Do you have a Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ physical disability? No No No No No ⃝ ⃝ ⃝ ⃝ ⃝ [E.g. hearing, mobility, Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ and visual Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ impairments] Do you have a Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ developmental No No No No No ⃝ ⃝ ⃝ ⃝ ⃝ disability? Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ [E.g. autism, behavior Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ disorders, and intellectual disabilities] Do you have a Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ chronic health No No No No No ⃝ ⃝ ⃝ ⃝ ⃝ condition? Doesn’t Know Know Doesn’t Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ [E.g. heart disease, Refused Refused Refused Refused Refused severe asthma, ⃝ ⃝ ⃝ ⃝ ⃝ traumatic brain injury, PTSD, cancer, emphysema, or liver disease] Have you ever been Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ diagnosed with a No No No No No ⃝ ⃝ ⃝ ⃝ ⃝ STI? Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ Are you living with Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ HIV/AIDS? No No No No No ⃝ ⃝ ⃝ ⃝ ⃝ Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ Head of Household Person 2 Person 3 Person 4 Person 5
Do you have a physical disability? [E.g. hearing, mobility, and visual impairments] ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Do you have a developmental disability? [E.g. autism, behavior disorders, and intellectual disabilities] ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Do you have a chronic health condition? [E.g. heart disease, severe asthma, traumatic brain injury, PTSD, cancer, emphysema, or liver disease] ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Have you ever been diagnosed with a STI? ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Are you living with HIV/AIDS? ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5