Ages 17+
19a. What was -- doing most of the past 12 months -(For males): working or doing something else? (For females): keeping house, working or doing something else?

If 'something else" ask:
b. What was -- doing?

If 45+ years and was not "working," "keeping house," or "going to school." ask:
c. Is -- retired?

d. If "retired," ask: Did he retire because of his health?

Ages 6-16
20a. What was -- doing most of the past 12 months - going to school or doing something else?

If "something else," ask:
b. What was -- doing?

Ages under 6

21a. Is -- able to take part at all in ordinary play with other children?

b. Is he limited in the kind of play he can do because of his health?

c. Is he limited in the amount of play because of his health?

22a. Is -- limited in any way because of his health?

b. In what way is he limited? Record limitation, not condition.

23a. Does -- health now keep him from working?

b. Is he limited in the kind of work he could do because of his health?

c. Is he limited in the amount of work he could do because of his health?

d. Is he limited in the kind or amount of other activities because of his health?

24a. Does -- NOW have a job?

b. In terms of health, is -- NOW able to (work - keep house) at all?

c. Is he limited in the kind of (work-housework) he can do because of his health?

d. Is he limited in the amount of (work-housework) he can do because of his health?

e. Is he limited in the kind or amount of other activities because of his health?

25. In terms of health would -- be able to go to school?

26a. Does (would) -- have to go to a certain type of school because of his health?

b. Is he (would he be) limited in school attendance because of his health?

c. Is he limited in the kinds or amount of other activities because of his health?

27a. Is -- limited in ANY WAY because of a disability or health?

b. In what way is he limited? Record limitation, not condition.

28a. About how long has he {been limited in --, been unable to --, had to go to a certain type of school?}

Ages 17+
19a. What was -- doing most of the past 12 months -(For males): working or doing something else? (For females): keeping house, working or doing something else?

If 'something else" ask:
b. What was -- doing?

If 45+ years and was not "working," "keeping house," or "going to school." ask:
c. Is -- retired?

d. If "retired," ask: Did he retire because of his health?

Ages 6-16
20a. What was -- doing most of the past 12 months - going to school or doing something else?

If "something else," ask:
b. What was -- doing?

Ages under 6

21a. Is -- able to take part at all in ordinary play with other children?

b. Is he limited in the kind of play he can do because of his health?

c. Is he limited in the amount of play because of his health?

22a. Is -- limited in any way because of his health?

b. In what way is he limited? Record limitation, not condition.

23a. Does -- health now keep him from working?

b. Is he limited in the kind of work he could do because of his health?

c. Is he limited in the amount of work he could do because of his health?

d. Is he limited in the kind or amount of other activities because of his health?

24a. Does -- NOW have a job?

b. In terms of health, is -- NOW able to (work - keep house) at all?

c. Is he limited in the kind of (work-housework) he can do because of his health?

d. Is he limited in the amount of (work-housework) he can do because of his health?

e. Is he limited in the kind or amount of other activities because of his health?

25. In terms of health would -- be able to go to school?

26a. Does (would) -- have to go to a certain type of school because of his health?

b. Is he (would he be) limited in school attendance because of his health?

c. Is he limited in the kinds or amount of other activities because of his health?

27a. Is -- limited in ANY WAY because of a disability or health?

b. In what way is he limited? Record limitation, not condition.

28a. About how long has he {been limited in --, been unable to --, had to go to a certain type of school?}

Ages 17+:
19 a. What was -- doing most of the past 12 months - (For males): working or
doing something else? (For females): keeping house, working, or doing something
else?

If "something else," ask:
b. What was -- doing?

If 45+ years and not "working," "keeping house," or "going to school," ask:
c. Is -- retired?

d. If "retired," ask: Did he retire because of his health?

Ages 6-16:
20 a. What was -- doing most of the past 12 months - going to school or doing
something else?

If "something else," ask:
b. What was -- doing?

