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 Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ [E.g. chronic Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ depression, bipolar disorder, or schizophrenia] Do you feel you Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ have an impairment No No No No No ⃝ ⃝ ⃝ ⃝ ⃝ caused by alcohol Doesn’t Know Doesn’t Know Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ use? Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ Do you feel you have Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ an impairment No No No No No caused by drug ⃝ ⃝ ⃝ ⃝ ⃝ abuse? This includes Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ prescription drugs if Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ used differently than prescribed. Just so I Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ understand No [Skip to Q24} No [Skip to Q24} No [Skip to Q24} No [Skip to Q24} No [Skip to Q24} ⃝ ⃝ ⃝ ⃝ ⃝ what you told me Doesn’t Know Doesn’t Know Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ previously, do you Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ have a disability? Do you expect this Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ disability to be long No No No No No ⃝ ⃝ ⃝ ⃝ ⃝ term or permanent? Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ Does this disability Yes ⃝ Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ impair your ability No ⃝ No No No No ⃝ ⃝ ⃝ ⃝ to live Doesn’t Know ⃝ Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know independently? ⃝ ⃝ ⃝ ⃝ Refused ⃝ Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ have two additional questions to see if you have experienced…” “We Head of Household Person 2 Person 3 Person 4 Person 5
Do you have any mental health issues? [E.g. chronic depression, bipolar disorder, 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 ⃝ Doesn’t Know ⃝ Refused Do you feel you have an impairment caused by alcohol use? ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Do you feel you have an impairment caused by drug abuse? This includes prescription drugs if used differently than prescribed. ⃝ 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 Just so I understand what you told me previously, do you have a disability? ⃝ Yes ⃝ No [Skip to Q24} ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No [Skip to Q24} ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No [Skip to Q24} ⃝ Know ⃝ Refused ⃝ Yes ⃝ No [Skip to Q24} ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No [Skip to Q24} ⃝ Doesn’t Know ⃝ Refused Do you expect this disability to be long term or permanent? ⃝ 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 Does this disability impair your ability to live independently? ⃝ 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 “We have two additional questions to see if you have experienced…” Head of Household Person 2 Person 3 Person 4 Person 5
2018-Working-Youth-Survey-1.docx