Do you feel you have Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ an impairment No No No No No ⃝ ⃝ ⃝ ⃝ ⃝ caused by alcohol Doesn’t Know Doesn’t Know Doesn’t 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 Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ This includes Refused Refused prescription drugs if Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ used differently than prescribed. Head of Household Person 2 Person 3 Person 4 Person 5 Just so I understand Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ what you told me No [SKIP to Q 35] No [SKIP to Q 35] No [SKIP to Q 35] No [SKIP to Q 35] No [SKIP to Q 35] ⃝ ⃝ ⃝ ⃝ ⃝ previously, do you Know Doesn’t Know Doesn’t Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ have a disability? Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ Head of Household Person 2 Person 3 Person 4 Person 5 Do you expect this Yes Yes Yes Yes Yes ⃝ ⃝ ⃝ ⃝ ⃝ disability to be No No No No No ⃝ ⃝ ⃝ ⃝ ⃝ and impair your Doesn’t Know Doesn’t Know Know Doesn’t Know Doesn’t Know ⃝ ⃝ ⃝ ⃝ ⃝ ability to live independently? Refused Refused Refused Refused Refused ⃝ ⃝ ⃝ ⃝ ⃝ Head of Household Person 2 Person 3 Person 4 Person 5 Physical Disability Physical Disability Physical Disability Physical Disability Physical Disability Which disability that Chronic Health Chronic Health Chronic Health Chronic Health Chronic Health we talked about does Condition Condition Condition Condition Condition Mental Health Issue Mental Health Issue Mental Health Issue Mental Health Issue Mental Health Issue this refer to? Substance Abuse Substance Abuse Substance Abuse Substance Abuse Substance Abuse [Mark all that apply] 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 feel you have an impairment caused by alcohol use? ⃝ 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 drug 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 Head of Household Person 2 Person 3 Person 4 Person 5 Just so I understand what you told me previously, do you have a disability? ⃝ Yes ⃝ No [SKIP to Q 35] ⃝ Know ⃝ Refused ⃝ Yes ⃝ No [SKIP to Q 35] ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No [SKIP to Q 35] ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No [SKIP to Q 35] ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No [SKIP to Q 35] ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 Do you expect this disability to be and impair your ability to live independently? ⃝ 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 Head of Household Person 2 Person 3 Person 4 Person 5 Which disability that we talked about does this refer to? [Mark all that apply] Physical Disability Chronic Health Condition Mental Health Issue Substance Abuse ⃝ Doesn’t Know ⃝ Refused Physical Disability Chronic Health Condition Mental Health Issue Substance Abuse ⃝ Doesn’t Know ⃝ Refused Physical Disability Chronic Health Condition Mental Health Issue Substance Abuse ⃝ Doesn’t Know ⃝ Refused Physical Disability Chronic Health Condition Mental Health Issue Substance Abuse ⃝ Doesn’t Know ⃝ Refused Physical Disability Chronic Health Condition Mental Health Issue Substance Abuse ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5
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