Ages under 6

21 a. Is -- able to take part at all in ordinary play with other children?

b. Is he limited in the kind of play he can do because of his health?

c. Is he limited in the amount of play because of his health?

22 a. Is -- limited in any way because of his health?

b. In what way is he limited? Record limitation, not condition.

23 a. Does -- health now keep him from working?

b. Is he limited in the kind of work he could do because of his health?

c. Is he limited in the amount of work he could do because of his health?

d. Is he limited in the kind or amount of other activities because of his health?

24 a. Does -- now have a job?

b. In terms of health, is -- now able to (work - keep house) at all?

c. Is he limited in the kind of (work - housework) he can do because of his health?

d. Is he limited in the amount of (work - housework) he can do because of his health?

e. Is he limited in the kind or amount of other activities because of his health?

25. In terms of health would -- be able to go to school?

26 a. Does (would) -- have to go to a certain type of school because of his health?

b. Is he (would he be) limited in school attendance because of his health?

c. Is he limited in the kind or amount of other activities because of his health?

27 a. Is -- limited in any way because of a disability or health?

b. In what way is he limited? Record limitation, not condition

28 a. About how long has he [been limited in -- , been unable to --] had to go to a certain type of school?

Ages 17+:
19 a. What was -- doing most of the past 12 months - (For males): working or
doing something else? (For females): keeping house, working, or doing something
else?

If "something else," ask:
b. What was -- doing?

If 45+ years and not "working," "keeping house," or "going to school," ask:
c. Is -- retired?

d. If "retired," ask: Did he retire because of his health?

Ages 6-16:
20 a. What was -- doing most of the past 12 months - going to school or doing
something else?

If "something else," ask:
b. What was -- doing?

Ages under 6

21 a. Is -- able to take part at all in ordinary play with other children?

b. Is he limited in the kind of play he can do because of his health?

c. Is he limited in the amount of play because of his health?

22 a. Is -- limited in any way because of his health?

b. In what way is he limited? Record limitation, not condition.

23 a. Does -- health now keep him from working?

b. Is he limited in the kind of work he could do because of his health?

c. Is he limited in the amount of work he could do because of his health?

d. Is he limited in the kind or amount of other activities because of his health?

24 a. Does -- now have a job?

b. In terms of health, is -- now able to (work - keep house) at all?

c. Is he limited in the kind of (work - housework) he can do because of his health?

d. Is he limited in the amount of (work - housework) he can do because of his health?

e. Is he limited in the kind or amount of other activities because of his health?

25. In terms of health would -- be able to go to school?

26 a. Does (would) -- have to go to a certain type of school because of his health?

b. Is he (would he be) limited in school attendance because of his health?

c. Is he limited in the kind or amount of other activities because of his health?

27 a. Is -- limited in any way because of a disability or health?

b. In what way is he limited? Record limitation, not condition

28 a. About how long has he [been limited in -- , been unable to --] had to go to a certain type of school?

Ages 17+:
19 a. What was -- doing most of the past 12 months - (For males): working or
doing something else? (For females): keeping house, working, or doing something
else?

If "something else," ask:
b. What was -- doing?

If 45+ years and not "working," "keeping house," or "going to school," ask:
c. Is -- retired?

d. If "retired," ask: Did he retire because of his health?

Ages 6-16:
20 a. What was -- doing most of the past 12 months - going to school or doing
something else?

If "something else," ask:
b. What was -- doing?

Ages under 6

21 a. Is -- able to take part at all in ordinary play with other children?

b. Is he limited in the kind of play he can do because of his health?

c. Is he limited in the amount of play because of his health?

22 a. Is -- limited in any way because of his health?

b. In what way is he limited? Record limitation, not condition.

23 a. Does -- health now keep him from working?

b. Is he limited in the kind of work he could do because of his health?

c. Is he limited in the amount of work he could do because of his health?

d. Is he limited in the kind or amount of other activities because of his health?

