing for about 20 minutes?

1[] Yes (4b)
2[] No (5 on page 88)
9[] DK (on page 88)

b. Who is this?
Mark (x) "Difficulty standing" box in person's column

1[] Difficulty standing

c. Anyone else?

[] Yes (Reask 4b and c)
[] No

Ask 4d-g for each person with "Difficulty standing" marked in 4b.
d. How much difficulty does -- have standing for about 20 minutes, some, a lot, or is -- completely unable to do this?

1[] Some difficulty
2[] A lot of difficulty
3[] Completely unable
9[] DK

e. At what age did -- first have difficulty doing this?

______ Years old
or
96[] Always had difficulty
97[] Never able
99[] DK

Ask only if "Completely unable" in 4d; otherwise, skip to 4g.
f. [Do you expect/is -- expected] to remain unable to do this for at least 12 months longer?

1[] Yes
2[] No
9[] DK

g. Did this difficulty result from a motor vehicle accident?

1[] Yes (4d for NP in 4b, or 5 on page 88)
2[] No (4d for NP in 4b, or 5 on page 88)
9[] DK (4d for NP in 4b, or 5 on page 88)

[p.200]

Section II - Disability - Continued

Part D- Functional Limitation - Continued

5a. Do (names of persons 18+) have any difficulty bending down from a standing position to pick up an object from the floor, for example, a shoe?

1[] Yes (5b)
2[] No (6 on page 90)
9[] DK (6 on page 90)

b. Who is this?
Mark (x) "Difficulty bending" box in person's column.

1[] Difficulty bending

c. Anyone else?

[] Yes (Reask 5b and c)
[] No

Ask 5d-g for each person with "Difficulty bending" marked in 5b.
d. How much difficulty does -- have bending down from a standing position, some, a lot, or is -- completely unable to do this?

1[] Some difficulty
2[] A lot of difficulty
3[] Completely unable
9[] DK

e. At what age did -- first have difficulty doing this?

______ Years old
or
96[] Always had difficulty
97[] Never able
99[] DK

Ask only if "Completely unable" in 5d; otherwise, skip to 5g.
f. [Do you expect/is -- expected] to remain unable to do this for at least 12 months longer?

1[] Yes
2[] No
9[] DK

g. Did this difficulty result from a motor vehicle accident?

1[] Yes (5d for NP in 5b, or 6 on page 90)
2[] No (5d for NP in 5b, or 6 on page 90)
9[] DK (5d for NP in 5b, or 6 on page 90)

[p.201]

Section II - Disability - Continued

Part D- Functional Limitation - Continued

6a. Do (names of persons 18+) have any difficulty reaching up over the head or reaching out as if to shake someone's hand?

1[] Yes (6b)
2[] No (7 on page 92)
9[] DK (7 on page 92)

b. Who is this?
Mark (x) "Difficulty reaching" box in person's column

1[] Difficulty reaching

c. Anyone else?

[] Yes (Reask 6b and c)
[] No

Ask 6d-g for each person with "Difficulty reaching" marked in 6b.
d. How much difficulty does -- have reaching up over the head or reaching out, some, a lot, or is -- completely unable to do this?

1[] Some difficulty
2[] A lot of difficulty
3[] Completely unable
9[] DK

e. At what age did -- first have difficulty doing this?

______ Years old
or
96[] Always had difficulty
97[] Never able
99[] DK

Ask only if "Completely unable" in 6d; otherwise, skip to 6g.
f. [Do you expect/Is -- expected] to remain unable to do this for at least 12 months longer?

1[] Yes
2[] No
9[] DK

g. Did this difficulty result from a motor vehicle accident?

1[] Yes (6d for NP in 6b, or 7 on page 92)
2[] No (6d for NP in 6b, or 7 on page 92)
9[] DK (6d for NP in 6b, or 7 on page 92)

[p.202]

Section II - Disability - Continued

Part D- Functional Limitation - Continued

7a. Do (names of persons 18+) have any difficulty using fingers to grasp or handle something such as picking up a glass from a table?

1[] Yes (7b)
2[] No (8 on page 94)
9[] DK (8 on page 94)

b. Who is this?
Mark (x) "Difficulty using fingers" box in person's column

1[] Difficulty using fingers

c. Anyone else?

[] Yes (Reask 7b and c)
[] No

Ask 7d-g for each person with "Difficulty using fingers" marked in 7b.
d. How much difficulty does -- have using the fingers to grasp or handle something, some, a lot, or is -- completely unable to do this?

1[] Some difficulty
2[] A lot of difficulty
3[] Completely unable
9[] DK

e. At what age did -- first have difficulty doing this?

______ Years old
or
96[] Always had difficulty
97[] Never able
99[] DK

Ask only if "Completely unable" in 7d; otherwise, skip to 7g.
f. [Do you expect/is -- expected] to remain unable to do this for at least 12 months longer?

1[] Yes
2[] No
9[] DK

g. Did this difficulty result from a motor vehicle accident?

1[] Yes (7d for NP in 7b, or 8 on page 94)
2[] No (7d for NP in 7b, or 8 on page 94)
9[] DK (7d for NP in 7b, or 8 on page 94)

[p.203]

Section II - Disability - Continued

Part D- Functional Limitation - Continued

8a. Do (names of persons 18+) have any difficulty holding a pen or pencil?

1[] Yes (8b)
2[] No (D2)
9[] DK (D2)

b. Who is this?
Mark (x) "Difficulty holding a pen or pencil" box in person's column

1[] Difficulty holding a pen or pencil

c. Anyone else?

[] Yes (Reask 8b and c)
[] No

Ask 8d-g for each person with "Difficulty holding a pen or pencil" marked in 8b.
d. How much difficulty -- have holding a pen or pencil, some, a lot, or is -- completely unable to do this?

1[] Some difficulty
2[] A lot of difficulty
3[] Never able
9[] DK

e. At what age did -- first have difficulty doing this?

______ Years old
or
96[] Always had difficulty
97[] Never able
99[] DK

Ask only if "Completely unable" in 8d; otherwise, skip to 8g.
f. Is -- expected to remain unable to do this for at least 12 months longer?

1[] Yes
2[] No
9[] DK

g. Did this difficulty result from a motor vehicle accident?

