I’m going to ask you some questions about your health.” “Now Head of Household Person 2 Person 3 Person 4 Person 5 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 Know Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ and visual impairments] Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ Do you have a Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ developmental No No No No No ⃝ ⃝ ⃝ ⃝ ⃝ disability? 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] Head of Household Person 2 Person 3 Person 4 Person 5 Do you have a Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ chronic health No No No No No ⃝ ⃝ ⃝ ⃝ ⃝ condition? Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know Know ⃝ ⃝ ⃝ ⃝ ⃝ [E.g. heart disease, Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ diabetes, severe asthma, traumatic brain injury, dementia, cancer, emphysema, or liver disease] 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 Know Know ⃝ ⃝ ⃝ ⃝ ⃝ Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ Do you have any Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ mental health No No No No No ⃝ ⃝ ⃝ ⃝ ⃝ issues? Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know Know ⃝ ⃝ ⃝ ⃝ ⃝ [E.g. chronic depression, Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ bipolar disorder, PTSD or schizophrenia] Head of Household Person 2 Person 3 Person 4 Person 5
“Now I’m going to ask you some questions about your health.” 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 ⃝ Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Do you have a developmental disability? [E.g. autism, behavior disorders, and intellectual disabilities] ⃝ Yes ⃝ No ⃝ 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 Do you have a chronic health condition? [E.g. heart disease, diabetes, severe asthma, traumatic brain injury, dementia, cancer, emphysema, or liver disease] ⃝ 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 ⃝ 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 ⃝ Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Know ⃝ Refused Do you have any mental health issues? [E.g. chronic depression, bipolar disorder, PTSD or schizophrenia] ⃝ 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 ⃝ Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5
2018-Working-Survey-1.docx