dp
[p.161]

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

ITEM X2
Indicate ADL Limitations in X2.

ITEM X3
Indicate IADL Limitations in X3

[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?

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

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)

d. Is -- legally blind?

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

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.

[p.171]

Section II- Disability - Continued

Part A- Sensory, Communication and Mobility - Continued

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

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

c. Anyone else?

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

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

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)

g. Is -- able to hear loud noises?

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

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.

[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

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

c. Anyone else?

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

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

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.

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

h. Anyone else?

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

[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?

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

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

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?

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)

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

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

p. Anyone else?

[p.174]

Section II- Disability - Continued

Part A- Sensory, Communication and Mobility - Continued

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

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?)

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

c. Anyone else?

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?

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?

[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?

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.

c. Does anyone else now use a brace?

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?

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

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.

c. Does anyone else now use an artificial limb?

[p.176]

Section II- Disability - Continued

Part A- Sensory, Communication and Mobility - Continued

ITEM A2
Refer to ages of all family members.

8a. Do (names of persons 18+) now have any problem with dizziness that has lasted for at least three months?

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

c. Anyone else?

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

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

f. Anyone else?

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

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

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

c. Anyone else?

[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?

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

c. Anyone else?

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?

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

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

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?

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

c. Anyone else?

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.

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

[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-

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

c. Anyone else?

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

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

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

[p.179]

Section II- Disability - Continued

PART C-ADL/IADL

Hand card DC1.
CARD DC1

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

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.

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

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?

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

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.

[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

3a. Do (read names of persons 5+) use any SPECIAL EQUIPMENT to do any of [these/the following] activities?

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

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

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.

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

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"

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

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"

[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?

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"

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

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"

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

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"

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

[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"

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

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

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

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?

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?

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?

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?

[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?

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?

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

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.

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

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

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

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

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?

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?

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?

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?

[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?

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?

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?

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?

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?

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?

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?

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?

[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?

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

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

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

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

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

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

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

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

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

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

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

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?

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

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

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?

[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?

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

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

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

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?

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

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

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?

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

[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

(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-

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.

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

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"

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

[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"

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

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"

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

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"

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

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"

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

[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"

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

Hand card DC2.
CARD DC2

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.

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?

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?

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?

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?

[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?

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?

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

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.

ITEM C8
Refer to X3 for this person. Mark (x) first appropriate box

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.

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

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

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?

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

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?

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

[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?

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

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?

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

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?

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?

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?

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?

[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?

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

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

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

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?

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

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

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

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?

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

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

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

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?

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

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

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

[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?

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

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

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?

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?

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

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

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?

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

[p.196]

Section II - Disability - Continued

Part D- Functional Limitation

ITEM D1
Refer to ages of all family members

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?

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

c. Anyone else?

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?

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

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?

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

[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?

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

c. Anyone else?

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?

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

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?

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

[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?

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

c. Anyone else?

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?

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

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?

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

[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?

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

c. Anyone else?

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?

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

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?

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

[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?

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

c. Anyone else?

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?

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

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?

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

[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?

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

c. Anyone else?

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?

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

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?

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

[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?

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

c. Anyone else?

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?

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

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?

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

[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?

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

c. Anyone else?

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?

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

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?

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

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

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)

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.

[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?

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

c. Anyone else?

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

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

c. Anyone else?

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

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

c. Anyone else?

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

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

c. Anyone else?

[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?

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

c. Anyone else?

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

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

c. Anyone else?

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?

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

c. Anyone else?

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

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?

[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-

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

c. Anyone else?

[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.

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

c. Anyone else?

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)

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

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

c. Anyone else?

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.

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?

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

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.

[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?

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

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

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

e. Who is this?

f. Anyone else?

[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?

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

c. Anyone else?

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

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

f. Anyone else?

[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?

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

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?

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

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

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

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?

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

[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?

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

c. Anyone else?

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?

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

c. Anyone else?

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?

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

c. Anyone else?

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

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

c. Anyone else?

[p.213]

Section II - Disability - Continued

Part G - Special Health Needs of Children

ITEM G1
Refer to family composition

)

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?

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

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?

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)

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

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

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?

[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?

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

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?

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)

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?

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

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?

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

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

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

[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?

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

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?

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)

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

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

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?

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)

[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?

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

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?

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

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

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?

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)

[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?

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

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?

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)

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

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.

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

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?

d. How many others?

[p.218]

Section II - Disability - Continued

Part G - Special Health Needs of Children - Continued

TABLE T

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

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

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

g. Is this therapy paid for?

[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

h. Who pays for this therapy?
(Anyone else?)
Mark (x) all that apply.

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.

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.