1[] Yes (8d for NP in 8b, or D2)
2[] No (8d for NP in 8b, or D2)
9[] DK (8d for NP in 8b, or D2)

ITEM D2
Refer to questions 1b, 2b, 3b, 4b, 5b, 6b, 7b, and 8b on pages 80-95 in this HIS-2

1[] Any limitations marked (9)
2[] No limitations marked (NP)
9. What is the MAIN problem or condition which causes -- trouble in (limitations marked in Part D, Q1-8)?
(Enter condition in X1 and mark box)
1[] In C2 (D2 for NP or D3 on page 96)
2[] Not in C2 (D2 for NP or D3 on page 96)

[p.204]

Section II - Disability - Continued

Part D- Functional Limitation - Continued

ITEM D3
Refer to age or HIS-1, Part B, Questions 2a/b and 5a/b (page 6-7)

2[] Under 18 (NP, or Part E on page 98)
1[] Yes in 2a/b or 5a/b (10)
2[] Other (NP, or Part E on page 98)
10. Earlier, I was told that -- was unable to work or was limited in the kind or amount of work -- could do because of an impairment or health problem. About how long has -- been unable to work or limited in the kind or amount of work - can do?
If less than one month, enter 1 month.

________
Number
1[] Months
2[] Years


3[] Never able

(D3 for NP, or Part E on page 98)

[p.205]

Section II - Disability - Continued

Part E - Mental Health

These next questions are about mental and emotional health. They refer again only to (names of nondeleted persons age 18+)

1a. Are (read names of persons 18+) FREQUENTLY depressed or anxious?

1[] Yes (1b)
2[] No (2)
9[] DK (2)

b. Who is this?
Mark (x) "Depressed or anxious" box in person's column.

1[] Depressed or anxious

c. Anyone else?

[] Yes (Reask 1b and c)
[] No (2)

2a. Do ([any of/either of]) you have a lot of trouble making or keeping friendships?

1[] Yes (2b)
2[] No (3)
9[] DK (3)

b. Who is this?
Mark (x) "Trouble with friendships" box in person's column

1[] Trouble with friendships

c. Anyone else?

[] Yes (Reask 2b and c)
[] No (3)

3a. Do ([any of/either of]) you have a lot of trouble getting along with other people in social or recreational settings?

1[] Yes (3b)
2[] No (4)
9[] DK (4)

b. Who is this?
Mark (x) "Trouble in social settings" box in person's column

1[] Trouble in social settings

c. Anyone else?

[] Yes (Reask 3b and c)
[] No (4)

4a. Do ([any of/either of]) you have a lot of trouble concentrating long enough to complete everyday tasks?

1[] Yes (4b)
2[] No (5 on page 100)
9[] DK (5 on page 100)

b. Who is this?
Mark (x) "Trouble concentrating" box in person's column

1[] Trouble concentrating

c. Anyone else?

[] Yes (Reask 4b and c)
[] No (5 on page 100)

[p.206]

Section II - Disability - Continued

Part E - Mental Health - Continued

5a. Do ([any of/either of]) you have SERIOUS difficulty coping with day-to-day stresses?

1[] Yes (5b)
2[] No (6)
9[] DK (6)

b. Who is this?
Mark (x) "Trouble in coping with stress" box in person's column

1[] Trouble coping with stress

c. Anyone else?

[] Yes (Reask 5b and c)
[] No (6)

6a. Do ([any of/either of]) you FREQUENTLY confused, disoriented or forgetful?

1[] Yes (6b)
2[] No (7)
9[] DK (7)

b. Who is this?
Mark (x) "Confused" box in person's column

1[] Confused

c. Anyone else?

[] Yes (Reask 6b and c)
[] No (7)

7a. Do ([any of/either of]) you have phobias or UNREASONABLY strong fears, that is, a fear of something or some situation where most people would not be afraid?

1[] Yes (7b)
2[] No (Check Item E1)
9[] DK (Check Item E1)

b. Who is this?
Mark (x) "Phobia" box in person's column

1[] Phobia

c. Anyone else?

[] Yes (Reask 7b and c)
[] No (Check Item E1)

ITEM E1
Refer to age or questions 1b, 2b,3b, 4b, 5b, 6b, and 7b on pages 98-101 for each person.

2[] Under 18 (NP, or 9 on page 102)
1[] Any box marked (8)
2[] No box marked (NP, or 9 on page 102)
8. During the past 12 months, did any of these problems SERIOUSLY interfere with -- ability to work or attend school or to manage -- day-to- day activities?

1[] Yes (E1 for NP, or 9 on page 102)
2[] No (E1 for NP, or 9 on page 102)
9[] DK (E1 for NP, or 9 on page 102)

[p.207]

Section II - Disability - Continued

Part E - Mental Health - Continued

These next questions are about specific mental and emotional disorders. Again, I will only ask about (names of persons 18 years of age and older)-

9a. During the past 12 months, did (names of persons 18+) have-

(1) Schizophrenia (skit-suh-free-nee-uh)?
1[] Yes 9b
2[] No
9[] DK


(2) Paranoid or delusional disorder, other than schizophrenia?
1[] Yes 9b
2[] No
9[] DK


(3) Manic Episodes or manic depression, also called bipolar disorder?
1[] Yes 9b
2[] No
9[] DK


(4) Major depression? Major depression is a depressed mood and loss of interest in almost all activities for at least 2 weeks.
1[] Yes 9b
2[] No
9[] DK


(5) Anti-social personality, obsessive-compulsive personality, or any other SEVERE personality disorder?
1[] Yes 9b
2[] No
9[] DK


(6) Alzheimer's (alltz'hi-merz) disease or another type of senile disorder?
1[] Yes 9b
2[] No
9[] DK


(7) Alcohol abuse disorder?
1[] Yes 9b
2[] No
9[] DK


(8) Drug abuse disorder?
1[] Yes 9b
2[] No (10)
9[] DK (10)

b. Who is this?
Mark (x) appropriate box in person's column and enter condition in X1

1[] Schizophrenia
2[] Paranoid disorder
3[] Bipolar disorder
4[] Major depression
5[] Personality disorder
6[] Senility
7[] Alcohol abuse
8[] Drug abuse disorder
(Enter condition in X1, then 9c)

c. Anyone else?

If "Yes" (Reask 9b and c)
If "No" (9a for next disorder, or 10 on page 104)

[p.208]

Section II - Disability - Continued

Part E - Mental Health - Continued

10a. DURING THE PAST 12 MONTHS, did ([any of/either of]) you have any OTHER mental or emotional disorders? Include only those disorders which SERIOUSLY interfered with [their/your] ability to work or attend school or to manage [their/your] day to day activities.

1[] Yes (10b)
2[] No (11)
9[] DK (11)

b. Who is this?
Mark (x) "Other disorder" box in person's column

1[] Other disorder

c. Anyone else?

