Refer to age

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

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

Refer to age

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

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

Refer to age

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

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

Refer to age

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

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

Refer to age

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

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

Refer to age

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

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

Refer to age

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

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

Refer to age

9a. Because of any impairment or health problem, does -- need the help of other persons with [his/her] personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling [his/her] routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part at all in the usual kinds of play activities done by most children [his/her] age?

b. Is -- limited to the kind or amount of play activities [he/she] can do because of any impairment or health problem?

11a. Does any impairment or health problem now keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of [his/her] health?

12a. Is -- limited in any way in any activities because of impairment or health problem?

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

Refer to age

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

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

Refer to age

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

Refer to age

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

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

Refer to age

8. What was -- doing MOST OF THE PAST 12 MONTHS; working at a job or business, keeping house, going to school, or something else?

Priority if 2 or more activities reported: (1) Spent the most time doing; (2) Considers the most important.

9a. Because of any impairment or health problem, does -- need the help of other persons with [his/her] personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling [his/her] routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children [his/her] age?

b. Is -- limited to the kind OR amount of play activities [he/she] can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of [his/her] health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

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

Refer to age

8. What was -- doing most of the past 12 months; working at a job or business, keeping house, going to school, or something else?
Priority if 2 or more activities reported: (1) Spent the most time doing; (2) Considers the most important.

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part at all in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind or amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem now keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in any way in any activities because of impairment or health problem?

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

Refer to age

8. What was -- doing MOST OF THE PAST 12 months; working at a job or business, keeping house, going to school, or something else?
Priority if 2 or more activities reported: (1) Spent the most time doing; (2) Considers the most important.

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

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

Refer to age

8. What was -- doing MOST OF THE PAST 12 months; working at a job or business, keeping house, going to school, or something else?
Priority if 2 or more activities reported: (1) Spent the most time doing; (2) Considers the most important.

9a. Because of any impairment or health problem, does -- need the help of other persons with -- personal care needs, such as eating, bathing, dressing, or getting around this home?

b. Because of any impairment or health problem, does -- need help of other persons in handling -- routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?

10a. Is -- able to take part AT ALL in the usual kinds of play activities done by most children -- age?

b. Is -- limited to the kind OR amount of play activities -- can do because of any impairment or health problem?

11a. Does any impairment or health problem NOW keep -- from attending school?

b. Does -- attend a special school or special classes because of any impairment or health problem?

c. Does -- need to attend a special school or special classes because of any impairment or health problem?

d. Is -- limited in school attendance because of -- health?

12a. Is -- limited in ANY WAY in any activities because of impairment or health problem?

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

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+
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+
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.

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.

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.

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.

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? ____ (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 ________

Ages 17+
25a. 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
26a. 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
27a. 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?


28a. Is -- limited in any way because of his health?


b. In what way is he limited? ________ (34)

29a. Does --'s 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?


30a. 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?


32 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?


33a. Is -- limited in ANY WAY because of a disability or health?


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

Ages 17+
23a. 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 (28a)
2 [] Keeping house (28b)
3 [] Retired, health (27)
4 [] Retired, other (27)
5 [] Going to school (30)
6 [] 17+ something else (27)

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
24a. What was -- doing most of the past 12 months - going to school or doing something else?

5 [] Going to school (30
7 [] 6-16 something else (29)

If "something else," ask:

b. What was -- doing?

1 [] Working (28a)
2 [] Keeping house (28b)
3 [] Retired, health (27)
4 [] Retired, other (27)
5 [] Going to school (30)
6 [] 17+ something else (27)
7 [] 6-16 something else (29)

Ages under 6
0 [] 1-5 yrs. (25)
0 [] Under 1 (26)

25a. 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?


26a. Is -- limited in any way because of his health?


b. In what way is he limited? ________ (32)

27a. 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?


28a. 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?


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


30a. 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?


31a. Is -- limited in ANY WAY because of a disability or health?


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

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 ____

Ages 17+

18 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 (NP-23)
2 [] Keeping house (NP-23)
3 [] Retired (NP-22)
4 [] Going to school (NP-25)
5 [] 17+ something else (NP-22)
6 [] 6-16 something else (NP-24)
0 [] 1-5 yrs. (NP-20)
0 [] Under 1 (NP-21)

If "something else," ask:

b. What was -- doing?

1 [] Working (NP-23)
2 [] Keeping house (NP-23)
3 [] Retired (NP-22)
4 [] Going to school (NP-25)
5 [] 17+ something else (NP-22)
6 [] 6-16 something else (NP-24)
0 [] 1-5 yrs. (NP-20)
0 [] Under 1 (NP-21)

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

c. Is -- retired?

Ages 6-16

19 a. What was -- doing most of the past 12 months - going to school or doing something
else?

1 [] Working (NP-23)
2 [] Keeping house (NP-23)
3 [] Retired (NP-22)
4 [] Going to school (NP-25)
5 [] 17+ something else (NP-22)
6 [] 6-16 something else (NP-24)
0 [] 1-5 yrs. (NP-20)
0 [] Under 1 (NP-21)

If "something else," ask:

b. What was -- doing? ____

1 [] Working (NP-23)
2 [] Keeping house (NP-23)
3 [] Retired (NP-22)
4 [] Going to school (NP-25)
5 [] 17+ something else (NP-22)
6 [] 6-16 something else (NP-24)
0 [] 1-5 yrs. (NP-20)
0 [] Under 1 (NP-21)

Ages under 6

20 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?


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


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

22 a. Does -- health 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?


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


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


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


d. 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?


25 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?


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


b. In what way is he limited?
Record verbatim response ________

Ages 17+
17a. 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 (22)
2[] Keeping house (22)
3[] Retired (21)
4[] Going to school (24)
5[] 17+ something else (21)
6[] 6-16 something else (23)

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

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

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

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 1-5

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?

Ages Under 1 yr.

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

b. In what way is he limited? ________ (25)

21a. Does -- health 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?

22a. In terms of health, is -- presently able to (work - keep house) at all?

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

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

d. 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?

24a. 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?

25a. What condition causes this limitation?
If "old age," ask:
Is this limitation caused by any specific condition?

b. Is this limitation caused by any other conditions?

c. What conditions?

If 2+ conditions reported in 25, ask:
d. Which of these conditions would you say is the MAIN cause of his limitation?