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

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

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?

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

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

ITEM G3
Refer to 12b for this person

[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

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

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

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

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.

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.

[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?

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

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?

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)

ITEM G4
Refer to ages of all family members

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?

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

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?

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

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

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?

[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?

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

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?

ITEM G5
Refer to ages of all family members

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?

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

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?

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)

[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?

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

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?

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)

ITEM G6
Refer to ages of all family members

20a. Do (names of persons under 5) NOW have any physical, mental or emotional problems which makes it difficult to chew, swallow, or digest?

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

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?

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)

[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?

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

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?

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)

[p.226]

Section II - Disability - Continued

Part H - Early Child Development

ITEM H1
Refer to age for each family member

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.

ITEM H3
Refer to H2.

Hand card DH1. Read categories if telephone interview.
CARD DH1

1. Which age group do you think -- belongs in?

2. Does -- usually show an interest in things around -- by looking at sights or by turning towards sounds?

3. Does -- usually seem happy or pleased when -- sees -- favorite people?

4. Can -- hold -- head up without support?

5. Does -- usually show an interest in things around -- by looking at sights or by turning towards sound?

6. Does -- usually seem happy or pleased when -- sees -- favorite people?

7. Can -- sit upright without leaning against anything?

8. Has -- ever crawled or crept on hands or stomach?

[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?

10. Does -- ever respond to people talking or playing with -- by making sounds, faces, or saying words?

11. Does -- usually pay attention to things that interest -- such as toys, picture books, or a person -- likes for as long as a minute?

12. Does -- usually seem happy and pleased when -- sees -- favorite people?

13. Can -- sit upright without leaning against anything?

14. Is -- able to show what -- wants by pointing at things, reaching out to be picked up, making special noises, or saying words?

15a. Does -- walk without holding on to anything?

b. Has -- ever crawled or crept on hands or stomach?

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"?

17. Does -- ever respond to people talking or playing with -- by making sounds or faces or by saying words?

18. Does -- usually pay attention for as long as a minute to things that interest --, such as toys, picture books, or a person -- likes?

19. Does -- usually seem happy or pleased when -- sees -- favorite people?

20. Does -- walk rapidly or run?

[p.228]

Section II - Disability - Continued

Part H - Early Child Development - Continued

21a. Does -- walk without holding on to anything?

b. Has -- ever crawled or crept on hands or stomach?

c. Can -- sit upright without leaning against anything?

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?

23a. Does -- talk in phrases or sentences most of the time?

b. Is -- able to show that -- likes or dislikes something by actions such as shaking -- head or using gestures?

24. Is -- able to use words to show what -- likes or dislikes, such as "want that" or "no want"?

25. Does -- ever play "make believe", such as feeding a doll, playing house, or pretending to be a TV or movie superstar?

26. Can -- play with another person? For example, can -- help another person build with blocks or feed a baby doll?

[p.229]

Section II - Disability - Continued

Part J - Education

ITEM J1
Refer to age for each family member.

1a. Is -- now going to school or on vacation from school?

Hand Card DJ1. Read categories if telephone interview.
CARD DJ1

b. Why isn't -- going to school?
Mark (x) only one.

c. Is this because of a physical, mental, or emotional problem?

d. Has -- had this problem for at least 12 months or is -- expected to have it for 12 months?

[p.230]

Section II - Disability - Continued

Part J - Education - Continued

Hand card DJ2
CARD DJ2

2. Does -- have significant problems at school with -

(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.

(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?

5. Does -- attend a special school or day camp for children with special needs?

[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?

(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?

ITEM J2
Refer to this child's age

8. Does -- now attend a special school or day camp for children with special needs?

[p.232]

Section II - Disability - Continued

Part K - Relationship to Respondent

ITEM K1
Enter person number of respondent for each family member

ITEM K2
Refer to each person's age

Verify or ask:
1a. How are you related to --?
Mark (x) only one

b. Are you -- biological, or natural, adoptive, step, or foster parent?
Mark (x) only one

c. How old was -- when -- first started living with you?

d. Are you -- full, half, step, adoptive, or foster [brother/sister]?
Mark (x) only one

[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?

b. Who in the household knows the MOST about -- health?
Enter name and person number or mark (x) box

[p.234]

Section II - Disability - Continued

Part L - Perceived Disability

1a. Do you consider yourself (or anyone in your family) to have a disability?

b. Who is this?
Mark (x) "Respondent-perceived disability" box in person's column

c. Anyone else?

2a. Would other people consider you (or anyone in the family) to have a disability?

b. Who would other consider to have a disability?
Mark (x) "Others perceived disability" box in person's column

c. Anyone else?

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.