[] Yes (Reask 10b and c)
[] No

Ask for each person with "Other disorder" marked in 10b.
d. What would you call the disorder -- has?
If more than one other disorder, probe for the "Main" one causing difficulty.
(Enter condition in X1 and mark box)

1[] In C2 (10d for NP with 10b, or 11)
2[] Not in C2 (10d for NP with 10b, or 11)

11a. DURING THE PAST 12 MONTHS, did ([any of/either of]) you take any prescription medication for any ongoing mental or emotional condition?

1[] Yes (11b)
2[] No (Item E2)
9[] DK (Item E2)

b. Who is this?
Mark (x) "Medication" box in person's column

1[] Medication

c. Anyone else?

[] Yes (Reask 11b and c)
[] No (Item E2)

ITEM E2
Refer to age or questions 1b, 2b, 3b, 4b, 5b, 6b, 7b, 9b, 10b, and 11b on pages 98-105 for each person.

0[] Under 18 (NP, or Part F on page 106)
1[] Any box marked (12)
2[] No box marked (NP, or Part F on page 106)
12a. Because of [this/any of these] mental or emotional problem(s), is -- UNABLE TO WORK OR LIMITED IN THE KIND OR AMOUNT OF WORK -- CAN DO?

1[] Yes (13)
2[] No (12b)
9[] DK (12b)

b. Because of [this/any of these] mental or emotional problem(s), does -- have trouble FINDING A JOB OR DOING JOB TASKS?

1[] Yes
2[] No
9[] DK

13. Because of [this/any of these] mental or emotional problem(s), during the past 12 months, has -- received any services from a mental health community support program?
Read if necessary: A community support program for clients with mental or emotional problems is a program that makes available mental health, health, social and support services based on individual need.

1[] Yes (E2 for NP, or Part F on page 106)
2[] No (E2 for NP, or Part F on page 106)
9[] DK (E2 for NP, or Part F on page 106)

[p.209]

Section II - Disability - Continued

Part F - Services and Benefits

1a. Some programs help people with disabilities to develop skills and opportunities for paid employment. During the past 12 months, did (read names of persons 18+) participate in a sheltered workshop, transitional work training, or supported employment?

1[] Yes (1b)
2[] No (1d)
9[] DK (1d)

b. Who is this?
Ask if necessary: In which programs did -- participate during the past 12 months, sheltered workshop, transitional work training, or supported employment?
Mark (x) appropriate box(es) in person's column

1[] Sheltered workshop
2[] Transitional work training
3[] Supported employment

c. Did anyone else participate in any of these programs during the past 12 months?

[] Yes (Reask 1b and c)
[] No (1d)

d. Are (names of persons 18+) now on a waiting list for any of these programs?

1[] Yes (1e)
2[] No (2 on page 108)
9[] DK (2 on page 108)

e. Who is this?

1[] Waiting list

f. Anyone else?

[] Yes (Reask 1e and f)
[] No (2 on page 108)

[p.210]

Section II - Disability - Continued

Part F - Services and Benefits - Continued

2a. During the past 12 months, did (read names of persons 18+) go to a day activity center for persons with disabilities which provides social, recreational and developmental activities during normal working hours?

1[] Yes (2b)
2[] No (2d)
9[] DK (2d)

b. Who is this?
Mark (x) "Day activity center" box in person's column

1[] Day activity center

c. Anyone else?

[] Yes (Reask 2b and c)
[] No (2d)

d. Are (names of persons 18+) now on a waiting list for a day activity center?

1[] Yes (2e)
2[] No (3 on page 110)
9[] DK (3 on page 110)

e. Who is this?
Mark (x) " Waiting list" box in person's column

1[] Waiting list

f. Anyone else?

[] Yes (Reask 2e and f)
[] No (3 on page 110)

[p.211]

Section II - Disability - Continued

Part F - Services and Benefits - Continued

3a. During the past 12 months, have (names of persons 18+) received any physical therapy?

1[] Yes (3b)
2[] No (4a)
9[] DK (4a)

b. Who is this?
(Anyone else?)
Mark (x) "Physical therapy" box in person's column

1[] Physical therapy

Ask 3c-d for each person with box marked in 3b.
c. Has the condition for which -- gets physical therapy been going on or is it expected to go on for at least 12 months?

1[] Yes (3b)
2[] No (NP with 3b, or 4)
9[] DK (NP with 3b, or 4)

d. What is the main condition for which -- gets physical therapy?
(Enter condition in X1 and mark box)

1[] In C2 (3c for NP with 3b, or 4)
2[] Not in C2 (3c for NP with 3b, or 4)

4a. During the past 12 months, have (names of persons 18+) received any occupational therapy?

1[] Yes (4b)
2[] No (5 on page 112)
9[] DK (5 on page 112)

b. Who is this?
(Anyone else?)
Mark (x) "Occupational therapy" box in person's column

1[] Occupational therapy

Ask 4c-d for each person with box marked in 4b.
c. Has the condition for which -- gets occupational therapy been going on or is it expected to go on for at least 12 months?

1[] Yes (4d)
2[] No (NP with 4b, or 5 on page 112)
9[] DK (NP with 4b, or 5 on page 112)

d. What is the main condition for which -- gets occupational therapy?
(Enter condition in X1 and mark box)

1[] In C2 (4c for NP with 4b, or 5 on page 112)
2[] Not in C2 (4c for NP with 4b, or 5 on page 112)

[p.212]

Section II - Disability - Continued

Part F - Services and Benefits - Continued

Vocational rehabilitation provides equipment and services to people with disabilities to improve their ability to work or live independently.
5a. Have (read names of persons 18+) EVER received any equipment or services through vocational rehabilitation?

1[] Yes (5b)
2[] No (6)
9[] DK (6)

b. Who is this?
Mark (x) "Vocational rehabilitation" box in person's column

1[] Vocational rehabilitation

c. Anyone else?

[] Yes (Reask 5b and c)
[] No (6)

A case manager coordinates personal care, and social or medical services for persons with special needs.
6a. During the past 12 months, did (read names of persons 18+) have a case manager?

1[] Yes (6b)
2[] No (7)
9[] DK (7)

b. Who is this?
Mark (x) "Case Manager" box in person's column

1[] Case manager

c. Anyone else?

[] Yes (Reask 6b and c)
[] No (7)

Ask only for persons 18+ without 6b marked; otherwise, go to 8.
7a. During the past 12 months, did (persons 18+ without 6b marked) NEED a case manager to coordinate personal care or social or medical services?

1[] Yes (7b)
2[] No (8)
9[] DK (8)

b. Who is this?
Mark (x) "Needs case manager" box in person's column

1[] Needs case manager

c. Anyone else?

[] Yes (Reask 7b and c)
[] No (8)

8a. Do (read names of persons 18+) have a court-appointed legal guardian?