24 a. Does -- now have a job?

b. In terms of health, is -- now able to (work - keep house) at all?

c. Is he limited in the kind of (work - housework) he can do because of his health?

d. Is he limited in the amount of (work - housework) he can do because of his health?

e. Is he limited in the kind or amount of other activities because of his health?

25. In terms of health would -- be able to go to school?

26 a. Does (would) -- have to go to a certain type of school because of his health?

b. Is he (would he be) limited in school attendance because of his health?

c. Is he limited in the kind or amount of other activities because of his health?

27 a. Is -- limited in any way because of a disability or health?

b. In what way is he limited? Record limitation, not condition

28 a. About how long has he [been limited in -- , been unable to --] had to go to a certain type of school?

Ages 17+
18a. What was -- doing MOST OF THE PAST 12 MONTHS -- (For males): working or doing something else? (For females): keeping house, working, or doing something else?

If "something else," ask:
b. What was -- doing?

If 45+ years and not "working," "keeping house," or "going to school," ask:
c. Is -- retired? ____

d. If "retired," ask: Did he retire because of his health? ____

Ages 6 --16
19a. What was -- doing MOST OF THE PAST 12 MONTHS -- going to school or doing something else?

If "something else," ask:

b. What was -- doing? ____

Ages under 6

20a. Is -- able to take part at all in ordinary play with other children?

b. Is he limited in the kind of play he can do because of his health?

c. Is he limited in the amount of play because of his health?

21a. Is -- limited in any way because of his health?

b. In what way is he limited? Record limitation, not condition. ________ (27)

22a. Does -- health now keep him from working?

b. Is he limited in the kind of work he could do because of his health?

c. Is he limited in the amount of work he could do because of his health?

d. Is he limited in the kind or amount of other activities because of his health?

23a. Does -- NOW have a job?

b. In terms of health, is -- NOW able to (work -- keep house) at all?

c. Is he limited in the kind of (work -- housework) he can do because of his health?

d. Is he limited in the amount of (work -- housework) he can do because of his health?

e. Is he limited in the kind or amount of other activities because of his health?

24. In terms of health would -- be able to go to school?

25a. Does (would) -- have to go to a certain type of school because of his health?

b. Is he (would he be) limited in school attendance because of his health?

c. Is he limited in the kind or amount of other activities because of his health?

26a. Is -- limited in ANY WAY because of a disability or health?

b. In what way is he limited? Record limitation, not condition ________

27 a. About how long has he

had to go to a certain type of school?

b. What (other) condition causes this limitation? ____

If "old age" only, ask: Is this limitation caused by any specific condition? ____

Enter condition in item C. Ask 27c.

c. Is this limitation caused by any other condition?

Mark box or ask:
d. Which of these conditions would you say is the MAIN cause of his limitation?

Ages 17+
18a. What was -- doing MOST OF THE PAST 12 MONTHS -- (For males): working or doing something else? (For females): keeping house, working or doing something else?

If "something else," ask:

b. What was -- doing? ____

If 45+ years and not "working," "keeping house," or "going to school," ask:

c. Is -- retired? ____

d. If "retired," ask: Did he retire because of his health? ____

Ages 6-16
19a. What was -- doing MOST OF THE PAST 12 MONTHS -- going to school or doing something else?

If "something else," ask:

b. What was -- doing? ____

Ages under 6

20a. Is -- able to take part at all in ordinary play with other children?

b. Is he limited in the kind of play he can do because of his health?

c. Is he limited in the amount of play because of his health?

21a. Is -- limited in any way because of his health?

b. In what way is he limited? Record limitation, not condition. ________ (27)

22a. Does -- health now keep him from working?

b. Is he limited in the kind of work he could do because of his health?

c. Is he limited in the amount of work he could do because of his health?

d. Is he limited in the kind or amount of other activities because of his health?

23a. Does -- NOW have a job?

b. In terms of health, is -- NOW able to (work -- keep house) at all?

c. Is he limited in the kind of (work -- housework) he can do because of his health?

d. Is he limited in the amount of (work -- housework) he can do because of his health?

e. Is he limited in the kind or amount of other activities because of his health?

