Are you blind or do you have degree serious difficulty seeing, even 7 4-year college graduate when wearing glasses? 8 More than 4-year college degree 1 Yes 2 No What language do you mainly speak at home? Because of a physical, mental, or emotional condition, do you 1 English have serious difficulty 2 Spanish concentrating, remembering, or 3 Chinese making decisions? 4 Samoan 5 Russian 1 Yes 6 Vietnamese 2 No 7 Portuguese 8 Some other language (please Do you have serious difficulty identify): walking or climbing stairs? _______________________ 1 Yes 2 No Are you of Spanish, Hispanic, or Latino origin or descent? Do you have difficulty dressing 1 No, not Spanish/Hispanic/ or bathing? Latino 2 Yes, Puerto Rican 1 Yes 3 Yes, Mexican, Mexican 2 No American, Chicano 4 Yes, Cuban Because of a physical, mental, 5 Yes, other Spanish/Hispanic/ or emotional condition, do you Latino have difficulty doing errands alone, such as visiting a or shopping? doctor’s office 1 Yes 2 No What is the highest grade or level of school that you have completed? 1 No formal education 2 5th grade or less 3 6th, 7th, or 8th grade 4 Some high school, but did not graduate 5 High school graduate or GED 6 Some college or 2-year
Are you blind or do you have serious difficulty seeing, even when wearing glasses? 1 Yes 2 No Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? 1 Yes 2 No Do you have serious difficulty walking or climbing stairs? 1 Yes 2 No Do you have difficulty dressing or bathing? 1 Yes 2 No Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone, such as visiting a doctor’s office or shopping? 1 Yes 2 No What is the highest grade or level of school that you have completed? 1 No formal education 2 5th grade or less 3 6th, 7th, or 8th grade 4 Some high school, but did not graduate 5 High school graduate or GED 6 Some college or 2-year degree 7 4-year college graduate 8 More than 4-year college degree What language do you mainly speak at home? 1 English 2 Spanish 3 Chinese 4 Samoan 5 Russian 6 Vietnamese 7 Portuguese 8 Some other language (please identify): _______________________ Are you of Spanish, Hispanic, or Latino origin or descent? 1 No, not Spanish/Hispanic/ Latino 2 Yes, Puerto Rican 3 Yes, Mexican, Mexican American, Chicano 4 Yes, Cuban 5 Yes, other Spanish/Hispanic/ Latino
ICH_SurveyStandard_English.docx