1[] Yes (8b)
2[] No (part G on page 114)
9[] DK (part G on page 114)

b. Who has a legal guardian?
Mark (x) "Legal guardian" box in person's column

1[] Legal guardian

c. Anyone else?

[] Yes (Reask 8b and c)
[] No (Part G on page 114)

[p.213]

Section II - Disability - Continued

Part G - Special Health Needs of Children

ITEM G1
Refer to family composition

1[] One or more members under 18 (1)
2[] All members 18+ (Part L on page 156

)

The next questions refer to family member who are under 18 years old, that is (read names of nondeleted persons under 18).
1a. Do (names of persons under 18) NOW go to a medical doctor or specialist on a regular basis for anything other than routine physical exams?

1[] Yes (1b)
2[] No (2)
9[] DK (2)

b. Who is this?
(Anyone else?)
Mark (x) "Regular visits" box in person's column

1[] Regular visits

Ask 1c-d for each person with box marked in 1b.
c. Has any problem or condition for which -- sees a doctor regularly been going on or is it expected to go on for at least 12 months?

1[] Yes (1d)
2[] No (NP with 1b, or 2)
9[] DK (NP with 1b, or 2)

Ask only if "Yes" in 1c.
d. What is the main problem or condition for which -- goes to a doctor regularly?
(Enter condition in X1 and mark box)

1[] In C2 (1c for NP with 1b, or 2)
2[] Not in C2 (1c for NP with 1b, or 2)

2a. Do you think that (names of persons under 18) have any significant problems or delays in physical development?

1[] Yes (2b)
2[] No (3 on page 116)
9[] DK (3 on page 116)

b. Who is this?
(Anyone else?)
Mark (x) "Problem or delay" box in person's column

1[] Problem or delay

Ask 2c for each person with box marked in 2b.
c. Have any doctors or health care professionals discussed or mentioned -- problem or delay in physical development?

1[] Yes (NP with 2b, or 3 on page 116)
2[] No (NP with 2b, or 3 on page 116)
9[] DK (NP with 2b, or 3 on page 116)

[p.214]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

3a. Do (names of persons under 18) NOW have a physical, mental, or emotional problem for which they regularly take prescription medication?

1[] Yes (3b)
2[] No (4)
9[] DK (4)

b. Who is this?
(Anyone else?)
Mark (x) "Prescription medication" box in person's column

1[] Prescription medication

Ask 3c-d for each person with box marked in 3b.
c. Has the problem or condition for which -- regularly takes prescription medication been going on or as is it expected to go on for at least 12 months?

1[] Yes (3d)
2[] No (NP with 3b, or 4)
9[] DK (NP with 3b, or 4)

Ask only if "Yes" in 3c.
d. Which is the main problem or condition for which -- regularly takes prescription medication?
(Enter condition in X1 and mark box)

1[] In C2 (3c for NP with 3b, or 4)
2[] Not in C2 (3c for NP with 3b, or 4)

4a. Has (names of persons under 18) ever been a patient in a hospital overnight for a physical, mental, or emotional condition that they STILL HAVE or GET FROM TIME TO TIME?

1[] Yes (4b)
2[] No (5)
9[] DK (5)

b. Who is this?
(Anyone else?)
Mark (x) "Hospital overnight" box in person's column

1[] Hospital overnight

Ask 4a-d for each person with box marked in 4b.
c. Has the problem or condition for which -- was hospitalized been going on or is it expected to go on for at least 12 months?

1[] Yes (4d)
2[] No (NP with 4b, or 5)
9[] DK (NP with 4b, or 5)

Ask only if "Yes" in 4c.
d. What is the main condition which cause -- hospitalization(s)?
(Enter condition in X1 and mark box)

1[] In C2 (4c for NP with 4b, or 5)
2[] Not in C2 (4c for NP with 4b, or 5)

5a. Do (names of persons under 18) NOW have any life-threatening allergic reactions to any foods?

1[] Yes (5b)
2[] No (6 on page 118)
9[] DK (6 on page 118)

b. Who is this?
(Anyone else?)
Mark (x) "Allergic reaction" box in person's column

1[] Allergic reaction

[p.215]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

6a. Are (names of persons under 18) following a special diet ordered by a doctor because of a serious ongoing medical condition?

1[] Yes (6b)
2[] No (7)
9[] DK (7)

b. Who is this?
(Anyone else?)
Mark (x) "Special diet" box in person's column

1[] Special diet

Ask 6c-d for each person with box marked in 6b.
c. Would going off this diet cause -- to have a serious life-threatening reaction or illness?

1[] Yes (6b)
2[] No (NP with 6b, or 7)
9[] DK (NP with 6b, or 7)

Ask only if "Yes" in 6c.
d. What is the main problem or condition for which -- follows a special diet?
(Enter condition in X1 and mark box)

1[] In C2 (6c for NP with 6b, or 7)
2[] Not in C2 (6c for NP with 6b, or 7)

7a. Do (names of persons under 18) NOW need special medical equipment in order to breathe?

1[] Yes (7b)
2[] No (8 on page 120)
9[] DK (8 on page 120)

b. Who is this?
(Anyone else?)
Mark (x) "Special equipment" box in person's column

1[] Special equipment

Ask 7c-d for each person with box marked in 7b.
c. Has the problem or condition for which -- needs this equipment been going on or is it expected to go on for at least 12 months?

1[] Yes (7d)
2[] No (NP with 7b, or 8 on page 120)
9[] DK (NP with 7b, or 8 on page 120)

Ask only if "Yes" in 7c.
d. What is the main problem or condition for which -- needs medical equipment in order to breathe?
(Enter condition in X1 and mark box)

1[] In C2 (7c for NP with 7b, or 8 on page 120)
2[] Not in C2 (7c for NP with 7b, or 8 on page 120)

[p.216]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

8a. Do (names of persons under 18) NOW go to a counselor, psychiatrist, psychologist, or social worker on a regular basis?

1[] Yes (8b)
2[] No (9)
9[] DK (9)

b. Who is this?
(Anyone else?)
Mark (x) "Counselor" box in person's column

1[] Counselor

Ask 8c for each person with box marked in 8b.
c. Has -- counseling gone on or is it expected to go on for at least 12 months?

1[] Yes (NP with 8b, or 9)
2[] No (NP with 8b, or 9)
9[] DK (NP with 8b, or 9)

9a. During the past 12 months, have (names of persons under 18) received any physical therapy?

1[] Yes (9b)
2[] No (10 on page 122)
9[] DK (10 on page 122)

b. Who is this?
(Anyone else?)
Mark (x) "Physical therapy" box in person's column

1[] Physical therapy

Ask 9c-d for each person with box marked in 9b
c. Has the problem or condition for which -- gets physical therapy been going on or is it expected to go on for at least 12 months?