24. In terms of health would -- be able to go to school?

25a. Does (would) -- have to go to a certain type of school because of his health?

b. Is he (would he be) limited in school attendance because of his health?

c. Is he limited in the kind or amount of other activities because of his health?

26a. Is -- limited in ANY WAY because of a disability or health?

b. In what way is he limited? Record limitation, not condition ________

27a. About how long has he

had to go to a certain type of school?

27a. About how long has he

had to go to a certain type of school?

Ages under 6
20a. Is -- able to take part at all in ordinary play with other children?

b. Is he limited in the kind of play he can do because of his health?

c. Is he limited in the amount of play because of his health?

21a. Is -- limited in any way because of his health?

b. In what way is he limited? ____ (27)

22a. Does -- health now keep him from working?

b. Is he limited in the kind of work he could do because of his health?

c. Is he limited in the amount of work he could do because of his health?

d. Is he limited in the kind or amount of other activities because of his health?

23a. Does -- NOW have a job?

b. In terms of health, is -- NOW able to (work -- keep house) at all?

c. Is he limited in the kind of (work -- housework) he can do because of his health?

d. Is he limited in the amount of (work -- housework) he can do because of his health?

e. Is he limited in the kind or amount of other activities because of his health?

31. In terms of health would -- be able to go to school?

25a. Does (would) -- have to go to a certain type of school because of his health?

b. Is he (would he be) limited in school attendance because of his health?

c. Is he limited in the kind or amount of other activities because of his health?

26a. Is -- limited in ANY WAY because of a disability or health?

b. In what way is he limited? Record limitation, not condition ________

27a. About how long has he

had to go to a certain type of school?

34a. About how long has he

[been limited in --
been unable to --
had to go to a certain type of school?]

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

34a. About how long has he

[been limited in --
been unable to --
had to go to a certain type of school?]

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

Ages 17+
17 a. What was -- doing most of the past 12 months (For males): working or doing something else? (For females): keeping house, working or doing something else?

1 [] Working (22a)
2 [] Keeping house (22b)
3 [] Retired, health (21)
4 [] Retired, other (21)
5 [] Going to school (24)
6 [] 17+ something else (21)
7 [] 6-16 something else (23)

If "something else," ask:
b. What was -- doing? ____

If 45+ years and not "working," "keeping house," or "going to school," ask:
c. Is -- retired? ____

d. If "Retired," ask: Did he retire because of his health?

Ages 6-16
18a. What was -- doing most of the past 12 months - going to school or doing something else?

If "something else," ask:
b. What was -- doing? ____

Ages under 6


19a. Is -- able to take part at all in ordinary play with other children?


b. Is he limited in the kind of play he can do because of his health?


c. Is he limited in the amount of play because of his health?


20a. Is -- limited in any way because of his health?


b. In what way is he limited? ____ (26)

21a. Does -- health now keep him from working?


b. Is he limited in the kind of work he could do because of his health?


c. Is he limited in the amount of work he could do because of his health?


d. Is he limited in the kind or amount of other activities because of his health?


22 a. Does -- now have a job?


b. In terms of health, is -- able to (work -- keep house) at all?


c. Is he limited in the kind of (work -- housework) he can do because of his health?


d. Is he limited in the amount of (work -- housework) he can do because of his health?


e. Is he limited in the kind or amount of other activities because of his health?


23. In terms of health would -- be able to go to school?


24 a. Does (would) -- have to go to a certain type of school because of his health?


b. Is he (would he be) limited in school attendance because of his health?


c. Is he limited in the kind or amount of other activities because of his health?


25 a. Is -- limited in ANY WAY because of a disability or health?


b. In what way is he limited? Record limitation, not condition ____

26. About how long has he
been limited in --
been unable to --
had to go to a certain type of school?

26. About how long has he
been limited in --
been unable to --
had to go to a certain type of school?

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