1[] Yes (9d)
2[] No (NP with 9b, or 10 on page 122)
9[] DK (NP with 9b, or 10 on page 122)

Ask only if "Yes" in 9c.
d. What is the main problem or condition for which -- gets physical therapy?
(Enter condition in X1 and mark box)

1[] In C2 (9c for NP with 9b, or 10 on page 122)
2[] Not in C2 (9c for NP with 9b, or 10 on page 122)

[p.217]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

10a. During the past 12 months, have (names of persons under 18) received any occupational therapy?

1[] Yes (10b)
2[] No (Item G2)
9[] DK (Item G2)

b. Who is this?
(Anyone else?)
Mark (x), "Occupational therapy" box in person's column

1[] Occupational therapy

Ask 10c-d for each person with box marked in 10b.
c. Has the problem or condition for which -- gets occupational therapy been going on or is it expected to go on for at least 12 months?

1[] Yes (10d)
2[] No (NP with 10b, or G2)
9[] DK (NP with 10b, or G2)

Ask only if "Yes" in 10c.
d. What is the main problem or condition for which -- gets occupational therapy?
(Enter condition in X1 and mark box)

1[] In C2 (10c for NP with 10b, or G2)
2[] Not in C2 (10c for NP with 10b, or G2)

ITEM G2
Refer to age or 9c and 10c on pages 120-123 for each person

2[] 18+ (NP, or 14 on page 132)
1[] Yes in 9c or 10c (11)
2[] Other (NP, or 14 on page 132)
11a. Does -- NOW receive any physical or occupational therapy AT HOME? THIS INCLUDES THERAPY GIVEN BY YOU, OTHER FAMILY MEMBERS, FRIENDS, VOLUNTEERS, OR PAID PROFESSIONALS.

1[] Yes (11b)
2[] No (12 on page 128)
9[] DK (12 on page 128)

b. What are the names of all persons who give -- therapy at home?

(Record up to 4 names in Table T on page 124, then return to 11c)

Ask 11c and d only if 4 names were entered in Table T for this person; otherwise, go to 11e in Table T.
c. Are there any other persons who give -- physical or occupational therapy at home?

1[] Yes (11d)
2[] No (11e in Table T on page 124)
9[] DK (11e in Table T on page 124)

d. How many others?

_________ Therapist(s) (11e in Table T on page 124)
(Number)

[p.218]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

TABLE T

Therapist at Home
Child's name
__________

Child's number
__________

Therapist name
____________
11e. Does (therapist) do physical or occupational therapy with -- ?

1[] Physical
2[] Occupational
3[] Both
9[] DK

Hand card DG1. Read categories if telephone interview.
CARD DG1

0. Parent
1. Other relative who lives here
2. Other relative who does not live here
3. Non-relative who lives here
4. Friend/neighbor
5. Unpaid volunteer from an organization or business
6. Paid employee of an organization or business
7. Paid employee of yours
8. Other

f. What is (therapist) relationship to --?
Mark (x) only one.

0[] Parent (11k)
1[] Other relative who lives here (11g)
2[] Other relative who does not live here (11g)
3[] Non-relative who lives here (11g)
4[] Friend/neighbor (11g)
5[] Unpaid volunteer from an organization or business (11j)
6[] Paid employee of an organization or business (11h)
7[] Paid employee of yours (11h)
8[] Other (11g)
9[] DK (11g)

g. Is this therapy paid for?

1[] Yes (11h on page 126)
2[] No (11j on page 126)
9[] DK (11j on page 126)

[p.219]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

Table T - Continued

Hand Card DG2. Read categories if telephone interview.
CARD DG2

0. Parent
1. Other relative who lives here
2. Other relative who does not live here
3. Private insurance
4. Rehabilitation program
5. Medicaid
6. Public school system
7. Other public source
8. Other private source
9. Other
h. Who pays for this therapy?
(Anyone else?)
Mark (x) all that apply.

00[] Parent
01[] Other relative who lives here
02[] Other relative who do not live here
03[] Private insurance
04[] Rehabilitation program
05[] Medicaid
06[] Public school system
07[] Other public source
08[] Other private source
09[] Other
99[] DK or Refused

Ask 11i only if box 00 and 01 is marked in 11h; otherwise, skip to 11j.
i. How much did [you/the family] pay for this therapy during the past 2 weeks? Do not count money that will be reimbursed by insurance, an HMO, or other source.
If none, enter 0; otherwise, enter amount in whole dollars.

$______
(Dollars)

j. How satisfied are you with this therapy? Would you say very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
If respondent is not a parent or guardian, explain, if necessary, that "you" refers to the family in general.

1[] Very satisfied
2[] Somewhat satisfied
3[] Somewhat dissatisfied
4[] Very dissatisfied
9[] DK

k. How many days during the past 2 weeks did (therapist) work with -- ?

00[] None in past 2 weeks
________ Days
(Number)

l. Please estimate the hours per day that (therapist) did therapy with --. Include therapy that is part of another activity such as play.

_____ Hour/Day
00[] Less than 1hour/day

If another therapist in Table T for this person, ask 11e on page 124 for the next therapist; otherwise, continue with 12a on page 128 for this person.

[p.220]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

12a. Does -- receive any physical or occupational therapy at any other place, that is, OTHER THAN AT HOME?

1[] Yes (12b)
2[] No (G2 on page 122 for NP, or 14 on page 132)
9[] DK (G2 on page 122 for NP, or 14 on page 132)

b. Does -- receive this therapy at school, at a location other than school or both places?
Mark (x) only one.

1[] School (12c)
2[] Location other than school (13 on page 130)
3[] Both (12c)

c. Is the therapy -- receives at school physical therapy, occupational therapy or both?

1[] Physical therapy
2[] Occupational therapy
3[] Both

ITEM G3
Refer to 12b for this person

1[] School only (G2 on page 122 for NP, or 14 on page 132)
2[] All others (13 on page 130)
[p.221]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

These questions are about the therapy that -- receives OTHER THAN AT HOME AND AT SCHOOL.
13a. Is this physical therapy, occupational therapy, or both?
Mark (x) only one

1[] Physical therapy
2[] Occupational therapy
3[] Both

b. During the past 2 weeks how often did -- receive [physical/(and) occupational] therapy NOT COUNTING THERAPY AT HOME OR SCHOOL?

00[] None
________ Times
(Number)

Show card DG2. Read categories if telephone interview.
CARD DG2

0. Parent
1. Other relative who lives here
2. Other relative who does not live here
3. Private insurance
4. Rehabilitation program
5. Medicaid
6. Public school system
7. Other public source
8. Other private source
9. Other

c. Who pays for this therapy?
Mark (x) all that apply.

00[] Parent
01[] Other family member in HH
02[] Other family member not in HH
03[] Private insurance
04[] Rehabilitation program
05[] Medicaid
06[] Public school system
07[] Other public source
08[] Other private source
09[] Other
99[] DK or Refused

Ask 13d only if box 00 or 01 is marked in 13c; otherwise, skip to 13e.
d. How much did [you/the family] pay for this therapy during the past 2 weeks. Do not count money that will be reimbursed by insurance, an HMO, or other source.
If none, enter 0; otherwise enter amount in whole dollars.

$_______
(Dollars)

e. How satisfied are you with this therapy? Would you say very satisfied, somewhat satisfied, somewhat dissatisfied, or very dissatisfied?
If respondent is not a parent or guardian, explain, if necessary, that "you" refers to the family in general.

1[] Very satisfied (G2 on page 122 for NP, or 14 on page 132)
2[] Somewhat satisfied (G2 on page 122 for NP, or 14 on page 132)
3[] Somewhat dissatisfied (G2 on page 122 for NP, or 14 on page 132)
4[] Very dissatisfied (G2 on page 122 for NP, or 14 on page 132)

[p.222]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

14a. (Besides physical or occupational therapy) do (names of persons under 18) NOW have any (other) medial or health procedures done AT HOME?

1[] Yes (14b)
2[] No (Item G4)
9[] DK (Item G4)

b. Who is this?
(Anyone else?)
Mark (x) "Medical procedures" box in person's column

1[] Medical procedures

Ask 14c-d for each person with box marked in 14b.

c. Has the problem or condition for which -- has (other) medical procedures done AT HOME been going on or is it expected to go on for at least 12 months?

1[] Yes (14d)
2[] No (NP with 14b, or G4)
9[] DK (NP with 14b, or G4)

Ask only if "Yes" in 14c.
d. What is the main problem or condition for which -- gets medical procedures done AT HOME?
(Enter condition in X1 and mark box)

1[] In C2 (14c for NP with 14b, or G4)
2[] Not in C2 (14c for NP with 14b, or G4)

ITEM G4
Refer to ages of all family members

1[] Any 1-17 years (15)
2[] All others (Item G6 on page 136)
15a. Do you think that (names of persons 1-17 years old) NOW have any problems or delays in understanding things, that is, delays in cognitive or mental development?

1[] Yes (15b)
2[] No (16)
9[] DK (16)

b. Who is this?
(Anyone else?)
Mark (x) "Mental development" box in person's column

1[] Mental development

Ask 15c for each person with box marked in 15b.
c. Have any doctors or health care professionals discussed or mentioned -- problem or delay in understanding things?

1[] Yes (NP with 15b, or 16)
2[] No (NP with 15b, or 16)
9[] DK (NP with 15b, or 16)

16a. Do you think that (names of persons 1-17 years old) NOW have any problems or delays in speech or language development?

1[] Yes (16b)
2[] No (17 on page 134)
9[] DK (17 on page 134)

b. Who is this?
(Anyone else?)
Mark (x) "Speech" box for each appropriate person.

1[] Speech

Ask 16c for each person with box marked in 16b.
c. Have any doctors or health care professionals discussed or mentioned -- problem or delay in speech or language development?

1[] Yes (NP with 16b, or 17 on page 134)
2[] No (NP with 16b, or 17 on page 134)
9[] DK (NP with 16b, or 17 on page 134)

[p.223]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

17a. Do you think that (names of persons 1-17 years old) NOW have any problems or delays in emotional or behavioral development?

1[] Yes (17b)
2[] No (Item G5)
9[] DK (Item G5)

b. Who is this?
(Anyone else?)
Mark (x) "Behavior" box in person's column

1[] Behavior

Ask 17c for each person with box marked in 17b.
c. Have any doctors or health care professionals discussed or mentioned -- problem or delay in emotional or behavioral development?

1[] Yes (NP with 17b, or G5)
2[] No (NP with 17b, or G5)
9[] DK (NP with 17b, or G5)

ITEM G5
Refer to ages of all family members

1[] Any 2-17 (18)
2[] Others (Item G6 on page 136)
18a. Because of a physical, mental, or emotional problem, do (names of persons 2-17 years old) NOW have any difficulty participating in strenuous activity, such as running or swimming, compared to other children their age?

1[] Yes (18b)
2[] No (19 on page 136)
9[] DK (19 on page 136)

b. Who is this?
(Anyone else?)
Mark (x) "Activity" box in person's column.

1[] Activity

Ask 18c-d for each person with box marked in 18b.
c. Has the problem or condition which causes -- to have difficulty participating in strenuous activity been going on or is it expected to go on for at least 12 months?

1[] Yes (18d)
2[] No (NP with 18b, or 19 on page 136)
9[] DK (NP with 18b, or 19 on page 136)

Ask only if "Yes" in 18c.
d. What is the main problem or condition which causes - - to have difficulty participating in strenuous activity?
(Enter condition in X1 and mark box)

1[] In C2 (18c for NP with 18b, or 19 on page 136)
2[] Not in C2 (18c for NP with 18b, or 19 on page 136)

[p.224]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

19a. Because of a physical, mental, or emotional problem, do (names of persons 2-17 years old) NOW have any difficulty playing or getting along with others their age?

1[] Yes (19b)
2[] No (Item G6)
9[] DK (Item G6)

b. Who is this?
(Anyone else?)
Mark (x) "Getting along" box in person's column

1[] Getting along

Ask 19c-d for each person with box marked in 19b.
c. Has the problem or condition which causes -- to have difficulty getting along with others been going on or is it expected to go on for at least 12 months?

1[] Yes (19d)
2[] No (NP with 19b, or G6)
9[] DK (NP with 19b, or G6)

Ask only if "Yes" in 19c.
d. What is the main problem or condition which causes -- to have difficulty getting along with others?
(Enter condition in X1 and mark box)

1[] In C2 (19c for NP with 19b, or G6)
2[] Not in C2 (19c for NP with 19b, or G6)

ITEM G6
Refer to ages of all family members

1[] Any persons under 5 (20)
2[] None under 5 (Part J on page 146)
20a. Do (names of persons under 5) NOW have any physical, mental or emotional problems which makes it difficult to chew, swallow, or digest?

1[] Yes (20b)
2[] No (21 on page 138)
9[] DK (21 on page 138)

b. Who is this?
(Anyone else?)
Mark (x) "Digest" box in person's column

1[] Digest

Ask 20c-d for each person with box marked in 20b.
c. Has the problem or condition which causes -- to have difficulty chewing, swallowing, or digesting been going on or is it expected to go on for at least 12 months?

1[] Yes (20d)
2[] No (NP with 20b, or 21 on page 138)
9[] DK (NP with 20b, or 21 on page 138)

Ask only if "Yes" in 20c.
d. What is the main problem or condition which causes -- to have difficulty chewing, swallowing, or digesting?
(Enter condition in X1 and mark box)

1[] In C2 (20c for NP with 20b, or 21 on page 138)
2[] Not in C2 (20c for NP with 20b, or 21 on page 138)

[p.225]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

21a. Do (names of persons under age 5) NOW need special medical equipment to assist with eating and toileting?

1[] Yes (21b)
2[] No (Part H on page 140)
9[] DK (Part H on page 140)

b. Who is this?
(Anyone else?)
Mark (x) "Eating or toileting" box in person's column

1[] Eating or toileting

Ask 21c-d for each person with box marked in 21b.
c. Has the problem or condition which causes -- to need special medical equipment been going on or is it expected to go on for at least 12 months?

1[] Yes (21d)
2[] No (NP with 21b, or Part H on page 140)
9[] DK (NP with 21b, or Part H on page 140)

Ask only if "Yes" in 21c.
d. What is the main problem or condition which causes -- to need special medical equipment to assist with eating or toileting?
(Enter condition to X1 and mark box)

1[] In C2 (21c for NP with 21b, or Part H on page 140)
2[] Not in C2 (21c for NP with 21b, or Part H on page 140)

[p.226]

Section II - Disability - Continued

Part H - Early Child Development

ITEM H1
Refer to age for each family member

1[] 5+ (NP, or part J on page 146)
2[] Under 5 (H2)
ITEM H2
Refer to child's date of birth and date of interview.
Calculate age in months or convert with card MC in HIS-501. Information Booklet.

_________ Months
[] Birthdate unknown (1)
ITEM H3
Refer to H2.

1[] Under 4 months (H1 for NP, or Part J on page 148)
2[] 4-8 months (2)
3[] 9-15 months (5)
4[] 16-29 months (11 on page 142)
5[] 30-59 months (18 on page 142)

Hand card DH1. Read categories if telephone interview.
CARD DH1

1[] Under 4 months
2[] 4-8 months
3[] 9-15 months
4[] 16-29 months
5[] 30-59 months
1. Which age group do you think -- belongs in?

1[] Under 4 months (H1 for NP, or Part j on page 146)
2[] 4-8 months (2)
3[] 9-15 months (5)
4[] 16-29 months (11 on page 142)
5[] 30-59 months (18 on page 142)

2. Does -- usually show an interest in things around -- by looking at sights or by turning towards sounds?

1[] Yes
2[] No

3. Does -- usually seem happy or pleased when -- sees -- favorite people?

1[] Yes
2[] No

4. Can -- hold -- head up without support?

1[] Yes (H1 for NP, or Part J on page 146)
2[] No (H1 for NP, or Part J on page 146)

5. Does -- usually show an interest in things around -- by looking at sights or by turning towards sound?

1[] Yes
2[] No

6. Does -- usually seem happy or pleased when -- sees -- favorite people?

1[] Yes
2[] No

7. Can -- sit upright without leaning against anything?

1[] Yes
2[] No

8. Has -- ever crawled or crept on hands or stomach?

1[] Yes (9 on page 142)
2[] No (9 on page 142)

[p.227]

Section II - Disability - Continued

Part H - Early Child Development - Continued

9. Is -- able to show what -- wants by pointing at something, reaching out to be picked up, making special noises, or saying words?

1[] Yes
2[] No

10. Does -- ever respond to people talking or playing with -- by making sounds, faces, or saying words?

1[] Yes (H1 on page 140 for NP, or Part J on page 146)
2[] No (H1 on page 140 for NP, or Part J on page 146)

11. Does -- usually pay attention to things that interest -- such as toys, picture books, or a person -- likes for as long as a minute?

1[] Yes
2[] No

12. Does -- usually seem happy and pleased when -- sees -- favorite people?

1[] Yes
2[] No

13. Can -- sit upright without leaning against anything?

1[] Yes
2[] No

14. Is -- able to show what -- wants by pointing at things, reaching out to be picked up, making special noises, or saying words?

1[] Yes
2[] No

15a. Does -- walk without holding on to anything?

1[] Yes (16)
2[] No (15b)

b. Has -- ever crawled or crept on hands or stomach?

1[] Yes
2[] No

16. Is -- able to show what -- wants or needs by using actions or words, such as leading you by the hand to open a door or saying words like "juice" or " that"?

1[] Yes
2[] No

17. Does -- ever respond to people talking or playing with -- by making sounds or faces or by saying words?

1[] Yes (H1 on page 140 for NP, or Part J on page 146)
2[] No (H1 on page 140 for NP, or Part J on page 146)

18. Does -- usually pay attention for as long as a minute to things that interest --, such as toys, picture books, or a person -- likes?

1[] Yes
2[] No

19. Does -- usually seem happy or pleased when -- sees -- favorite people?

1[] Yes
2[] No

20. Does -- walk rapidly or run?

1[] Yes (22 on page 144)
2[] No (22 on page 144)

[p.228]

Section II - Disability - Continued

Part H - Early Child Development - Continued

21a. Does -- walk without holding on to anything?

1[] Yes (22)
2[] No (21b)

b. Has -- ever crawled or crept on hands or stomach?

1[] Yes
2[] No

c. Can -- sit upright without leaning against anything?

1[] Yes
2[] No

22. Is -- able to show what -- wants or needs by using actions, or words, such as leading you by the hand to open a door or saying words like "juice" or "that" or talking?

1[] Yes
2[] No

23a. Does -- talk in phrases or sentences most of the time?

1[] Yes (25)
2[] No (24)
3[] Child is deaf (23b)

b. Is -- able to show that -- likes or dislikes something by actions such as shaking -- head or using gestures?

1[] Yes (25)
2[] No (25)

24. Is -- able to use words to show what -- likes or dislikes, such as "want that" or "no want"?

1[] Yes (25)
2[] No (25)

25. Does -- ever play "make believe", such as feeding a doll, playing house, or pretending to be a TV or movie superstar?

1[] Yes
2[] No

26. Can -- play with another person? For example, can -- help another person build with blocks or feed a baby doll?

1[] Yes (H1 on page 140 for NP, or Part J on page 146)
2[] No (H1 on page 140 for NP, or Part J on page 146)

[p.229]

Section II - Disability - Continued

Part J - Education

ITEM J1
Refer to age for each family member.

1[] Under 3 (6 on page 150)
2[] 3-17 (1)
3[] 18+ (NP, or Part K on page 152)
1a. Is -- now going to school or on vacation from school?

1[] Yes (2 on page 146)
2[] No (1b)

Hand Card DJ1. Read categories if telephone interview.
CARD DJ1

1. Not old enough yet
2. Illness
3. Receiving home teaching by parents or others
4. Permanently expelled/suspended from school
5. Quit school to get a job
6. Quit school for other reason
7. Graduated
8. Other

b. Why isn't -- going to school?
Mark (x) only one.

1[] Not old enough yet (3 on page 148)
2[] Illness (3 on page 148)
3[] Receiving home teaching by parents or others (1c)
4[] Permanently expelled/suspended from school (J1 for NP, or Part K on page 152)
5[] Quit school to get a job (J1 for NP, or Part K on page 152)
6[] Quit school for other reason (J1 for NP, or Part K on page 152)
7[] Graduated (J1 for NP, or Part K on page 152)
8[] Other (J1 for NP, or Part K on page 152)
9[] DK (J1 for NP, or Part K on page 152)

c. Is this because of a physical, mental, or emotional problem?

1[] Yes (1d)
2[] No (J1 for NP, or Part K on page 152)

d. Has -- had this problem for at least 12 months or is -- expected to have it for 12 months?

1[] Yes (3 on page 148)
2[] No (J1 for NP, or Part K on page 152)

[p.230]

Section II - Disability - Continued

Part J - Education - Continued

Hand card DJ2
CARD DJ2

A. Understanding instructional materials
B. Paying attention in class
C. Following rules or controlling his/her behavior
d. Communicating with teachers and other students
2. Does -- have significant problems at school with -

a. Understanding instructional materials?
1[] Yes
2[] No
3[] Can't do or does not apply because of limitation


b. Paying attention in class?
1[] Yes
2[] No
3[] Can't do or does not apply because of limitation


c. Following rules or controlling [his/her] behavior?
1[] Yes
2[] No
3[] Can't do or does not apply because of limitation


d. Communicating with teachers and other students?
1[] Yes
2[] No
3[] Can't do or does not apply because of limitation

(Special education is teaching designed to meet the individual needs of a child with special needs. It is paid for by the public school system and may take place at a regular school, a special school, a private school, at home, or at a hospital.)
3. Is -- now receiving special education services? Do not include gifted or talented programs.

1[] Yes
2[] No
9[] DK

(An IEP, or individual Education Plan, is a written plan for a child with special needs describing what that child will learn)
4. Does -- now have an Individual Education Plan or IEP?

1[] Yes
2[] No
9[] DK

5. Does -- attend a special school or day camp for children with special needs?

1[] Yes (J1 on page 146 for NP, or Part K on page 152)
2[] No (J1 on page 146 for NP, or Part K on page 152)
9[] DK (J1 on page 146 for NP, or Part K on page 152)

[p.231]

Section II - Disability - Continued

Part J - Education - Continued

(Early Intervention Services are services designed to meet the needs of very young children with special needs. They are provided by the State or school system at no cost to the parent.)
6. Does -- now receive Early Intervention Services?

1[] Yes
2[] No
9[] DK

(An Individual Family Service Plan (IFSP) is a written plan of goals and services for young children with special needs and their families.)
7. Does -- now have an Individual Family Service Plan or IFSP?

1[] Yes
2[] No
9[] DK

ITEM J2
Refer to this child's age

1[] 1-2 years (8)
2[] Other (J1 on page 146 for NP, or Part K on page 152)
8. Does -- now attend a special school or day camp for children with special needs?

1[] Yes (J1 on page 146 for NP, or Part K on page 152)
2[] No (J1 on page 146 for NP, or Part K on page 152)

[p.232]

Section II - Disability - Continued

Part K - Relationship to Respondent

ITEM K1
Enter person number of respondent for each family member

Person number _____
ITEM K2
Refer to each person's age

1[] 18+ (NP)
2[] Under 18 (1)

Verify or ask:
1a. How are you related to --?
Mark (x) only one

1[] Mother (1b)
2[] Father (1b)
3[] Brother/Sister (1d)
4[] Grandparent (2 on page 154)
5[] Other relative (2 on page 154)
6[] Nonrelative (2 on page 154)
7[] Self (K1 for NP, or Part L on page 156)
8[] Spouse (K1 for NP, or Part L on page 156)

b. Are you -- biological, or natural, adoptive, step, or foster parent?
Mark (x) only one

1[] Biological/natural (2 on page 154)
2[] Adoptive (1c)
3[] Step (1c)
4[] Foster (1c)

c. How old was -- when -- first started living with you?

______
1[] Months (2 on page 154)
2[] Years (2 on page 154)
000[] Since birth (2 on page 154)
999[] DK (2 on page 154)

d. Are you -- full, half, step, adoptive, or foster [brother/sister]?
Mark (x) only one

1[] Full (2 on page 154)
2[] Half (2 on page 154)
3[] Step (2 on page 154)
4[] Adoptive (2 on page 154)
5[] Foster (2 on page 154)

[p.233]

Section II - Disability - Continued

Part K - Relationship to Respondent - Continued

2a. Are you the person in the household who knows that most about -- health?

1[] Yes (K1 on page 152 for NP, or Part L on page 156)
2[] No (2b)

b. Who in the household knows the MOST about -- health?
Enter name and person number or mark (x) box

99[] No one in household or DK
Person number _____
First name ______
Last name ______
(K1 on page 152 for NP, or Part L on page 156)

[p.234]

Section II - Disability - Continued

Part L - Perceived Disability

1a. Do you consider yourself (or anyone in your family) to have a disability?

1[] Yes (1b)
2[] No (2)
9[] DK (2)

b. Who is this?
Mark (x) "Respondent-perceived disability" box in person's column

1[] Respondent-perceived disability

c. Anyone else?

[] Yes (Reask 1b and c)
[] No (2)

2a. Would other people consider you (or anyone in the family) to have a disability?

1[] Yes (2b)
2[] No (L1)
9[] DK (L1)

b. Who would other consider to have a disability?
Mark (x) "Others perceived disability" box in person's column

1[] Others perceived disability

c. Anyone else?

[] Yes (Reask 2b and c)
[] No (L1)

ITEM L1
Enter person number (s) of respondents(s) for Section II, Disability?
_________
Person number(s) of respondents

Review X1 for each person. If a condition is also in C2 on the HIS-1, enter the condition NUMBER in the triangular space. If it is not C2, complete a Disability Condition Page in Part M for it and enter the condition LETTER in the triangular space.